A Randomized Controlled Trial of Cognitive Remediation and D-cycloserine for Individuals With Bipolar Disorder
Phase: PHASE3
Conditions: Bipolar Disorder
Sponsor: University of Arizona

STUDY PROTOCOL
Open Access
A randomized controlled trial of cognitive
remediation and d-cycloserine for individuals
with bipolar disorder
Nicholas JK Breitborde1*, Spencer C Dawson2, Cindy Woolverton2, David Dawley1, Emily K Bell1, Kaila Norman1,
Angelina Polsinelli2, Beth Bernstein1, Pamela Mirsky1, Christine Pletkova1, Felix Grucci III1, Carly Montoya1,
Bernard Nanadiego1, Ehsan Sarabi1, Michael DePalma1 and Francisco Moreno1
Abstract
Background: Cognitive remediation (CR) has shown significant promise in addressing the cognitive deficits that
accompany serious mental illness. However, this intervention does not appear to completely ameliorate the
cognitive deficits that accompany these illnesses. D-cycloserine (DCS), an NMDA receptor partial agonist, has been
shown to enhance the therapeutic benefits of learning-based psychosocial interventions for psychiatric disorders.
Thus, the goal of this study is to examine the utility of combining cognitive remediation and d-cycloserine in the
treatment of cognitive deficits among individuals with bipolar disorder.
Methods/Design: Approximately forty individuals with bipolar disorder will be recruited to participate in this study.
Participants will be randomized to one of two study arms: CR + DCS or CR + placebo. The primary outcome for this
study is change in cognitive functioning. We will also examine several secondary outcomes, including the rate of
change of cognitive functioning, social functioning, and symptomatology.
Discussion: Cognitive deficits are a rate-limiting factor in functional recovery among individuals with bipolar disorder.
Unfortunately, treatment options for these deficits are limited. The results of the proposed study may reveal a valuable
intervention strategy (i.e., CR with concurrent DCS) to improve cognitive functioning among individuals with bipolar
disorder. Ultimately, this treatment strategy may prove useful in addressing the cognitive deficits that are ubiquitous
across serious mental illnesses.
Trial registration: ClinicalTrials.gov NCT01934972.
Background
In the 2013 update to Global Burden of Disease Study,
bipolar disorder was identified as one of the top ten
most debilitating psychiatric illnesses (Salomon et al.
2013). Although a significant portion of the illness-related
disability that accompanies bipolar disorder stems from
the episodes of manic and dysthymic mood that define
this disorder, there is growing recognition that deficits in
cognitive functioning are also significant contributors to
the disability experienced by individuals with bipolar dis-
order. More specifically, individuals with bipolar disorder
experience deficits in multiple domains of cognitive
functioning that are present throughout the manic, dys-
thymic, and euthymic phases of the illness (Green 2006).
These deficits serve as a rate-limiting factor with regard to
many aspects of the recovery process in bipolar disorder,
including social and vocational functioning (Bearden et al.
2011; Baune et al. 2013; Dickerson et al. 2004).
Given the nearly ubiquitous occurrence of cognitive
deficits among individuals with serious mental illness,
there is significant interest in developing interventions
designed to improve cognitive functioning. One inter-
vention that has shown great promise in ameliorating
these cognitive deficits is cognitive remediation (CR).
This intervention, which is recognized as a “best practice”
in the treatment of serious mental illness (Browne et al.;
APA/CAAP Task Force on Serious Mental Illness and
* Correspondence: breitbor@email.arizona.edu
1Department of Psychiatry, The University of Arizona, Tucson, AZ, USA
Full list of author information is available at the end of the article
© 2014 Breitborde et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public
Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this
article, unless otherwise stated.
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Severe Emotional Disturbance 2007), is typically com-
prised of a series of repeated exercises delivered by a clin-
ician or via a computer that are designed to improve
performance in cognitive functioning. To date, one trial of
cognitive remediation among individuals with bipolar dis-
order has been completed (Deckersbach et al. 2010). In
this open trial, Deckersbach and colleagues provided 18
individuals with bipolar disorder with a series of cognitive
behavioral therapy sessions in which participants learned
strategies to manage and monitor mood, improve plan-
ning and organization, and increase attention and mem-
ory. At the end of treatment, participants reported
improvements in self-rated organization and planning.
However, the lack of a control condition and objective
measures of cognitive functioning suggest that the prom-
ising results of this study should be interpreted with cau-
tion. A more recent trial of functional remediation, an
intervention designed to address both cognitive and func-
tional deficits (Martínez-Arán et al. 2011), found no ef-
fects of this intervention on cognitive functioning among
individuals with bipolar disorder (Torrent et al. 2013).
Despite the apparent benefits of CR for individuals
with serious mental illnesses, this intervention does not
appear to completely ameliorate the cognitive deficits
that accompany these illnesses. Consequently, there is
growing interest in the use of pharmacological cognitive
enhancers to increase the benefits of CR (Goff et al.
2011; Krystal et al. 2009; Chou et al. 2012). In such
models, cognitive enhancers are not thought to promote
improved cognition by themselves; rather they are hy-
pothesized to augment the physiological mechanism(s)
through which CR produces its therapeutic benefits (e.g.,
learning (Hofmann et al. 2011) or neuroplasticity (Cain
et al. 2014)) One such promising cognitive enhancer is
d-cycloserine (DCS)—a partial or full agonist of NMDA
receptors (depending on the subunit composition of the
receptor (Dravid et al. 2010)) that may facilitate the
learning process for emotional and non-emotional infor-
mation through the promotion of long-term potentiation
(Assini et al. 2009; Lelong et al. 2001; Onur et al. 2010;
Ressler et al. 2004). Of note, dysfunction in glutamate
transmission, which is regulated in part by NMDA re-
ceptors, has been hypothesized to contribute to the
cognitive dysfunction that accompanies bipolar disorder
(Goldberg & Roy Chengappa 2009).
To date, several controlled trials have found that DCS
augmentation can enhance the therapeutic benefits of
learning-based psychosocial interventions for anxiety
disorders (Norberg et al. 2008; Bontempo et al. 2012).
However, we are unaware of any study that specifically
examines the benefits of pairing DCS with CR for indi-
viduals with bipolar disorder. One recently completed
trial examined whether a weekly dose of 50 mg DCS en-
hanced the benefits of CR among individuals with
schizophrenia (Cain et al. 2014). This study found that
subjects who received both DCS and cognitive remedi-
ation showed greater improvements in performance on
an auditory discrimination task as compared to subjects
who received cognitive remediation alone. Conversely,
only subjects who received cognitive remediation alone
experienced improvements in global cognition as mea-
sured using the composite score for the MATRICS
Consensus Cognitive Battery (MCCB: (Nuechterlein
et al. 2008)). Subjects who received both cognitive re-
mediation and DCS showed no improvement in the
composite or specific cognitive domain scores for the
MCCB.
Thus, the goal of this study is to complete a controlled
trial of CR and DCS among individuals with bipolar
disorder. Of note, unlike the previous negative trial of
cognitive remediation and DCS in schizophrenia (Cain
et al. 2014), our study included a higher dose of DCS
(250 mg two times per week versus 50 mg one time per
week) and a longer (52 sessions over 26 weeks versus
24–40 sessions over 8 weeks) and more intensive cogni-
tive remediation training program. The results of this
study may ultimately inform the provision of care for
the cognitive deficits that accompany bipolar disorder.
Methods/Design
The methods/design of this study are described below
and are summarized in Figure 1. This project was ap-
proved by the University of Arizona Human Subjects
Protection Program and is registered with ClinicalTrials.
gov (NCT01934972).
Participants
Approximately, forty individuals with bipolar disorder
will be recruited to participate in this study. Eligibility
criteria include (i) diagnosis of Bipolar I or Bipolar II
disorder as determined per the Structured Clinical
Interview for the DSM-IV (First et al. 2002); (ii) ages
18–65; (iii) premorbid IQ greater than or equal to 70 as
estimated by the reading subtest of the Wide Range
Achievement Test (Wilkinson & Robertson 2006); (iv)
ability to provide informed consent; (v) fluency in English
per self-report from the participant; (vi) current remission
of depressive symptomatology as indicated by a score of 8
or less on the Bipolar Depression Rating Scale (Berk et al.
2007); (vii) current remission of manic symptoms as indi-
cated by a score of 7 or less on the Young Mania Scale
(Young et al. 1978); and (vii) agreement to use at least one
form of birth control during study participation. Exclusion
criteria included: (i) hypersensitivity to previous receipt of
d-cycloserine per participant report; (ii) epilepsy or history
of seizures; (iii) meeting DSM-IV criteria for alcohol or
drug abuse in the past month or dependence in the past
three months; (iv) active suicidal or homicidal ideation;
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(v) initiation or increase in dosage of any antidepressant
within six weeks or mood stabilizer within four weeks;
(vi) previous or current participation in cognitive remedi-
ation; (vii) current use of d-cycloserine; (viii) reduced
kidney or liver functioning, B12 deficiency, folic acid defi-
ciency, megaloblastic anemia; or sideroblastic anemia;
(ix) current use of any medication known to have prob-
lematic interactions with d-cycloserine, including etio-
namide and isoniazid; (x) history of the blood disease
porphyria; (xi) current active symptoms of psychosis
defined as not meeting remission criteria for psychotic
symptoms (Andreasen et al. 2005) using the Positive and
Negative Syndrome Scale (Kay et al. 1987); (xii) evidence
of dementia or other organic impairment that may reduce
cognitive functioning; and (xiii) breastfeeding or preg-
nancy in female participants.
Interventions
Cognitive remediation
For the current study, we will provide participants meta-
cognitive remediation (MCR: (Breitborde et al. 2014)).
As part of MCR, participants complete computerized
cognitive training activities that are included in the program
PSSCogRehab (Bracy 1995)–a computerized cognitive
training program frequently used in past studies of cog-
nitive remediation in serious mental illness (Kurtz et al.
2007; Greig et al. 2007; Bell et al. 2001; Fiszdon et al.
2004; Fiszdon et al. 2005; Fiszdon et al. 2006; Hogarty
et al. 2004; Eack et al. 2009; Eack et al. 2007; Breitborde
et al. 2011). This program provides participants with
training in 4 areas of cognitive functioning: attention,
visual-spatial abilities, memory, and problem-solving
abilities. Participants initially complete simple training
tasks in each domain and, once mastered, gradually
progress to more difficult tasks.
After each PSSCogRehab task, participants complete a
“metacognitive discussion” with a therapist designed to
increase participants’ metacognitive skills. Outside of the
psychiatric literature, improvements in metacognitive
skills have been shown to facilitate improvements in
cognitive performance and successful transfer of this
knowledge across domains of functioning (Salomon &
Perkins 1989; Perkins & Salomon 1994; Veenman et al.
2006; Schraw 1998).
Drawing on seminal work by Schraw and colleagues
(Schraw 1998; Schraw & Dennison 1994; Schraw &
Figure 1 Participant flow and study design.
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Moshman 1995; Schraw et al. 2006), we conceptualize meta-
cognition as comprised of two components: (i) knowledge
about cognition and (ii) regulation of cognition. Know-
ledge about cognition refers to the ability to reflect on
cognition and learning, whereas regulation of cognition
refers to being able to control and regulate aspects of
cognition and learning. During the metacognitive dis-
cussion, the therapist and participant review the partici-
pants’ (i) knowledge about cognition and (ii) regulation
of cognition during the completion of PSSCogRehab
task. With regard to the former, this discussion may in-
clude evaluating the pros and cons of different strat-
egies to successfully complete a PSSCogRehab task.
With regard to the latter, this discussion may include
identifying strategies that individuals could use to re-
duce the negative effect of defeatist beliefs on their cog-
nitive performance. At the end of the metacognitive
discussion, the therapist and participant explore the
possible “real-world” application of the metacognitive
skills utilized in completing the PSSCogRehab activities.
For example, the therapist and participant may (i) identify
“real-world” situations where defeatist beliefs also reduce
the participant’s cognitive performance and (ii) explore
whether the participant could utilize the same strategies
to cope with defeatist beliefs identified and practiced dur-
ing the MCR session in these “real world” situations.
For the current study, participants will complete two,
one-hour cognitive remediation sessions per week for
6 months (i.e., 26 weeks; 52 visits). In a previous study
of MCR among individuals with first-episode psychosis
(Breitborde et al. 2014), we found that individuals who
received this dosage of MCR experienced greater cognitive
and functional improvements (e.g., increased educational/
occupational functioning) than individuals who completed
only the PSSCogRehab computer activities (i.e., no meta-
cognitive discussion).
d-Cycloserine vs. Placebo
Following
the
baseline
evaluation,
participants
will
present for twice weekly sessions where they will receive
CR. Upon arrival at each visit, participants will be pro-
vided with a 250 mg capsule of d-cycloserine or placebo
to ingest. To reduce the time needed for plasma levels of
d-cycloserine to reach their peak concentration, partici-
pants will be asked not to eat any food for 12 hours
prior to each visit (Zhu et al. 2001). Participants will also
be required to wait one hour after ingesting the capsule
to allow for the d-cycloserine to reach peak plasma
levels (Zhu et al. 2001). After this one-hour period,
participants will complete of one hour of CR.
Randomization and treatment allocation
Treatment allocation of this study is depicted in Figure 1.
Upon enrollment in the study, participants will be
randomized using a 1:1 ratio to one of two study arms:
(i) CR + DCS or (ii) CR + placebo. Randomization will be
completed using a block randomization procedure with
blocks of varying size. Both participants and study
personnel will be blind with regard to participant assign-
ment to either DCS or pharmacological placebo.
Assessment battery
All participants will complete a number of assessments
during study completion. Although the majority of mea-
sures will be completed twice over the course of the
study (i.e., baseline and 6-month follow-up), certain
measures will be administered on a more frequent basis.
Study measures and administration schedule are sum-
marized below and in Figure 1.
All assessors will complete a training program prior to
administering study-related assessments. For assessments
that require clinical judgment (e.g., symptom severity
measures), assessors will rate a series of training videos
prior to administration of these measures. Assessors will
be required to reach specific reliability criteria (e.g., intra-
class correlation ≥0.75 for ratings of continuous variables)
as compared to expert ratings of these training videos.
Primary outcome measure: change in global cognitive
functioning
Cognitive functioning among study participants will
be assessed at baseline and 6-month follow-up using
the MATRICS Consensus Cognitive Battery (MCCB:
(Nuechterlein et al. 2008)). For this study, the primary
outcome measure will be change in the MCCB global
cognition composite score from the baseline to 6-month
assessment.
Secondary outcome measures
Cognitive functioning: change in specific cognitive domains
The MCCB will also be used to assess change in specific
domains of cognitive functioning among study partici-
pants. The MCCB measures seven specific domains of
cognitive functioning: (i) processing speed; (ii) attention/
vigilance; (iii) working memory; (iv) visual learning;
(v) verbal learning; (vi) reasoning/problem-solving; and
(vii) social cognition. Per existing recommendations
(Yatham et al. 2010), the MCCB will be supplemented
with the following measures to increase the appropri-
ateness of this assessment battery to the specific cogni-
tive deficits common among individuals with bipolar
disorder: (i) California Verbal Learning Test (CVLT:
(Ressler et al. 2004)); (ii) Stroop Test (Stroop 1935); (iii)
Trail Making Test-Part B (Reitan & Wolfson 1985); and
(iv) Wisconsin Card Sorting Test (WCST: (Heaton et al.
1993)). Finally, participants will also complete the
Cognitive Neuroscience Test Reliability and Clinical
Applications for Schizophrenia battery (CNTRACS:
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(Barch et al. 2012; Henderson et al. 2012; Ragland
et al. 2012; Silverstein et al. 2012)) at both the baseline
and 6-month assessment.
Cognitive functioning: rate of improvement
Recent evidence raises the possibility that DCS may not
increase the benefit received from participation in psy-
chosocial interventions, but instead may help individuals
achieve this benefit more quickly (Siegmund et al. 2011;
Kushner et al. 2007; Wilhelm et al. 2008; Chasson et al.
2010). Thus, to assess the rate of improvement in cogni-
tive functioning, participants will complete the Repeat-
able Battery for the Assessment of Neuropsychological
Status (RBANS: (Randolph 1998)). This brief assessment
battery measures five domains of cognitive functioning:
(i) immediate memory; (ii) visuospatial and construc-
tional skills; (iii) language; (iv) attention; and (v) delayed
memory. With four alternative forms, the RBANS is de-
signed specifically to reduce the practice effect associated
with multiple administrations of a neuropsychological test.
This assessment battery will be administered at baseline,
Week 5, Week 14, and 6-month follow-up.
Cognitive functioning: subjective assessment
The Measure of Insight into Cognition-Self Report
(MIC-SR: (Medalia et al. 2008)) is a 12 item questionnaire
designed to assess self-perception of cognitive abilities.
This measure assesses subjective perceptions of three do-
mains of cognitive functioning: (i) attention; (ii) memory;
and (iii) executive functioning. Although a clinician-rated
version of Measure of Insight into Cognition (MIC-CR:
(Medalia & Thysen 2008)) is available, we opted not to
include this measure as it assesses individuals’ aware-
ness of their cognitive deficits as opposed to their subject-
ive perception of the severity of their cognitive deficits
(Saperstein et al. 2012).
Medication use, adherence, and side effects
Several psychiatric medications commonly used in the
treatment of bipolar disorder may influence glutamate
signaling (e.g., lamotrigine and lithium (Sitges et al. 2007;
Dixon & Hokin 1998)). As such, medication use among
study participants will be tracked using a semi-structured
assessment used in past studies of cardiovascular func-
tioning in first-episode psychosis (Srihari et al. 2013;
Phutane et al. 2011). Adherence to prescribed psychi-
atric medication not including DCS will be assessed at
baseline and 6-month follow-up using the Medication
Adherence Rating Scale (MARS: (Thompson et al.
2000)). The Systematic Assessment For Treatment
Emergent Events (SAFTEE: (Levine & Schooler 1986))
will be administered at each cognitive remediation visit
to assess for side-effects associated with DCS.
Metacognition
The Metacognitive Awareness Inventory (MAI: (Schraw
& Dennison 1994)) is 52-item questionnaire designed to
measure metacognitive abilities (i.e., the ability to evalu-
ate, regulate, and understand learning and cognitive
skills). The MAI is designed to assess the two domains
of functioning hypothesized to comprise metacognitive
abilities: (i) knowledge about cognition and (ii) regula-
tion of cognition (Brown 1987; Flavell 1987). Knowledge
about cognition refers to the ability to reflect on cogni-
tion and learning, whereas regulation of cognition refers
to being able to control and regulate aspects of cognition
and learning.
Personality traits
The Ten Item Personality Inventory (TIPI: (Gosling et al.
2003)) will be used to assess the Big Five Personality Traits
among study participants: extraversion, agreeableness,
conscientiousness, emotional stability, and openness to
experience. This measure has been shown to have good
discriminant and convergent validity when compared to
other longer assessments of the Big Five Personality Traits
(e.g., NEO Personality Inventory (Costa 1992)).
Quality of life
Participants’ quality of life will be assessed using the
WHO Brief Quality of Life scale (WHOQOL-BREF:
(Group 1998)). This 26-item self-report measure as-
sesses four domains of quality of life: (i) physical health;
(ii) psychological health; (iii) social relationships; and
(iv) quality of the environment. Additionally, all partici-
pants will complete a more specific measure of health-
related quality of life (i.e., the RAND 36-Item Health
Survey: (Hays et al. 1998)). This questionnaire measures
8 domains of health-related quality of life: (i) physical
functioning; (ii) pain; (iii) role limitations due to phys-
ical health; (iv) role limitations due to emotional health;
(v) energy and fatigue; (vi) social functioning; (vii) emo-
tional well-being; and (viii) general health.
Real world functioning
The University of California, San Diego, Performance-
Based
Skills
Assessment-Brief
(UPSA-B:
(Mausbach
et al. 2007)) will be used to assess real world functioning
among study participants (i.e., communication and fi-
nancial skills). This measure is highly correlated with the
full UPSA (r = 0.91) and predicts residential independ-
ence among individuals with severe mental illnesses
(Mausbach et al. 2007).
Recovery
Participants’ stage of recovery in bipolar disorder will be
assessed
using
the
Stages
of
Recovery
Instrument
(STORI: (Andresen et al. 2006)). Drawing on Andresen
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and colleagues’ model of recovery in severe mental illness
(Andresen et al. 2003), this 50-item questionnaire assigns
individuals to one of five stages of recovery: (i) morator-
ium (i.e., a period of loss and hopelessness); (ii) awareness
(i.e., recognition that one can achieve a fulfilling life and
positive sense of self); (iii) preparation (i.e., developing
skills needed to achieve desired fulfilling life and positive
sense of self); (iv) rebuilding (i.e., actively working to
achieve fulfilling life and positive sense of self); and
(v) growth (i.e., maintaining a fulfilling life and posi-
tive sense of self).
Social functioning
The Social Functioning Scale (SFS: (Birchwood et al.
1990)) will be used to measure level of social functioning
among study participants. The SFS is a 79-item instru-
ment that assesses seven areas of functioning: (i) social
engagement/withdrawal; (ii) interpersonal behavior/
communication; (iii) participation in prosocial activities;
(iv) participation in recreational activities; (v) independence
competence (i.e., ability to perform tasks of independent
living); (vi) independence performance (i.e., completion
of tasks of independent living); and (vii) educational/
vocational functioning.
Service utilization
Participants’ use of healthcare services will be assessed
using the Service Use and Resource Form (SURF:
(Rosenheck et al. 2003)). This clinician-administered
measure assesses the frequency of participants’ use of
inpatient and outpatient psychiatric and medical ser-
vices over the past six months. The SURF also tracks
participants’ level of contact with the legal system, in-
surance status, and financial resources.
Symptomatology
Severity of bipolar symptomatology will be assessed at
each CR visit using both clinician-administered and
self-report scales. Clinician-administered scales include
the Inventory of Depressive Symptomatology (Rush
et al. 2006), Bipolar Depression Rating Scale (Berk et al.
2007), and Young Mania Scale (Young et al. 1978).
Self-report scales include the Inventory of Depressive
Symptomatology Self-Report Scale (Rush et al. 2006) and
the Altman Self-Rating Mania Scale (Altman et al. 1997).
Treatment motivation and therapeutic alliance for
CR/Active control condition
Following the completion of each cognitive remediation
or active control visit, participants will complete the
Intrinsic Motivation Inventory (Choi et al. 2010) and the
Session Rating Scale (Duncan et al. 2003) to assess their
motivation to participate in CR and their alliance with
the clinician delivering the intervention, respectively.
Proposed analyses
Prior to the analyses, data will be screened for outliers
and departures from a normal distribution. Data analyses
will be completed using an “intention-to-treat” principle
(Montori & Guyatt 2001). Consequently, data from all
participants will be included in the analyses regardless of
their level of participation in study interventions over
the course of the project. Per existing statistical guidelines
(Collins et al. 2001; Graham 2009), missing data will be es-
timated using multiple imputation (Rubin 1987).
The interaction between time (i.e., baseline vs. 6-month)
and treatment condition (DCS vs. placebo) on our primary
outcome variable (MCCB composite cognition score) will
be assessed using a repeated measures ANOVA. An a
priori estimate of statistical power was completed using
G*Power 3.1 (Faul et al. 2009). Assuming a correlation
greater than or equal to 0.40 between baseline and six
month MCCB composite cognition scores and a medium
effect size (i.e., f = 0.25), the power to detect a statistically
significant interaction between time and treatment condi-
tion (i.e., cycloserine/placebo) is greater than or equal to
0.80. Should we find a statistically significant time X treat-
ment condition interaction, post-hoc probing of the inter-
action will be completed using t-tests with Bonferroni
corrections to maintain an alpha of 0.05.
Discussion
Cognitive deficits are a rate-limiting factor in functional
recovery
among
individuals
with
bipolar
disorder
(Bearden et al. 2011; Baune et al. 2013; Dickerson
et al. 2004). Unfortunately, treatment options for these
deficits are limited. The results of the proposed study
may reveal a valuable intervention strategy (i.e., CR
with concurrent DCS) to improve cognitive functioning
among individuals with bipolar disorder. Ultimately, this
treatment strategy may prove useful in addressing the cog-
nitive deficits that are ubiquitous across serious mental
illnesses.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
Study concept and design: NJKB; Drafting of the manuscript: NJKB; Critical
Revision of the manuscript: SCD, CW, AP, DD, EB, KN, MD, FG, PM, BB, CP, ES,
CM, BN, and FAM. All authors approved the final version of this manuscript.
Acknowledgments
This project is supported by funds from the Linda Peterson Family to NJKB.
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Author details
1Department of Psychiatry, The University of Arizona, Tucson, AZ, USA.
2Department of Psychology, The University of Arizona, Tucson, AZ, USA.
Received: 19 February 2014 Accepted: 30 September 2014
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doi:10.1186/s40359-014-0041-4
Cite this article as: Breitborde et al.: A randomized controlled trial of
cognitive remediation and d-cycloserine for individuals with bipolar
disorder. BMC Psychology 2014 2:41.
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