Cognitive enhancement therapy for mood disorders: A new paradigm?

At a recent conference in New York City, problems with the term ‘Cognitive Remediation’ were discussed, including its assumed focus on cognitive deficit, particularly in mood disorders. Cognitive Remediation intervention trials presented at the conference often focused strongly on enhancing patient’s cognitive strengths, and thus, there was a consensus that a name change would be beneficial for this area and may translate to better understanding for clinicians and patients receiving the treatment. Concerns about the term ‘Cognitive Remediation’ may be particularly important when related to mood disorders. Cognitive Remediation for mood disorders has sometimes been conceptualised as an adaptation from Cognitive Remediation for schizophrenia. However, there are important differences related to the usual magnitude of deficits, the likely plasticity of deficits and the importance of subjective deficit which is likely to be a considerably more important factor in mood disorders. The use of the same term, ‘Cognitive Remediation’, as for the treatment in schizophrenia may therefore be problematic. Research has now established that cognitive impairment is a core feature of mood disorders, and that impairment persists after clinical recovery has occurred. Cognitive impairment is strongly associated with day-to-day functioning, including in occupational and interpersonal areas, and thus, impacts greatly on individuals’ recovery. However, it is also recognised that many patients do not have objectively defined cognitive deficit (Douglas et al., 2018). Furthermore, it is not only objective deficit but also the subjective perception of cognitive problems which may interfere with functioning and full recovery. Despite the strength of these findings, knowledge of and motivation to address cognitive difficulties does not appear to have been translated into substantial change in clinical practice. As clinicians, we find we are often trying to motivate clinicians and therapists to recognise the importance of targeting cognitive function as part of a more comprehensive approach to enhancing overall recovery from mood disorders but are hampered by the lack of understanding of what approaches can be used. Part of the difficulty in helping clinicians and mental health providers to understand the importance of targeting cognitive function in mood disorder recovery may be that the term ‘Cognitive Remediation’ or ‘Cognitive Rehabilitation’ has developed from separate health populations, including schizophrenia and traumatic brain injury (TBI). In TBI literature, Cognitive Remediation refers to ‘a systematically applied set of medical and therapeutic services to improve cognitive functioning’ and may involve dietary, pharmacological or surgical approaches, as well as cognitive training (Cernich et al., 2010). Rather than serving to remedy or reverse damage, as the term remediation implies, Cognitive Remediation interventions in mood disorders aim to focus on areas of weaknesses and strengths to improve cognitive and functional recovery, even in individuals who may not, objectively speaking, have observable cognitive impairment. We therefore suggest a three pronged approach to the education of both patients and professionals regarding this problem. First, there should be continuing education regarding the importance of cognitive function and difficulties regarding this – both subjective and objective. Second, there should be an attempt to educate regarding what ‘Cognitive Remediation’ in mood disorders entails. Third, we suggest a change in the term ‘Cognitive Remediation’ for the sorts of treatments which are being proposed in mood disorders. We suggest instead the use of the term Cognitive Enhancement Therapy for Mood Disorders* or CET-MD, which we will justify below. Cognitive enhancement therapy for mood disorders: A new paradigm?