Risk and resilience for cognitive impairment in bipolar disorder: toward a personalised approach

Cognitive impairment is a central characteristic of bipolar disorder, affecting an estimated 30–60% of individuals diagnosed with this condition. Cognitive dysfunction encompasses deficits across multiple domains, including attention, verbal memory, processing speed, and executive functions. Such impairments can contribute to a less favourable disease trajectory and prognosis, as well as challenges in achieving functional recovery. Heterogeneity in cognitive outcomes is the norm, with some patients exhibiting a relatively preserved profile, others experiencing deficits in specific domains, and still others demonstrating widespread impairment across all cognitive functions. Due to this variability, adopting more personalised treatment strategies is crucial. These should not only address factors linked to cognitive decline—such as number of previous episodes, comorbidities, psychotic symptoms…—or provide compensatory interventions once difficulties have emerged, such as functional remediation, but also prioritise prevention and resilience. Preventive measures might include psychoeducation programmes, promoting healthy lifestyles and enhancing cognitive reserve. Achieving tailored therapies requires systematic assessments of neurocognition and functional outcomes from the outset, repeated regularly to identify both risk and resilience factors and design specific interventions: functional remediation for some, pharmacological adjustments for others, or enhancement of cognitive reserve in another subset of patients. For certain patients, cognitive impairment can be prevented; for others, it may be unavoidable. Our responsibility is to identify patients early and accurately to prevent cognitive decline where possible, and to offer the best available compensatory and rehabilitative strategies where prevention falls short.