June 10, 2020

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By Kelly Allott

Cognition refers to our thinking skills or the mental processes we use to perceive, understand, learn and function in the world around us. Cognition includes a number of thinking skills, including our ability to concentrate or focus, process and understand information, learn and remember information, use language and solve problems. Cognition helps us to plan and execute everything we do. Cognition is critically important for enabling us to achieve our daily, short-term, and long-term goals.

We all experience problems with our cognitive functioning from time to time. For example, when we have not had enough sleep, when we are feeling stressed or have consumed food or substances that dampen or cloud our thinking. Having a mental illness, however, significantly increases the chances of experiencing cognitive difficulties. A wealth of research shows that young people who have a mental illness are more likely to experience cognitive impairments than young people without a mental illness. Impairments in all aspects of cognitive functioning have been found, including in concentration, information processing, learning and memory and executive functions such as planning and problem solving. Cognitive impairments can precede the symptoms of mental illness. For example, research shows that cognitive impairments in childhood or early adolescence, significantly increase a person’s risk for later developing mental illness 1 . Cognitive impairments can also be a symptom of mental illness, for example, concentration difficulties are a common symptom of depression and anxiety. More severe, widespread and persistent cognitive impairments tend to be seen in psychotic disorders, but cognitive difficulties can be observed in all mental illnesses, including bipolar disorder, major depressive disorder, eating disorders and anxiety disorders. They are also associated with having experienced childhood or other trauma and substance use. Accordingly, recent commentary has argued that cognitive impairment is a transdiagnostic feature of psychopathology 2.

Mental health clinicians in Australian primary youth mental health services (headspace) have estimated that well over a third of young people presenting for care have clinically concerning cognitive impairments 3. Within specialist mental health services, we know rates of cognitive impairment are even higher. Young people have reported through qualitative studies that when experienced, cognitive impairments are distressing, and they impair functioning at school and work, in relationships, and in activities of daily living 4,5. These subjective accounts are supported by a wealth of quantitative studies. Recognition of the prevalent, pervasive and negative role that cognitive impairment can play in mental health conditions has led to strong international agreement among experts and clinicians that cognitive assessment and treatment is a critical component of effective mental health care 2,6. For example, there are published guidelines on cognitive assessment and treatment from expert consensus groups such as the International Society for Bipolar Disorders and the Royal Australian and New Zealand College of Psychiatrists.

Despite the demonstrated importance of cognitive functioning in the assessment and early intervention of mental health, clinical practice has lagged behind. Indeed, clinicians and young people have reported that assessment and intervention for cognition is an essential, but unmet need in current services 3,5,7. In order to move the field forward it is important that we (researchers) engage with service users, families, health providers and service managers to better understand the needs, barriers and facilitators of cognition being a domain of function that is routinely part of mental health care. There are numerous evidence-based and novel approaches for addressing or enhancing cognitive functioning, including biochemical (pharmaceutical, nutrition), behavioural (cognitive training, exercise), and physical (electrical stimulation) 8. We have also recently advocated for harnessing cognitive strengths in helping young people recover from severe mental illness 9. Nevertheless, we need to better understand how these different approaches to addressing cognition in early intervention are viewed by service users, families and health providers and their relative cost-benefit profiles. In today’s era of resource-limited health care, it is becoming increasingly important to demonstrate not only the acceptability and effectiveness, but also the economic value of interventions for cognitive impairment.

1.         Zammit S, Allebeck P, David AS, Dalman C, Hemmingsson T, Lundberg I, et al. A longitudinal study of premorbid IQ score and risk of developing schizophrenia, bipolar disorder, severe depression, and other nonaffective psychoses. Archives of General Psychiatry. 2004;61(4):354-60.

2.         McIntyre RS, Anderson N, Baune BT, Brietzke E, Burdick K, Fossati P, et al. Expert Consensus on Screening and Assessment of Cognition in Psychiatry. CNS Spectrums. 2019;24(1):154-62.

3.         Allott K, van-der-EL K, Bryce S, Hamilton M, Adams S, Burgat L, et al. Need for clinical neuropsychological assessment in headspace youth mental health services: A national survey of providers. Australian Journal of Psychology. 2019;71(2):108-16.

4.         Wright AL, Phillips LJ, Bryce S, Morey-Nase C, Allott K. Subjective experiences of cognitive functioning in early psychosis: a qualitative study. Psychosis. 2019;11(1):63-74.

5.         Morey-Nase C, Phillips LJ, Bryce S, Hetrick S, Wright AL, Caruana E, et al. Subjective experiences of neurocognitive functioning in young people with major depression. BMC Psychiatry. 2019;19(1):209.

6.         Bryce S, Allott K. Cognitive screening: A significant unmet need in youth mental health. Australian And New Zealand Journal Of Psychiatry. 2019;53(8):813.

7.         Saperstein AM, Medalia A, Bello I, Dixon LB. Addressing cognitive health in coordinated specialty care for early psychosis: Real-world perspectives. Early Intervention in Psychiatry. 2020.

8.         Dresler M, Sandberg A, Bublitz C, Ohla K, Trenado C, Mroczko-Wasowicz A, et al. Hacking the Brain: Dimensions of Cognitive Enhancement. ACS chemical neuroscience. 2019;10(3):1137-48.

9.         Allott K, Steele P, Boyer F, de Winter A, Bryce S, Alvarez-Jimenez M, et al. Cognitive strengths-based assessment and intervention in first-episode psychosis: A complementary approach to addressing functional recovery? Clinical Psychology Review. 2020;79:101871.