Cognitive and occupational functioning in bipolar disorder and ADHD: impact of comorbidity

Bipolar disorder and attention-deficit/hyperactivity disorder (ADHD) share overlapping clinical symptoms and cognitive deficits. Up to 20% of individuals with bipolar disorder also meet the criteria for ADHD (bipolar disorder + ADHD), a subgroup that may experience greater cognitive and functional impairments than those with bipolar disorder or ADHD alone.

To (a) characterise cognitive profiles in bipolar disorder, ADHD and bipolar disorder + ADHD compared with healthy controls; (b) examine associations between cognitive and occupational functioning; and (c) investigate associations between cognitive function and polygenic scores (PGS) for bipolar disorder, ADHD and educational attainment.

In this observational study, 477 euthymic individuals with bipolar disorder (including 78 with bipolar disorder + ADHD), 59 adult individuals with ADHD and 171 healthy controls completed standardised neuropsychological testing. Full-scale IQ and final school grades indexed current and premorbid cognitive ability, respectively. Occupational functioning was evaluated both cross-sectionally and through 5 years of registry-based follow-up. PGS were available for 295 bipolar disorder and 132 healthy control participants.

All patient groups performed significantly below healthy controls across most cognitive domains. Bipolar disorder + ADHD exhibited poorer working memory than bipolar disorder (d = -0.35, 95% CI [-0.66, -0.03]). Occupational function was lowest in bipolar disorder + ADHD (versus bipolar disorder, d = -0.44, 95% CI [-0.69, -0.19]). In bipolar disorder, poorer executive function (standardised regression coefficient (_standβ) = 0.20, 95% CI [0.09, 0.31]) and older age predicted reduced occupational outcomes. PGS for educational attainment was associated positively with cognition in both bipolar disorder (working memory: _standβ = 0.19, 95% CI [0.08, 0.30]) and healthy controls (executive function: _standβ = 0.20, 95% CI [0.09, 0.32]), while PGS for bipolar disorder or ADHD were not significantly associated with cognitive performance.

Individuals with bipolar disorder + ADHD showed disproportionate working memory and functional impairment compared with bipolar disorder or ADHD alone. Executive function is a key predictor of occupational outcomes in bipolar disorder and is partly shaped by genetic propensity for educational attainment. These findings highlight the importance of considering ADHD comorbidity and cognitive profiles when evaluating functional prognosis and tailoring interventions.