CBT for Bipolar Disorder: The Jury Is Still Out

Cognitive-behavioral therapy seems to help only some bipolar patients.

In at least five randomized controlled trials (RCTs), the addition of psychological treatment (usually, cognitive-behavioral therapy) to mood stabilizers improved outcomes and reduced recurrence rates in already remitted bipolar patients without much comorbidity. Now, researchers have examined this issue in a multicenter, pragmatic RCT involving a more representative group of 253 bipolar patients: 40% had other psychiatric diagnoses, 47% had lifetime or current substance abuse, and 32% were in active episodes.

Participants were randomized to receive usual care plus CBT (20 sessions: weekly for 15 weeks, then tapered through week 26) or usual care alone. Usual care included medications; 84% were receiving mood stabilizers at baseline. CBT focused on recognizing symptoms; coping with mood symptoms, stressors, and interpersonal problems; accepting the illness; and adhering to medication. In-person assessments were bimonthly for 18 months.

Recurrence of DSM-IV bipolar disorder occurred in 50% of usual-care patients and in 53% of CBT patients. Mood-severity ratings were also nearly identical in the two groups. Stratified analyses to account for patients in episode at baseline had similar results. In a secondary analysis, patients with fewer than 12 previous episodes did significantly better with CBT than with usual care, but CBT seemed to be less effective in patients with more episodes.

Comment: This study suggests that when other clinical factors are uncontrolled (e.g., psychiatric and substance-use comorbidity, the initiation of active treatment), CBT may not be very effective for patients with many previous episodes. A commentator argues that including patients with active illness might have diluted the effects of CBT. It is unclear whether such patients would receive CBT as an initial therapy in usual practice. More generally, we are reminded that results from studies using highly selected patient samples might not generalize easily to typical psychiatric patients.

— Peter Roy-Byrne, MD

Published in Journal Watch Psychiatry June 7, 2006