Cognitive Behavioural Therapy as an Adjunct to Pharmacotherapy in Bipolar Disorder: A Systematic Review of Treatment Outcomes and Relapse Prevention

Adeline C Phelps; Hendsun Hendsun; Ernawati Ernawati

doi:10.28932/jmh.v8i2.13114

Authors

Adeline C Phelps Fakultas Kedokteran, Universitas Tarumanagara, Jakarta, Indonesia
Hendsun Hendsun International Education College, Zhejiang Chinese Medical University, Hangzhou, China
Ernawati Ernawati Fakultas Kedokteran, Universitas Tarumanagara, Jakarta, Indonesia

DOI:

https://doi.org/10.28932/jmh.v8i2.13114

Keywords:

bipolar, disorder, CBT, conventional, therapy

Abstract

Bipolar disorder is a chronic psychiatric condition characterized by recurrent mood episodes and significant functional impairment. Although pharmacotherapy remains the primary treatment, relapse rates remain high, highlighting the need for effective adjunctive interventions. This study aimed to synthesize evidence on the effectiveness of Cognitive Behavioural Therapy (CBT) as an adjunct to pharmacotherapy in improving treatment outcomes and preventing relapse in bipolar disorder. A literature review was conducted using PubMed, Scopus, and ScienceDirect, identifying 30 eligible studies published between 2013 and 2023. Most included studies employed randomized controlled trials and quasi-experimental designs. Of the 30 studies, 22 reported statistically significant improvements (p < 0.05) in patients receiving CBT in addition to pharmacotherapy. Synthesized findings indicate that CBT contributes to reductions in depressive symptoms, improved cognitive and psychosocial functioning, and enhanced emotional regulation. Several studies also demonstrated neurobiological changes, particularly in prefrontal and limbic connectivity. Studies with structured CBT protocols (8–20 sessions) and adequate duration showed more consistent benefits. However, variability in outcomes was observed due to differences in study design, sample size, and intervention protocols. Overall, CBT appears to be an effective adjunctive therapy in bipolar disorder, particularly when delivered in a structured and sustained manner.

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References

American Psychiatric Association. What are bipolar disorders? 2024 [Cited 2024 Aug 22]. Available from: https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders.

Carvalho AF, Firth J, Vieta E. Bipolar disorder. N Engl J Med. 2020; 383(1):58–66.

McIntyre RS, Berk M, Brietzke E, Goldstein BI, López-Jaramillo C, Kessing LV, et al. Bipolar disorders. Lancet. 2020; 396(10265):1841–56.

Hett D, Morales-Muñoz I, Durdurak BB, Carlish M, Marwaha S. Rates and associations of relapse over 5 years of 2649 people with bipolar disorder: a retrospective UK cohort study. Int J Bipolar Disord. 2023; 11(1):23.

Özdel K, Kart A, Türkçapar MH. Cognitive Behavioral therapy in treatment of bipolar disorder. Noro Psikiyatr Ars. 2021;58(supplement).

Deckersbach T, Peters AT, Shea C, Gosai A, Stange JP, Peckham AD, et al. Memory performance predicts response to psychotherapy for depression in bipolar disorder: A pilot randomized controlled trial with exploratory functional magnetic resonance imaging. J Affect Disord. 2018; 229:342–50.

Chou T, Dougherty DD, Nierenberg AA, Deckersbach T. Restoration of default mode network and task positive network anti-correlation associated with mindfulness-based cognitive therapy for bipolar disorder. Psychiatry Res Neuroimaging. 2022; 319:111419.

Meyer K, Hindi Attar C, Fiebig J, Stamm T, Bassett TR, Bauer M, et al. Daring to feel: Emotion-focused psychotherapy increases amygdala activation and connectivity in euthymic bipolar disorder a randomized controlled trial. Biol Psychiatry Cogn Neurosci Neuroimaging. 2023; 8(7):750–9.

Girelli F, Rossetti MG, Perlini C, Bellani M. Neural correlates of cognitive behavioral therapy-based interventions for bipolar disorder: A scoping review. J Psychiatr Res. 2024; 172:351–9.

Kato T, Baba K, Guo W, Chen Y, Nosaka T. Impact of bipolar disorder on health-related quality of life and work productivity: Estimates from the national health and wellness survey in Japan. J Affect Disord. 2021; 295:203–14.

Rowland TA, Marwaha S. Epidemiology and risk factors for bipolar disorder. Ther Adv Psychopharmacol. 2018; 8(9):251–69.

Jain A, Mitra P. Bipolar disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [Cited 2026 Mar 21]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558998/

Gutierrez G, et al. Online cognitive behavioral therapy for bipolar disorder: A systematic review and network meta-analysis. J Affect Disord. 2023; 331:1–10.

ISBD Task Force. A systematic review of interventions in early bipolar disorder. Int J Bipolar Disord. 2023; 11(1):1–19.

Yilmaz S, Huguet A, Kisely S, Rao S, Wang J, Price M, Morriss R, Inder M, Perich T, Wright K. The clinical efficacy of psychological interventions for bipolar depression: a systematic review and individual patient data (IPD) meta-analysis. Psychol Med. 2025; 55:e154.

Nakao M, Shirotsuki K, Sugaya N. Cognitive behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. Biopsychosoc Med. 2021; 15(1):16 2.

Chiang KJ, Tsai JC, Liu D, Lin CH, Chiu HL, Chou KR. Efficacy of cognitive-behavioral therapy in patients with bipolar disorder: A meta-analysis of randomized controlled trials. Mazza M, editor. PLoS One. 2017; 12(5):e0176849.

Valdivieso-Jiménez G. Efficacy of cognitive behavioural therapy for bipolar disorder: A systematic review. Rev Colomb Psiquiatr (Engl Ed). 2023;5 2(3):213-224.

Razavi MS, Fathi M, Vahednia E, Ardani AR, Honari S, Akbarzadeh F, Talaei A. Cognitive rehabilitation in bipolar spectrum disorder: A systematic review. IBRO Neurosci Rep. 2024;16:509-517.

Watanabe K, Harada E, Inoue T, Tanji Y, Kikuchi T. Perceptions and impact of bipolar disorder in Japan: results of an Internet survey. Neuropsychiatr Dis Treat. 2016; 12:2981–7.

Jain A, Mitra P. Bipolar disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. [Cited 2026 Mar 21]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK558998/

Nakao M, Shirotsuki K, Sugaya N. Cognitive–behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. Biopsychosoc Med. 2021;15(1):16.

Nishi D, Ishikawa H, Kawakami N. Prevalence of mental disorders and mental health service use in Japan. Psychiatry Clin Neurosci. 2019; 73(8):458–65.

Yatham LN, Kennedy SH, Parikh S V, Schaffer A, Bond DJ, Frey BN, et al. Canadian network for mood and anxiety treatments and international society for bipolar disorders 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord. 2018;20(2):97–170.

Pavlova B, Warnock-Parkes E, Alda M, Uher R, Clark DM. Cognitive behavioural therapy for social anxiety disorder in people with bipolar disorder: a case series. Int J Bipolar Disord. 2024; 12(1):1.

Jones BDM, Umer M, Kittur ME, Finkelstein O, Xue S, Dimick MK, Ortiz A, Goldstein BI, Mulsant BH, Husain MI. A systematic review on the effectiveness of dialectical behavior therapy for improving mood symptoms in bipolar disorders. Int J Bipolar Disord. 2023;11(1):6.

Razavi MS, Fathi M, Vahednia E, Ardani AR, Honari S, Akbarzadeh F, Talaei A. Cognitive rehabilitation in bipolar spectrum disorder: A systematic review. IBRO Neurosci Rep. 2024; 16:509-517.

Ramadan S, Tay L, Kaur H, Parrish T, Abdelmoteleb S, Totlani J, et al. Bipolar disorder: Systematic review of approved psychiatric medications (2008-2024) and pipeline Phase-3 medications. J Affect Disord. 2025; 390:119778.

Cuijpers P, Harrer M, Miguel C, Ciharova M, Papola D, Basic D, et al. Cognitive behavior therapy for mental disorders in adults: A unified series of meta-analyses. JAMA Psychiatry. 2025; 82(6):563-71.