Psychosocial Treatments for Adolescents With Bipolar Disorder

While pharmacotherapy is the first-line of treatment in bipolar spectrum disorders (BPSD), psychotherapy trials for youth with bipolar disorder are increasing. A recent review I am a co-author on reported on 13 unique studies (in press). Since then, three additional randomized, controlled trials (RCT) have been published and one RCT has just been completed, further strengthening the evidence base.

In a study of 23 children aged between 7 and 14 with bipolar disorder — not otherwise specified or cyclothymic disorder — my colleagues and I tested the impact of omega-3 fatty acids (Ω3) and individual-family psychoeducational psychotherapy (IF-PEP) alone and in combination against placebo and active monitoring (presentation Oct. 22 at AACAP Annual Meeting). We  found that combining Ω3 and IF-PEP was superior to no treatment in decreasing mood symptoms across their 12-week trial.

A recent study tested 20 adolescents aged between 12 and 18 with BPSD using dialectical behavior therapy (DBT) or psychosocial treatment as usual (TAU) in a one-year trial.1 Youth received up to 36 DBT sessions (half individual, half family skills training) or a variable number of TAU sessions (consisting of psychoeducational, cognitive-behavioral and supportive techniques). 

Both DBT and TAU were positively evaluated by teens and their parents. However, those assigned to DBT attended more sessions. At follow-up, youths who had received DBT had less severe depressive symptoms, demonstrated a near three-fold decrease in suicidal ideation, and were more likely to be euthymic throughout the year compared to those receiving TAU.

A 2009 RCT examined young adults at high risk for psychosis.2 Participants (N=129) received either 18 sessions of Family Focused Treatment for clinical high risk (FFT-CHR) or enhanced care (three sessions of family psychoeducation focused on symptom prevention). Of the 79% of participants available at 6-month follow-up, those who received FFT-CHR had fewer attenuated positive symptoms. Some age differences in treatment response were noted. Improvement in role functioning was better for teens aged between 16 and 19 who received EC and for those over age 19 who received FFT-CHR. Conversion to psychosis was higher in those receiving EC (adjusted odds ratio = 4.7).

West and colleagues compared child- and family-focused cognitive-behavioral therapy (CFF-CBT) to TAU in 69 children aged 7 to 13 diagnosed with BPSD.3 Both treatment conditions included 12 weekly sessions and then six monthly booster sessions over a nine-month interval. Children who received CFF-CBT had fewer mood symptoms immediately after weekly treatment ended as well as at the end of the booster phase.

Results from these four studies corroborate results from a recent review of 13 clinical trials. We now know that psychoeducation plus family skill building is probably efficacious.4 Possibly efficacious treatments include dialectical behavior therapy and family-based cognitive behavior therapy.5 An experimental treatment is interpersonal and social rhythm therapy. Effectiveness trials suggest family psychoeducation plus skill building have excellent acceptability and sustainability in community settings.6

Treatment mediator analyses suggest psychoeducation leads families to improve the quality of services they utilize, mediated by parental treatment beliefs. Improved quality of services utilized mediates improved outcomes.7 Treatment moderators include greater impairment in the child8 and high family expressed emotion.9 Predictors of treatment response include greater impairment and a more stress/trauma history for the child and less Cluster B personality symptoms in parents.

An additional benefit of family psychoeducation plus skill building is a reduction in behavioral symptoms.10 Preliminary evidence suggests family psychoeducation plus skill building might protect at-risk youth from developing BPSD.11 While no dismantling studies have been conducted, therapeutic ingredients that are common across various treatment trials should be utilized. 

More work is needed to test psychotherapies in diverse populations to determine what modifications are appropriate based on differing ages or treatment format (e.g. group or individual/family), mechanisms of change and essential treatment components. However, our current body of knowledge indicates that psychosocial treatments provide clear benefit in the treatment of youth with bipolar spectrum disorders.

Mary A. Fristad, PhD, ABPP, is the Director of Research and Psychological Services in The Ohio State University Division of Child and Adolescent Psychiatry. She will be part of a symposium on psychosocial treatments for youth with bipolar disorder at the American Academy for Child & Adolescent Psychiatry Annual Meeting on October 22.


  1. Goldstein TR, et al. “Dialectical Behavior Therapy (DBT) for Adolescents with Bipolar Disorder: Results from a Pilot Randomized Trial.” J Child Adolesc Psychopharmacol.  2014 Jul 10. [Epub ahead of print]
  2. Miklowitz, DJ, et al. “Expressed emotion moderates the effects of family-focused treatment for bipolar adolescents.” J Am Acad Child Adolesc Psychiatry. 2009;  (48):643-651.
  3. West AE, et al. “Child- and Family-Focused Cognitive-Behavioral Therapy for Pediatric Bipolar Disorder: A Randomized Clinical Trial.” J Amer Acad Child Adol Psychiatr. In press.
  4. MacPherson HA, et al. “Predictors and moderators in the randomized trial of multi-family psychoeducational psychotherapy for childhood mood disorders.” J Clin Child Adolesc Psychol. 2014; 43(3):459-72.
  5. Feeny NC, et al. “Cognitive-behavioral therapy for bipolar disorders in adolescents: A pilot study.” Bipolar Disorders. 2006; 8:508-515.
  6. MacPherson HA, et al. “Implementation of multi-family psychoeducational psychotherapy for childhood mood disorders in an outpatient community setting.” Journal of Marital and Family Therapy. 2013; 40(2): 193–211.
  7. Mendenhall AN, et al. “Factors influencing service utilization and mood symptom severity in children with mood disorders: Effects of multifamily psychoeducation groups (MFPGs).” Journal of Consulting and Clinical Psychology. 2009; 77: 463-473.
  8. MacPherson HA, et al. “Predictors and moderators in the randomized trial of multi-family psychoeducational psychotherapy for childhood mood disorders.” Journal of Clinical Child and Adolescent Psychology. 2014; 43(3):459-72.
  9. Miklowitz DJ, et al. “Early intervention for symptomatic youth at risk for bipolar disorder: A randomized trial of family-focused therapy.” J Am Acad Child Adolesc Psychiatry. 2013; (52); 121-131.
  10. Boylan K, et al. “Examination of disruptive behavior outcomes and moderation in a randomized psychotherapy trial for mood disorders.” J Am Acad Child Adolesc Psychiatry. 2013; 52(7): 699-708.
  11. Nadkarni RB and Fristad MA. “Clinical course of children with a depressive spectrum disorder and transient manic symptoms.” Bipolar Disorders. 2010; 12: 494-503.