Low-quality evidence suggests cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) may be effective for acute bipolar depression, according to a meta-analysis published in the Journal of Affective Disorders.

Cochrane, MEDLINE, EMBASE, PsycINFO, Scopus, Clinical Trails Registries, and Web of Science databases were searched for randomized controlled trials (RCTs) published between 1952 and 2020 that evaluated psychological interventions for adults diagnosed with bipolar I or bipolar II disorder. Control conditions could be treatment/care as usual, waitlist, active control, or placebo. Continuous or categorical scales were utilized to assess treatment outcome depression symptom level before and after treatment in the included studies. A total of 32 studies met criteria and were included in the qualitative review, while 22 studies met required outcomes and were included in the meta-analysis.

The researchers determined that the quality of most studies was low. There were 14 studies that did not have sufficiently reported allocation concealment and blinding of participants and personnel was unclear or not possible in all studies. The majority of studies did not have sufficiently reported detection bias.

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Compared with usual care (group therapy and individual face-to-face therapy), CBT was more effective across 8 RCTs, with low heterogeneity (P =.31 I2 = %15). CBT outcomes comparing usual care favored intervention. CBT follow-up of 482 participants of 6 RCTs saw significantly better treatment outcomes compared with others in 1 study but saw high heterogeneity. Compared with usual care or placebo, CBT had no effect on symptoms of depression at follow-up (z = 1.99 P =.05 SMD = -0.32). DBT significantly impacted depression symptoms at post-treatment (z = 2.63 P =.009 SMD = -1.18).

Therapy target was clear in 14 studies (3 acute depression, 8 relapse prevention, 3 quality of life), with variability in therapy type and comparator. Effect sizes were clustered around a small effect size (SMD = -0.119 [95% CI -0.280-0.043]). Psycho-education, mindfulness-based therapy, family therapy, and interpersonal and social rhythm therapy did not affect depression, trials showed.

Limitations of the study include the exclusion of nonmedical, relationship-based treatments and papers written in languages other than English and papers that did not report means and standard deviations of depression scores.

“In terms of reducing depression post-treatment, based upon our analysis the evidence favors CBT, regardless of whether relapse prevention or acute depression is the target, however from the studies we included we cannot determine whether CBT performs better than other therapies, as there were few direct comparisons,” the researchers noted.

“This leaves open the question of whether there could be further increases in the efficacy of CBT for bipolar depression if acute depression is the primary focus in the protocol: more studies are needed to address this question. Furthermore, recommended interventions for bipolar depression are largely based on psychological models of unipolar depression: it is possible they may be more effective if derived from evidence-based models of bipolar depression.”


Yilmaz S, Huguet A, Kisely S, et al. Do psychological interventions reduce symptoms of depression for patients with bipolar I or II disorder? A meta-analysis. J Affective Disorders. 2022;301:193-204. doi:10.1016/j.jad.2021.12.112