Cognitive Behavioral Therapy For Bipolar Disorder
Bipolar disorder is one of the most serious and common psychiatric disorders. The aim of this article is to review the efficacy of cognitive-behavioral therapy in bipolar patients. Some studies show consistent evidence that cognitive therapy, which accompanies psychoeducation
and pharmacological therapy, offers efficacy in different stages of the disease. In most studies, patients showed improvement in quality of life, decreased both frequency and duration of mood episodes, as well as higher degrees of compliance and hospitalization. In order to assess the different stages and severity of the disease, more work is needed to standardize diagnostic criteria and to prove CBT's effectiveness for bipolar disorder in the
context of measurement tools. According to Black (2019), Dr.Rego says that as a result of good treatment, he knows that the mood episodes are stabilized and that the patient is equipped with cognitive and behavioral skills necessary to make the triggers more aware and can manage them more effectively. "In the case of bipolar disorder, in addition to a decrease in
hospitalization, we can measure the outcome of treatment with a relapse, better relationships with people, and a general improvement in quality of life,” he explains. Bipolar disorder is a disorder of the genetic and biological origin of the disease, which delays the understanding of the importance of cognitive models in the treatment of this disorder (Dent, Close & Ryder,2004). Treatment of bipolar disorder is generally based on biological intervention. In order to reduce the frequency and severity of attacks, it is continued both in acute and prophylactic periods. Although drug therapy is effective and adaptable with a proper dosage adjustment, a study found that 41% to 60% of patients with a two-year follow-up experience repeated episodes of mania and depression (Roth & Fonagy,2005). It has been
concluded that 40% to 60% of bipolar patients do not comply with drug treatment and show adequate compliance, and even if they respond very well to treatment, the effect of drug therapy on social functioning is limited. ( Basco,2000). As research shows that the onset and
process of bipolar disorder is related to stress factors (physical and social factors and life events), and physiological and cognitive tendencies, it is becoming more common to use CBT together with the drug in the treatment of this disorder ( Scott,2001). In general, the cognitive-
the behavioral approach works to improve coping skills in bipolar patients, to reinforce self-efficacy and responsibility in the treatment process, to identify and support psychosocial
stressors, to develop strategies for cognitive and behavioral difficulties, and to change underlying schema and beliefs ( Schwannauer,2004). In other words, the basic principle of BDT is to determine the interventions appropriate to the needs of the attack and to reformulate the targets of the intervention multiple times depending on the patient, and even to design the
intervention specifically for the patient, such as a tailor. (Heni&Otto,2001). This flexible approach is becoming even more important, especially in patients with rapid-cycle bipolar disorder. Cooperation and compliance with drug therapy in bipolar patients, a problem frequently expressed by physicians area. In such cases, they state that the whole task does not
fall to the person engaged in biological intervention, that even if the need for medication is explained, it is the main goal of the patient to transfer the questions in his mind to his psychotherapist, to discuss his negative thoughts about the treatment and to agree on why the treatment is necessary (Otto,Reilly-Harrington&Sachs,2003). The authors suggest a method
called Life-History Approach to support compliance with drug therapy. In this method, the patient is asked to draw a lifeline and mark the manic, hypomanic, depressive attacks on this line, and then explain the events that occurred during these periods. It is discussed whether the current treatment will continue or a new treatment program will be arranged through what the
patient tells us (Vieta, Pacchiarotti, Scott, Sanchez-Moreno, Di Marzo&Colom,2005). Many similar methods deal with and attempt to interfere with the belief that disrupts the treatment of patients. For example, behavioral methods such as “motivational interviewing” or “creating a
drug follow-up schedule” and marking the patient's medication days can be counted.
Cognitive-behavioral therapy also supports adherence to drug therapy in order to be effective in the long term and prevent a recurrence. Similarly, psychoeducation also increases compliance with drug therapy and therefore becomes standard practice in addition to drug treatment.(Vieta et al.,2005). The first study on the efficacy of classical CBT techniques in the treatment
of bipolar disorder belongs to Cochran (Cochran,1984). In this study, besides the drug, the effects of a 6-session CBT application to adapt to the drug treatment were investigated. Cognitive-behavioral therapy has been applied to 34 bipolar disorder patients and 35 people in the control group (Perry, Tarrier, Morriss, McCarthy &Limb,1999). The study focused on prodromal symptoms consisting of two phases. The first stage is the
psychoeducation stage in which patients are trained to identify the symptoms lasting from 7 to 12 sessions and the second stage is the development of an action plan against the symptoms noticed by the patient. According to Perry and his colleague (1999), a standard symptom list and a card-picking exercise were used to describe what are the symptoms and timing of the
prodromal symptoms. As a result, it has been found that social functionality has increased significantly, manic symptoms have decreased, and the duration of the intermediate periods
before manic repeats have increased. At the same time, early detection of prodromal symptoms
decreased manic symptoms but had no effect on depressive symptoms. As to why this is, the majority of bipolar patients have shown to take the hassle of reporting depressive symptoms (Lam,2001). According to Perry et al.,(1999), they concluded that there was no point in reducing depressive symptoms and increasing awareness of only depressive symptoms without developing the skills to cope with depressive symptoms (Perry, Tarrier, Morriss,McCarthy& Limb,1999). On the other hand, it is observed that the treatment group has an increase in the use of antidepressants. This is possible because participants are sensitive to “abnormal feelings”, so they receive more frequent treatment against depressive symptoms (Zaretsky, Rizvi&Parikh,2007). One of the earliest studies on this subject is the work of Palmer and his friends. Cognitive-behavioral group therapy was carried out with 40 bipolar patients receiving outpatient treatment for 6 months and consisted of 17 weeks of sessions (Palmer,Williams& Adams,1995). At the end of this process, the participants found that there was a change in their manic and depressive symptoms and an increase in their social
compliance. However, no follow-up study was performed. In a study in which the effect of an 11-week cognitive-behavioral group therapy program was investigated in order to decrease symptoms and prevent recurrence in bipolar patients, techniques such as psychoeducational, cognitive restructuring, assertiveness, problem-solving training, event regulation, and compliance with drug treatment were included (Otto, Reilly Harrington&Sachs,2003). The program has been observed to decrease the number of new attacks and increase euthymic periods when compared to the control group using drugs alone. They have taken forty-nine
bipolar patients into cognitive-behavioral group therapy (Patelis-Siotis, Young, Robb, Marriott, Bieling&Cox,2001). 38 patients completed the program, which aims to improve psychosocial functioning, including psychoeducation and cognitive-behavioral interventions. Groups of 7-12 attended 2-hour sessions for 14 weeks. Although significant changes in
psychosocial functioning were observed at the end of the process, there was no change in symptoms before and after therapy. Researchers have explained this in the form of that participants are involved in the study at a time when they are slightly depressed or euthymic and therefore there is not much change in the symptoms. This study shows that cognitive-behavioral group therapy may be a useful intervention method to improve the quality of life of bipolar patients. In another study, 45 patients who were diagnosed with bipolar disorder and substance addiction were tried to be treated using a method called Integrated Group treatment (Newman, Leahy, Beck, Reilly-Harrington&Gyula,2002). This method focuses on the common symptoms of recovery and depressiveness for both disorders and aims to prevent
depressiveness by using cognitive-behavioral techniques. At the end of 20 sessions lasting one hour, there was an increase in the number of periods in which participants did not use substances or alcohol compared to patients who did not receive supplementary treatment. In addition, mood symptoms decreased. It was reported that the group had a high compliance
rate and there was no difference between the groups. There was no difference in hospitalization rates. Totterdell ve Kellett, By using cyclothymia CBT, they changed the pattern of daily mood and sleep and looked at how much it would affect mood fluctuations (Colom, Vieta , Reinares, Martinez-Aran, Torrent&Goikolea,2003). In this study, the participants rated their mood every 4 hours for 49 weeks and recorded their daily sleep time.
After four weeks of evaluation interviews, CBT was applied to the person for 20 weeks. In addition to the charts generated through the records, formulations related to cognitive, behavioral, and schemas were made and shared with the participants during the duration of the session. In the follow-up sessions at the end of the twenty-week period, it was observed that the participant was able to notice changes in mood and to change his or her nonfunctional behavior (for instance, taking refuge in bed when he or she feels very sad) to deal with these fluctuations. In addition, findings such as the fact that patients started to sleep more regularly, the acute anxiety level decreased, the compulsive washing behavior decreased, and an improvement in social function was obtained.
In summary, studies indicate that CBT has a significant number of treatment outcomes for bipolar patients. In bipolar disorder, CBT is not an alternative to drug therapy, but rather a complement to treatment. However, CBT has a role beyond that. CBT tries to improve the treatment compatibility and cooperation in order to increase the effectiveness of drug therapy on the
one hand, while on the other hand, it tries to regulate what the patient can do during the acute and remission periods of a lifelong disorder and how to live with it. This psychosocial intervention is seen as the greatest support of CBT to pharmacological interventions. Thus, CBT has a field of study in bipolar disorder that includes both acute periods, remission periods, and generally the patient's life.
REFERENCES
Basco MR. Cognitive-behavior therapy for Bipolar I Disorder. J Cogn Psychother 2000;14:287-305.
Cochran SD. Preventing medical noncompliance in the outpatient treatment of bipolar affective disorders. J Consult Clin Psychol 1984; 52:873-878.
Colom F, Vieta E, Reinares M, Martinez-Aran A, Torrent C, Goikolea JM et al.
Psychoeducation efficacy in bipolar disorders: Beyond compliance enhancement. J ClinPsychiatry 2003; 64:1101-1105.
Dent J, Close H, Ryder J. Bipolar affective disorders. In Oxford Guide to Behavioral Experiments in Cognitive Therapy (Eds J Benneth-Levy, G Butler, M Fennell, A Hackman, M Mueller, D Westbrook):225-242. NewYork, Oxford University Press, 2004.
Henin A, Otto MW, Reilly-Harrington NA. Introducing flexibility in manualized treatments:Application of recommended strategies to the cognitive-behavioral treatment of bipolar disorder. Cogn Behav Pract 2001; 8:317-328.
Lam DH, Hayward P, Wright ER, Bright K, Sham P. Relapse prevention in patients with bipolar disorder: Cognitive therapy outcome after two years. Am J Psychiatry 2005; 162:324-329.
Lam DH, Wong G, Sham P. Prodromes, coping strategies, and course of illness in bipolar affective disorder: A naturalistic study. Psychol Med 2001; 31:1397-1402.
Newman CF, Leahy RL, Beck AT, Reilly-Harrington NA, Gyulai N. Bipolar Disorder: A Cognitive Therapy Approach. Washington DC, American Psychological Association, 2002.
Otto MW, Reilly-Harrington N, Sachs GS. Psyhoeducational and cognitive behavioral strategies in the management of bipolar disorder. J Affect Disord 2003; 73:171-181
Palmer AG, Williams H, Adams M. CBT in a group format for bi-polar affective disorder.
Behav Cogn Psychother 1995; 23:153-168.
Patelis-Siotis I, Young LT, Robb JC, Marriott M, Bieling PJ, Cox LC et al. Group cognitive behavioral therapy for bipolar disorder: A feasibility and effectiveness study. J Affect Disord
2001; 65:145-153.
Perry A, Tarrier N, Morriss R, McCarthy E, Limb K. Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain
treatment. BMJ 1999; 318:149-153.
Rosemary Black.Cognitive-behavioral therapy for bipolar disorder. Apr 16, 2019. https://www.psycom.net/bipolar-psychosocial-treatment
Roth A, Fonagy P. What Works for Whom? A Critical Review of Psychotherapy Research,2nd edition. UK, Guilford Press, 2005.
Scott J. Cognitive therapy as an adjunct to medication in bipolar disorder. Br J Psychiatry 2001; 178:164-168.
Scott J, Paykel E, Morriss R, Bentall R, Kinderman P, Johnson T et al. Cognitive behavioral therapy for severe and recurrent bipolar disorders. Br J Psychiatry 2006; 188:313-320.
Schwannauer M. Cognitive behavioral therapy for bipolar affective disorder. In Mood Disorders: A Handbook of Science and Practice (Ed. M Power):259-273. England, Wiley,2004.
Totterdell P, Kellett S. Restructuring mood in cyclothymia using cognitive behavior therapy: An intensive time-sampling study. J Clin Psychol 2008; 64:501-518.
Vieta E, Pacchiarotti I, Scott J, Sanchez-Moreno J, Di Marzo S, Colom F. Evidence based research on the efficacy of psychologic interventions in bipolar disorders: A critical review. Curr Psychiatr Rep 2005; 7:449-455.
Zaretsky AE, Rizvi S, Parikh SV. How well do psychosocial interventions work in bipolar disoder? Can J Psychiatry 2007; 52:14-19.
Zaretsky AE, Segal ZV, Gemar W. Cognitive therapy for bipolar depression: A pilot study. Can J Psychiatry 1999; 44:491-493.
and pharmacological therapy, offers efficacy in different stages of the disease. In most studies, patients showed improvement in quality of life, decreased both frequency and duration of mood episodes, as well as higher degrees of compliance and hospitalization. In order to assess the different stages and severity of the disease, more work is needed to standardize diagnostic criteria and to prove CBT's effectiveness for bipolar disorder in the
context of measurement tools. According to Black (2019), Dr.Rego says that as a result of good treatment, he knows that the mood episodes are stabilized and that the patient is equipped with cognitive and behavioral skills necessary to make the triggers more aware and can manage them more effectively. "In the case of bipolar disorder, in addition to a decrease in
hospitalization, we can measure the outcome of treatment with a relapse, better relationships with people, and a general improvement in quality of life,” he explains. Bipolar disorder is a disorder of the genetic and biological origin of the disease, which delays the understanding of the importance of cognitive models in the treatment of this disorder (Dent, Close & Ryder,2004). Treatment of bipolar disorder is generally based on biological intervention. In order to reduce the frequency and severity of attacks, it is continued both in acute and prophylactic periods. Although drug therapy is effective and adaptable with a proper dosage adjustment, a study found that 41% to 60% of patients with a two-year follow-up experience repeated episodes of mania and depression (Roth & Fonagy,2005). It has been
concluded that 40% to 60% of bipolar patients do not comply with drug treatment and show adequate compliance, and even if they respond very well to treatment, the effect of drug therapy on social functioning is limited. ( Basco,2000). As research shows that the onset and
process of bipolar disorder is related to stress factors (physical and social factors and life events), and physiological and cognitive tendencies, it is becoming more common to use CBT together with the drug in the treatment of this disorder ( Scott,2001). In general, the cognitive-
the behavioral approach works to improve coping skills in bipolar patients, to reinforce self-efficacy and responsibility in the treatment process, to identify and support psychosocial
stressors, to develop strategies for cognitive and behavioral difficulties, and to change underlying schema and beliefs ( Schwannauer,2004). In other words, the basic principle of BDT is to determine the interventions appropriate to the needs of the attack and to reformulate the targets of the intervention multiple times depending on the patient, and even to design the
intervention specifically for the patient, such as a tailor. (Heni&Otto,2001). This flexible approach is becoming even more important, especially in patients with rapid-cycle bipolar disorder. Cooperation and compliance with drug therapy in bipolar patients, a problem frequently expressed by physicians area. In such cases, they state that the whole task does not
fall to the person engaged in biological intervention, that even if the need for medication is explained, it is the main goal of the patient to transfer the questions in his mind to his psychotherapist, to discuss his negative thoughts about the treatment and to agree on why the treatment is necessary (Otto,Reilly-Harrington&Sachs,2003). The authors suggest a method
called Life-History Approach to support compliance with drug therapy. In this method, the patient is asked to draw a lifeline and mark the manic, hypomanic, depressive attacks on this line, and then explain the events that occurred during these periods. It is discussed whether the current treatment will continue or a new treatment program will be arranged through what the
patient tells us (Vieta, Pacchiarotti, Scott, Sanchez-Moreno, Di Marzo&Colom,2005). Many similar methods deal with and attempt to interfere with the belief that disrupts the treatment of patients. For example, behavioral methods such as “motivational interviewing” or “creating a
drug follow-up schedule” and marking the patient's medication days can be counted.
Cognitive-behavioral therapy also supports adherence to drug therapy in order to be effective in the long term and prevent a recurrence. Similarly, psychoeducation also increases compliance with drug therapy and therefore becomes standard practice in addition to drug treatment.(Vieta et al.,2005). The first study on the efficacy of classical CBT techniques in the treatment
of bipolar disorder belongs to Cochran (Cochran,1984). In this study, besides the drug, the effects of a 6-session CBT application to adapt to the drug treatment were investigated. Cognitive-behavioral therapy has been applied to 34 bipolar disorder patients and 35 people in the control group (Perry, Tarrier, Morriss, McCarthy &Limb,1999). The study focused on prodromal symptoms consisting of two phases. The first stage is the
psychoeducation stage in which patients are trained to identify the symptoms lasting from 7 to 12 sessions and the second stage is the development of an action plan against the symptoms noticed by the patient. According to Perry and his colleague (1999), a standard symptom list and a card-picking exercise were used to describe what are the symptoms and timing of the
prodromal symptoms. As a result, it has been found that social functionality has increased significantly, manic symptoms have decreased, and the duration of the intermediate periods
before manic repeats have increased. At the same time, early detection of prodromal symptoms
decreased manic symptoms but had no effect on depressive symptoms. As to why this is, the majority of bipolar patients have shown to take the hassle of reporting depressive symptoms (Lam,2001). According to Perry et al.,(1999), they concluded that there was no point in reducing depressive symptoms and increasing awareness of only depressive symptoms without developing the skills to cope with depressive symptoms (Perry, Tarrier, Morriss,McCarthy& Limb,1999). On the other hand, it is observed that the treatment group has an increase in the use of antidepressants. This is possible because participants are sensitive to “abnormal feelings”, so they receive more frequent treatment against depressive symptoms (Zaretsky, Rizvi&Parikh,2007). One of the earliest studies on this subject is the work of Palmer and his friends. Cognitive-behavioral group therapy was carried out with 40 bipolar patients receiving outpatient treatment for 6 months and consisted of 17 weeks of sessions (Palmer,Williams& Adams,1995). At the end of this process, the participants found that there was a change in their manic and depressive symptoms and an increase in their social
compliance. However, no follow-up study was performed. In a study in which the effect of an 11-week cognitive-behavioral group therapy program was investigated in order to decrease symptoms and prevent recurrence in bipolar patients, techniques such as psychoeducational, cognitive restructuring, assertiveness, problem-solving training, event regulation, and compliance with drug treatment were included (Otto, Reilly Harrington&Sachs,2003). The program has been observed to decrease the number of new attacks and increase euthymic periods when compared to the control group using drugs alone. They have taken forty-nine
bipolar patients into cognitive-behavioral group therapy (Patelis-Siotis, Young, Robb, Marriott, Bieling&Cox,2001). 38 patients completed the program, which aims to improve psychosocial functioning, including psychoeducation and cognitive-behavioral interventions. Groups of 7-12 attended 2-hour sessions for 14 weeks. Although significant changes in
psychosocial functioning were observed at the end of the process, there was no change in symptoms before and after therapy. Researchers have explained this in the form of that participants are involved in the study at a time when they are slightly depressed or euthymic and therefore there is not much change in the symptoms. This study shows that cognitive-behavioral group therapy may be a useful intervention method to improve the quality of life of bipolar patients. In another study, 45 patients who were diagnosed with bipolar disorder and substance addiction were tried to be treated using a method called Integrated Group treatment (Newman, Leahy, Beck, Reilly-Harrington&Gyula,2002). This method focuses on the common symptoms of recovery and depressiveness for both disorders and aims to prevent
depressiveness by using cognitive-behavioral techniques. At the end of 20 sessions lasting one hour, there was an increase in the number of periods in which participants did not use substances or alcohol compared to patients who did not receive supplementary treatment. In addition, mood symptoms decreased. It was reported that the group had a high compliance
rate and there was no difference between the groups. There was no difference in hospitalization rates. Totterdell ve Kellett, By using cyclothymia CBT, they changed the pattern of daily mood and sleep and looked at how much it would affect mood fluctuations (Colom, Vieta , Reinares, Martinez-Aran, Torrent&Goikolea,2003). In this study, the participants rated their mood every 4 hours for 49 weeks and recorded their daily sleep time.
After four weeks of evaluation interviews, CBT was applied to the person for 20 weeks. In addition to the charts generated through the records, formulations related to cognitive, behavioral, and schemas were made and shared with the participants during the duration of the session. In the follow-up sessions at the end of the twenty-week period, it was observed that the participant was able to notice changes in mood and to change his or her nonfunctional behavior (for instance, taking refuge in bed when he or she feels very sad) to deal with these fluctuations. In addition, findings such as the fact that patients started to sleep more regularly, the acute anxiety level decreased, the compulsive washing behavior decreased, and an improvement in social function was obtained.
In summary, studies indicate that CBT has a significant number of treatment outcomes for bipolar patients. In bipolar disorder, CBT is not an alternative to drug therapy, but rather a complement to treatment. However, CBT has a role beyond that. CBT tries to improve the treatment compatibility and cooperation in order to increase the effectiveness of drug therapy on the
one hand, while on the other hand, it tries to regulate what the patient can do during the acute and remission periods of a lifelong disorder and how to live with it. This psychosocial intervention is seen as the greatest support of CBT to pharmacological interventions. Thus, CBT has a field of study in bipolar disorder that includes both acute periods, remission periods, and generally the patient's life.
REFERENCES
Basco MR. Cognitive-behavior therapy for Bipolar I Disorder. J Cogn Psychother 2000;14:287-305.
Cochran SD. Preventing medical noncompliance in the outpatient treatment of bipolar affective disorders. J Consult Clin Psychol 1984; 52:873-878.
Colom F, Vieta E, Reinares M, Martinez-Aran A, Torrent C, Goikolea JM et al.
Psychoeducation efficacy in bipolar disorders: Beyond compliance enhancement. J ClinPsychiatry 2003; 64:1101-1105.
Dent J, Close H, Ryder J. Bipolar affective disorders. In Oxford Guide to Behavioral Experiments in Cognitive Therapy (Eds J Benneth-Levy, G Butler, M Fennell, A Hackman, M Mueller, D Westbrook):225-242. NewYork, Oxford University Press, 2004.
Henin A, Otto MW, Reilly-Harrington NA. Introducing flexibility in manualized treatments:Application of recommended strategies to the cognitive-behavioral treatment of bipolar disorder. Cogn Behav Pract 2001; 8:317-328.
Lam DH, Hayward P, Wright ER, Bright K, Sham P. Relapse prevention in patients with bipolar disorder: Cognitive therapy outcome after two years. Am J Psychiatry 2005; 162:324-329.
Lam DH, Wong G, Sham P. Prodromes, coping strategies, and course of illness in bipolar affective disorder: A naturalistic study. Psychol Med 2001; 31:1397-1402.
Newman CF, Leahy RL, Beck AT, Reilly-Harrington NA, Gyulai N. Bipolar Disorder: A Cognitive Therapy Approach. Washington DC, American Psychological Association, 2002.
Otto MW, Reilly-Harrington N, Sachs GS. Psyhoeducational and cognitive behavioral strategies in the management of bipolar disorder. J Affect Disord 2003; 73:171-181
Palmer AG, Williams H, Adams M. CBT in a group format for bi-polar affective disorder.
Behav Cogn Psychother 1995; 23:153-168.
Patelis-Siotis I, Young LT, Robb JC, Marriott M, Bieling PJ, Cox LC et al. Group cognitive behavioral therapy for bipolar disorder: A feasibility and effectiveness study. J Affect Disord
2001; 65:145-153.
Perry A, Tarrier N, Morriss R, McCarthy E, Limb K. Randomised controlled trial of efficacy of teaching patients with bipolar disorder to identify early symptoms of relapse and obtain
treatment. BMJ 1999; 318:149-153.
Rosemary Black.Cognitive-behavioral therapy for bipolar disorder. Apr 16, 2019. https://www.psycom.net/bipolar-psychosocial-treatment
Roth A, Fonagy P. What Works for Whom? A Critical Review of Psychotherapy Research,2nd edition. UK, Guilford Press, 2005.
Scott J. Cognitive therapy as an adjunct to medication in bipolar disorder. Br J Psychiatry 2001; 178:164-168.
Scott J, Paykel E, Morriss R, Bentall R, Kinderman P, Johnson T et al. Cognitive behavioral therapy for severe and recurrent bipolar disorders. Br J Psychiatry 2006; 188:313-320.
Schwannauer M. Cognitive behavioral therapy for bipolar affective disorder. In Mood Disorders: A Handbook of Science and Practice (Ed. M Power):259-273. England, Wiley,2004.
Totterdell P, Kellett S. Restructuring mood in cyclothymia using cognitive behavior therapy: An intensive time-sampling study. J Clin Psychol 2008; 64:501-518.
Vieta E, Pacchiarotti I, Scott J, Sanchez-Moreno J, Di Marzo S, Colom F. Evidence based research on the efficacy of psychologic interventions in bipolar disorders: A critical review. Curr Psychiatr Rep 2005; 7:449-455.
Zaretsky AE, Rizvi S, Parikh SV. How well do psychosocial interventions work in bipolar disoder? Can J Psychiatry 2007; 52:14-19.
Zaretsky AE, Segal ZV, Gemar W. Cognitive therapy for bipolar depression: A pilot study. Can J Psychiatry 1999; 44:491-493.
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