Efficacy of Group Cognitive–behavioral Therapy in Maintenance Treatment and Relapse Prevention for Bipolar Adolescents

Document Type : Original Article


1 Department of Child and Psychiatry, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran

2 Department of Epidemiology and Biostatistics, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran

3 Behavioral Sciences Research Center, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran


Background: Despite conducting wide-ranging of pharmacotherapy for bipolar adolescents, many of them are showing a deficit in functioning with high relapse rate. The aim of the current study was to develop a manual and investigate the efficacy of group cognitive–behavioral therapy (G-CBT) for female bipolar adolescents. Materials and Methods: During the first qualitative phase of a mixed-methods study, a manual of G-CBT was developed. Then, 32 female bipolar adolescents aged 12–19 years old, receiving usual maintenance medications (UMM), were selected. Participants were randomized to the control (UMM) and intervention group (5, 2 h weekly sessions based on G-CBT manual with UMM). The parents in intervention group participated in three parallel sessions. All participants filled the following questionnaires before 1, 3, and 6 months after the initiation of the study: Young Mania Rating Scale, Children Depression Inventory and Global Assessment of Functioning. The results were analyzed using SPSS 21 software. The concurrent qualitative phase was analyzed through thematic analysis. Results: The results showed no significant differences in all questionnaires' scores through intervention and follow-up sessions (P > 0.05). However, using cutoff point of CDI, G-CBT was effective for intervention group (relapse rate: 25% vs. 44.4%). Two themes were extracted from the second qualitative phase: emotion recognition and emotion regulation, especially in anger control. Conclusions: The results showed that the addition of G-CBT to UMM leads to decrease in the depressive scores but has no effect on manic symptoms and relapse rate.


Geller B, Craneg JL, Bolhofner K, Nickelsburg MJ, Williams M. Phenomenology and longitudinal course of children with a prepubertal and early adolescent bipolar disorder phenotype. Bipolar Disorder in Childhood and Early Adolescence. New York, NY, US: Guilford Press; 2003. p. 25-50.  Back to cited text no. 1
Birmaher B, Axelson D, Pavuluri M. Bipolar Disorder: Lewis's child and adolescent psychiatry. Lippincott Williams & Wilkins; 2007. p. 513-25.  Back to cited text no. 2
Gabrielle A, Carlson Stephanie E, Meyer C. Early onset bipolar disorder. Test book of psychiatry, kaplan and sadock. Lippincott Williams & Wilkins; 2009. p. 3663-70.  Back to cited text no. 3
Sadock BJ, Sadock VA, Ruiz P. Child psychiatry (31.12 b: Early-Onset Bipolar Disorder); Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (11th edition). Philadelphia, PA: Lippincott Williams & Wilkins. 2015. p. 1236-42.  Back to cited text no. 4
Suppes T, Leverich GS, Keck PE, Nolen WA, Denicoff KD, Altshuler LL, et al. The Stanley Foundation Bipolar Treatment Outcome Network. II. Demographics and illness characteristics of the first 261 patients. J Affect Disord 2001;67:45-59.  Back to cited text no. 5
Delbello MP, Findling RL, Kushner S, Wang D, Olson WH, Capece JA, et al. Apilot controlled trial of topiramate for mania in children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry 2005;44:539-47.  Back to cited text no. 6
Manji HK, Zarate CA. Molecular and cellular mechanisms underlying mood stabilization in bipolar disorder: Implications for the development of improved therapeutics. Mol Psychiatry 2002;7 Suppl 1:S1-7.  Back to cited text no. 7
Fallah E, Arman S, Najafi M, Shayegh B. Effect of tamoxifen and lithium on treatment of acute mania symptoms in children and adolescents. Iran J Child Neurol 2016;10:16-25.  Back to cited text no. 8
Carlson GA, Pataki C, Meyer SE. Bipolar Disorder: Dulcan's Textbook of Child and Adolescent Psychiatry; (2nd Edition), Arlington, VA, US. American Psychaitric association publishing; 2016. p. 277-304.  Back to cited text no. 9
Prako J, latalova K, Grambel A, Jelenova D, Kamaradova D, Mainerova B,et al. Psychoeducation for patients with bipolar affective disorder. Europian Psychiatry; 22nd Europian Congress of Psychiatry. 2013;28.supp1. p.1-1819.  Back to cited text no. 10
Hardy KV. Cognitive behavioral therapy (CBT). Encyclopedia of the Neurological Sciences. 2nd ed. Elsevier Inc. 2014. p. 822-3.  Back to cited text no. 11
Jones S. Psychotherapy of bipolar disorder: A review. J Affect Disord 2004;80:101-14.  Back to cited text no. 12
Hlastala SA, Kotler JS, McClellan JM, McCauley EA. Interpersonal and social rhythm therapy for adolescents with bipolar disorder: Treatment development and results from an open trial. Depress Anxiety 2010;27:457-64.  Back to cited text no. 13
Moore L, Gibson J, Carr A. Group cognitive behavior therapy for depression-does it help bipolar patients too?. European Psychiatry. 24; 17th EPA congress-Lisbon, Portugal 2009. p. 589.  Back to cited text no. 14
Molavi P, Shahrivar Z, Mahmoodi Gharaee J, Basharpoor S, Sharghi A, Nikparvar F. Short-time outcome predictors of bipolar disorder type I in children and adolescents. Iran J Psychiatry Clin Psychol 2012;18:128-37.  Back to cited text no. 15
Carlson GA, Meyer SE. Diagnostic Interviews: Dulcan's Textbook of Child and Adolescent Psychiatry; Arlington, VA, US. American Psychaitric association publishing 2010. p. 79-88.  Back to cited text no. 16
Ghanizadeh A, Mohammadi MR, Yazdanshenas A. Psychometric properties of the Farsi translation of the Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version. BMC Psychiatry 2006;6:10.  Back to cited text no. 17
Youngstrom EA, Gracious BL, Danielson CK, Findling RL, Calabrese J. Toward an integration of parent and clinician report on the Young Mania Rating Scale. J Affect Disord 2003;77:179-90.  Back to cited text no. 18
Karimi S. Standardization, Validation and Reliability Testing of Persian Version of “Child Depression Inventory of Kovacs” in Guidance School Students, MSc Dissertation in Clinical Psychology. Post Graduate Education School Islamic Azad University (Khorasgan Branch); 2009.  Back to cited text no. 19
Carlson GA, Meyer SE. Rating Scales: Dulcan's Textbook of Child and Adolescent Psychiatry; Arlington, VA, US. American Psychaitric association publishing 2010. p. 89-110.  Back to cited text no. 20
Sadock BJ, Sadock VA, Ruiz P. Diagnosis and psychiatry: Examination of the psychiatric patient. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 9th ed., Ch. 7. Philadelphia, PA: Lippincott Williams & Wilkins 2009. p. 886-1070.  Back to cited text no. 21
Aas IH. Guidelines for rating Global Assessment of Functioning (GAF). Ann Gen Psychiatry 2011;10:2.  Back to cited text no. 22
Alaghbandrad J, Amini H, Sharifi V, Dashti B. A 2 Year Followup Study on Patients with First Episode Psychosis Admitted to Ruzbeh Hospital: Demographic and Clinical Characteristic and Comparison of a Specialized Program. Final Report. Tehran: Tehran University of Medical Sciences; 2010.  Back to cited text no. 23
Weinstein SM, Henry DB, Katz AC, Peters AT, West AE. Treatment moderators of child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder. J Am Acad Child Adolesc Psychiatry 2015;54:116-25.  Back to cited text no. 24
West AE, Henry DB, Pavuluri MN. Maintenance model of integrated psychological treatment in pediatric bipolar disorder: A pilot feasibility study. J Am Acad Child Adolesc Psychiatry 46:205-12.  Back to cited text no. 25
Feeny NC, Danielson CK, Schwartz L, Youngstrom EA, Findling RL. Cognitive-behavioral therapy for bipolar disorders in adolescents: A pilot study. Bipolar Disord 2006;8 (5 Pt 1):508-15.  Back to cited text no. 26
Miklowitz DJ, Schneck CD, George EL, Taylor DO, Sugar CA, Birmaher B, et al. Pharmacotherapy and family-focused treatment for adolescents with bipolar I and II disorders: A 2-year randomized trial. Am J Psychiatry 2014;171:658-67.  Back to cited text no. 27