Therapy for bipolar disorder

Medicine is usually the base of treatment for bipolar disorder. But medicine alone often does not do the whole job. Talk therapy (also called psychotherapy) can teach skills, support, and ways to spot trouble early. It can help both the person and their family.^1,2

Studies show that adding the right kind of therapy to medicine helps people stay well longer and recover from depression sooner.^3,4 This page explains the four main types, what each one is like, and how to find one.

How therapy helps when you already take medicine

Bipolar disorder causes swings between mania or hypomania (very high energy, little need for sleep) and depression. Medicine helps even out those swings. Therapy adds skills and support.¹

Good therapy for bipolar disorder usually helps you:^2,6

• Understand the illness and why steady treatment matters.
• Notice your own early warning signs, so you can act before an episode grows.
• Keep regular sleep and daily routines.
• Handle stress, conflict and big life changes.
• Make a plan for what to do if symptoms come back.

What the research shows. A 2021 review pooled 39 trials with almost 3,900 people. Adding a structured, step-by-step therapy to usual care lowered the odds of a new episode by about 44%.³ Therapy also eased depression symptoms, though the results for each single type were less certain.³

A large U.S. study called STEP-BD tested therapy for people in a depressive episode. All 293 people took medicine. Some got up to 9 months of intensive therapy. Others got a short program of 3 sessions.⁴

Source for the table: NIMH summary of the STEP-BD therapy study.⁴

The three intensive therapies in that study were family-focused therapy, IPSRT and CBT. None was clearly better than the others.⁴ That means you can often choose based on what is available and what fits you.

Psychoeducation: learning about the illness

Psychoeducation means structured lessons about bipolar disorder. It is more than reading a handout. It mixes facts, skills practice and discussion. Guidelines suggest at least 6 sessions.²

Topics usually include:^2,6

• What mania, hypomania and depression look like.
• Why taking medicine every day matters, and how to talk with your doctor about side effects.
• Your personal early warning signs, such as sleeping less, spending more or pulling away from people.
• Steady routines, and avoiding alcohol and street drugs.
• A written plan for what to do when warning signs appear.

Group programs have strong results. In one well-known trial from Spain, people who were stable joined 21 weekly group sessions of 90 minutes each. A comparison group met just as often but without the lessons.⁵ After 5 years, the lesson group had fewer than half as many episodes (about 4 versus 8 on average). They also spent far fewer days ill.⁵

The 2021 review found that psychoeducation with skills practice worked better in a group or family setting than one-on-one.³ See also support groups and peer support.

Family-focused therapy

Bipolar disorder affects the whole household. Family-focused therapy (FFT) brings the person and one or more family members into sessions together. A typical course is about 21 sessions over several months.⁶

FFT has three main parts:^2,6

1. Learning together. Everyone learns about the illness, its warning signs and its treatment. Families often feel less blame and confusion once they understand it.
2. Communication practice. Family members practice saying what they feel calmly, listening well and asking for change without a fight.
3. Problem-solving. The family learns to break big problems into small steps and agree on a plan.

In trials, FFT started after a recent episode led to fewer relapses than less intensive care.⁶ In one study, about 3 in 10 people in FFT had a new episode in the follow-up period, compared with about 6 in 10 who got individual lessons only.⁶ NIMH notes it has helped both teens and adults when started along with mood-stabilizing medicine.¹

The 2021 review also found that people stayed in treatment longer when family was involved.³ If you are a family member, see supporting someone with bipolar disorder and supporting someone in treatment.

IPSRT: steadying your daily rhythms

Interpersonal and social rhythm therapy (IPSRT) is built on a simple idea. In bipolar disorder, mood is closely tied to the body's daily rhythms, such as sleep. Mood shifts are also linked to stress in relationships and big life changes.^1,2

IPSRT has two parts:^2,6

• Social rhythms. You track your mood and the times you do basic things each day. Examples are when you wake up, eat meals, start work or activities, and go to bed. Then you work with the therapist to make those times more regular, a bit like setting a steady clock.
• Relationships. You work on the people problems tied to your moods. These can be grief, conflict, feeling alone, or a big role change such as retirement or becoming a caregiver.

IPSRT is usually one-on-one. It often starts weekly and moves to monthly visits once you are stable.⁶ NIMH says it works when used together with medicine.¹ In studies, people who got IPSRT early in treatment stayed well longer and did better at work than people who got intensive case management.⁶

The relationship part grew out of interpersonal therapy for depression. See interpersonal therapy (IPT). For everyday sleep and routine tips, see living well with bipolar disorder.

CBT: working with thoughts and actions

Cognitive behavioral therapy (CBT) looks at the links between your thoughts, feelings and actions. For bipolar disorder, it is changed to fit the illness.^2,6 You might:

• Use a mood diary to catch early signs of an episode.
• Notice and test very negative thoughts during depression, such as "I always fail."
• Notice overly big plans or risky ideas when mood climbs, and slow down before acting.
• Plan small, steady activities so you do not sink during low times or overdo it during high times.

CBT usually takes about 12 to 22 sessions, alone or in a group.⁶ It lowered depression symptoms in the 2021 review.³ The VA/DoD guideline also suggests CBT for people who are mostly well but still have anxiety.²

Results for preventing new episodes are mixed. One large trial found no overall benefit. CBT seemed to help mainly people who had had fewer past episodes.⁶ So CBT may work best when started earlier in the illness or when depression and anxiety are the main problems.

To learn the basic CBT model, see our CBT overview and thought check tool. These are general tools, not a replacement for therapy tailored to bipolar disorder.

CBT for sleep problems

Poor sleep can be both a warning sign and a trigger for mood episodes. NIMH notes that CBT adapted for insomnia can help as part of treating bipolar depression.¹

In a small pilot trial, adults with bipolar I and insomnia got 8 sessions of CBT for insomnia changed for bipolar disorder. Over the next 6 months, about 1 in 20 had a manic or hypomanic relapse. In the comparison group, it was about 1 in 3.⁷ This was a small study, so it needs to be repeated.⁷

The version in that trial was made for bipolar disorder.⁷ So it is best to work on sleep with a therapist who knows bipolar disorder. Learn more about insomnia.

Therapy in later life

Most therapy research in bipolar disorder has been done with younger and middle-aged adults. In the 2021 review, the average age was about 36.³ Experts note there is little research on therapy built for older adults with bipolar disorder.⁹

Older adults often have more physical health problems, and some have changes in memory or thinking.⁹ Experts suggest making therapy more flexible to fit health changes.⁹ In practice, that may mean:

• Shorter sessions, or phone and video visits on days when getting out is hard.
• Written notes or a notebook to remember what was covered. Our memory notebook can help.
• Bringing a spouse, adult child or caregiver to some sessions, with your permission.
• Working on later-life changes, such as retirement, grief, moving or caring for a partner.

New mania that first appears after age 50 needs a careful medical check. See bipolar disorder in later life.

How to find therapy and pay for it

Ask your psychiatrist or primary care doctor for a referral. You can also ask a possible therapist:

• Do you treat many people with bipolar disorder?
• Do you offer psychoeducation, family-focused therapy, IPSRT or CBT for bipolar disorder?
• Will you work with my psychiatrist and, if I agree, my family?
• Do you offer group sessions or video visits?

Medicare. Part B covers individual and group therapy and family counseling when it helps your treatment. You can see doctors and certain licensed professionals, including marriage and family therapists and mental health counselors. After the yearly deductible, you usually pay 20% of the Medicare-approved amount.¹⁰ Costs can differ by setting and other insurance.¹⁰

For more help, see how to find a therapist, paying for therapy and online therapy and apps. NAMI also calls support groups and psychoeducation key parts of treatment.⁸

When to get help right away

Therapy is a long-term support. It is not an emergency service. Get help right away if you or someone you love:

• Talks about suicide, feels hopeless, or says others would be better off without them. Call or text 988 (the Suicide and Crisis Lifeline), any time of day.
• Is in danger, has hurt themselves, or cannot be kept safe. Call 911.
• Has stopped sleeping for days, is taking big risks, or seems out of touch with reality. Call the doctor the same day, or 988 for guidance.

Our safety plan tool can help you plan ahead. Families can read when a family member is in a mental health crisis.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.