The Impact of Cognitive Behavioral Therapy on Relapse Rates in Bipolar Disorder: A Meta-Analysis

Purpose: To evaluate the efficacy of adjunctive cognitive behavioral therapy (CBT) for reducing relapse rates in bipolar disorder (BD), focusing on differential effects by relapse type (depressive vs manic) and treatment duration. Patients and Methods: We searched PubMed, Embase, Cochrane Library, CNKI, Wanfang, and SinoMed (inception to 25 August 2025). Ten randomized controlled trials (N=930) were included. This study was registered in PROSPERO (CRD420251109273). Risk of bias was assessed using the Cochrane Risk of Bias tool (RoB 2.0). Risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated, with prespecified subgroup analyses by treatment duration (≤ 6 vs > 6 months). This meta-analysis followed the PRISMA 2020 reporting standards for systematic reviews and meta-analyses. Results: Short-term CBT (≤ 6 months) significantly reduced overall relapse rates (RR = 0.73, 95% CI: [0.55, 0.96], P < 0.05) and depressive relapse rates (RR = 0.62, 95% CI: [0.44, 0.88], P < 0.05). For long-term CBT (> 6 months), no significant benefit was observed for overall relapse rates (RR = 1.08, 95% CI: [0.90, 1.30], I 2 = 0, P > 0.05) or depressive relapse rates (RR = 1.07, 95% CI: [0.84, 1.38], I 2 = 0, P > 0.05). CBT also significantly improved depressive symptom scores on the Beck Depression Inventory (BDI; MD = − 2.54, 95% CI: [− 3.83, − 1.24], P < 0.05), Inventory of Depressive Symptomatology-Clinician Rated (IDS-C; MD = − 2.83, 95% CI: [− 5.53, − 0.13], P < 0.05), and Montgomery-Åsberg Depression Rating Scale (MADRS; MD = − 4.10, 95% CI: [− 6.71, − 1.50], P < 0.05). By contrast, no significant benefit was observed for manic relapse rates or manic symptom scores on the Young Mania Rating Scale (YMRS). Sensitivity analyses confirmed the robustness of the results. Conclusion: Adjunctive CBT reduces overall and depressive relapse rates in BD but not manic outcomes. Limitations include long-term evidence limited to two confounded trials, heterogeneity limiting precision, high attrition in five studies, and performance bias from unblinding. Evidence on functional recovery and social cognition remains limited. CBT should be prioritized for depressive symptoms. Future trials should enhance manic-relapse prevention and address these gaps.