The Most Effective Evidence-Based Occupational Therapy Interventions For Adolescents With Bipolar Disorder A Systematic Literature Review

Running head: ADOLESCENTS WITH BIPOLAR DISORDER 1
The Most Effective Evidence-Based Occupational Therapy Interventions
for Adolescents with Bipolar Disorder:
A Systematic Literature Review
A Graduate Research Project Submitted in Partial Fulfillment of the Requirements

for the Degree of Master of Science in Occupational Therapy
Department of Occupational Therapy
The College of St. Scholastica
Duluth, MN.
by
Mary Conlin
Amanda Lorinser
May 2012
Graduate Research Project Faculty Advisor: Diane Anderson, PhD, MPH, OTR/L
I, the undersigned, approve the final copy of the thesis:
___ ______________ ____May 11, 2012_____________

Faculty advisor date
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2
ADOLESCENTS WITH BIPOLAR DISORDER
Committee Members
Diane Anderson, PhD, MPH, OTR/L

Assistant Professor
Chair of the Department
Department of Occupational Therapy
College of St. Scholastica
Gerald Henkel-Johnson, Psy.D., L.P.

Associate Professor
Interim Dean School of Sciences
Chair of the Department
Department of Psychology and Sociology
College of St. Scholastica
3
Acknowledgements
Mary would like to thank her parents and siblings for supporting, encouraging and
praying for her throughout her several years of schooling. She would also like to thank Jonathan
Neumann for always supporting, loving, and respecting her. Mary would like to collectively
thank many other loved ones who have prayed for and encouraged her to keep on her journey to
achieve her goal to become an occupational therapist.
Amanda would like to thank her parents and brother for all the love and support they
have given her during the past twenty-three years. Without their encouragement to dream big and
pursue her dreams, she would not be where she is today. She would also like to thank the many
people in her life who have inspired her to continue on the path to becoming an occupational
therapist.
Mary and Amanda would also like to thank both of the committee members, Diane
Anderson and Gerald Henkel-Johnson, for their time and effort in helping us create this final
systematic literature review. Lastly, we would like to thank Brad Snelling for assisting us in our
literature search.
4
Abstract
As part of the Centennial Vision, the American Occupational Therapy Association has
declared mental health an emerging area of practice for the field of occupational therapy. It is
estimated that 750,000 children in the United States are affected by bipolar disorder (Watling &
Nielsen, 2010). The purpose of this systematic literature review was to identify the most
effective and current evidence-based occupational therapy interventions available for adolescents
with bipolar disorder. Seven interdisciplinary studies ranging in level of rigor from I-V were
found that supported four occupation-based interventions for this population, including cognitive
behavioral therapy, dialectical behavior therapy, interpersonal social rhythms therapy, and family
focused treatment. Each identified intervention corresponded with the Occupational Therapy
Practice Framework: Domain and Process, 2nd Edition and supported the development of key
areas of occupation. Through the use of these interventions, occupational therapists can continue
to benefit this population by incorporating routine development, problem solving,
communication, coping skills, social skills, and emotional behavioral regulation training into
treatment in order to achieve optimal occupational success.
Key Words: Occupational therapy, bipolar disorder, adolescents

5
Table of Contents
Introduction………………………………………………………………………………… 6
Background Literature……………………………………………………………………… 6
Bipolar Disorder……………………………………………………………………. 6
Occupational Therapy Practice Framework: Domain and Process, 2nd Edition…… 11
Intervention Strategies……………………………………………………………… 12
Family Focused Treatment………………………………………………….. 12
Cognitive Behavioral Therapy……………………………………………… 13
Dialectical Behavior Therapy………………………………………………. 15
Interpersonal Social Rhythm Therapy……………………………………… 16
Methodology………………………………………………..………………………………. 19
Results………………………………………………..……………………………………... 22
Family Focused Treatment………………………………………………………….. 22
Cognitive Behavioral Therapy and Dialectical Behavior Therapy…………………. 25
Interpersonal Social Rhythm Therapy……………………………………………… 28
Discussion…………………………………………………………………………………... 30
Study Limitations…………………………………………………………………… 34
Future Research……………………………………………………………... 35
References.………………………………………………………………………………….. 38
Appendix A-Bipolar Disorder Diagnostic Criteria……………………..…………………... 43
Appendix B-Level of Evidence……………………………………………………………... 45
Appendix C…………………………………………………………………………………. 46
Table 1-Inclusion Table…………………………………………………………….. 46
Table 2-Exclusion Table……………………………………………………………. 49
6
Bipolar disorder is a brain disorder that is commonly diagnosed and treated in the adult
population. Only recently have children and adolescents been diagnosed with bipolar disorder,
with some diagnosed as early as age four (Birmaher et al., 2009). The most common form of
treatment for bipolar disorder is the use of medication such as antipsychotics, lithium,
antidepressants, and anticonvulsants (National Alliance on Mental Illness [NAMI], 2010).
Though these treatment methods may be effective, they also have a potential for serious side
effects. According to the National Alliance on Mental Illness (2010), many children who are on
certain medications for the treatment of bipolar disorder can experience tardive dyskinesia,
kidney disease, infertility, and weight gain that leads to glucose issues such as diabetes or an
increase in blood lipids that can later result in worsening heart problems. In order to avoid these
serious side effects, non-psychopharmacological therapy such as occupational therapy should be
considered to treat adolescents with bipolar disorder and lessen the amount of medication
needed. Through this systematic literature review, therapies that fall within the domain of
occupational therapy practice were reviewed for their effectiveness in treating adolescents with
bipolar disorder.
Background Literature Review
Bipolar Disorder
Bipolar disorder, sometimes known as manic-depressive disorder, is described by the
National Institute of Mental Health (NIMH) as “a brain disorder that causes unusual shifts in
mood, energy, activity levels, and the ability to carry out day-to-day tasks” (U.S. Department of
Health and Human Services [DHHS], 2009, p.1). Bipolar disorder is a lifelong mood disorder
where a person experiences recurring episodes of depression and mania (Watling & Nielsen,
7
2010). Most people with this disorder do not experience any symptoms between episodes, while
others may have lingering symptoms (DHHS, 2009).
Commonly, mental health specialists diagnose bipolar disorder in adults by using the
guidelines outlined by the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition-
Text Revision (DSM-IV-TR) (American Psychiatric Association [APA], 2000; DHHS, 2008).
There are six separate sets of criteria for bipolar I disorder: Single Manic Episode, Most Recent
Episode Hypomanic, Most Recent Episode Manic, Most Recent Episode Mixed, Most Recent
Episode Depressed, and Most Recent Episode Unspecified. Bipolar I Disorder, Single Manic
Episode, is used to describe individuals who are having a first episode of mania. The remaining
criteria sets are used to specify the nature of the current (or most recent) episode in individuals
who have had recurrent mood episodes. Bipolar I disorder in adults is diagnosed in a person who
has one or more manic or mixed episodes, whereas bipolar II is characterized by the presence of
one or more major depressive episodes, as well as at least one hypomanic episode (APA, 2000;
Spangler, 2011). There is only one set of criteria for this subtype of the disorder in the DSM-IV-
TR. (Refer to Appendix A for definitions of the diagnostic sets for bipolar I and II disorders).
While both bipolar I and II may present with major depressive episodes, this type of episode is
not required to attain a diagnosis of bipolar I (Spangler, 2011). It is estimated that up to 3.5% of
the adult population has bipolar disorder and it is 5 to 10 times more commonly diagnosed if a
first-degree relative has previously been diagnosed with the disorder (Buckley, 2008; Spangler,
2011).
There are several theories regarding the development of bipolar disorder including
biochemical, neuroendocrine, genetic, socioenvironmental, psychosocial, and
psychophysiological theories. The biochemical theory hypothesizes that neuronal responses are
8
influenced by signals from multiple neurotransmitters, such as serotonin, that alter mood.
Neuroendocrine theory addresses the idea that drastic alterations in mood may be caused by
stress which in turn affects the hypothalamic-pituitary-adrenal (HPA) axis. The genetic theory
proposes that the bipolar disorder is due to genetic causes. This is supported by studies that have
been conducted with twins and biological and adoptive families (Cara, 2005).
The socioenvironmental theory operates under the assumption that the life experiences
one goes through, the environments that a person has been exposed to, and the changes he or she
has experienced within these contexts affect one’s chance of being diagnosed with bipolar
disorder. The psychosocial theory hypothesizes that a person is affected by relatives and family
members who openly express extreme emotions and that this exposure during the early stages of
bipolar disorder may encourage relapses of manic or depressive episodes. Lastly, the
psychophysiological theory is based on the concept that physiological changes are affected by
changes in environmental seasons. According to this theory, the individual is unable to adapt to
these seasonal changes and therefore bipolar disorder is triggered (Cara, 2005). These theories
were developed based on information regarding the adult population; they may or may not apply
to the child or adolescent population.
Often, bipolar disorder develops in late adolescence or early adulthood, with about half of
all cases beginning before 25 years of age (DHHS, 2008). The age of onset has been
controversial. Some researchers find that the age of onset of bipolar disorder in the United States
is at 18 years of age, while other researchers have determined that the age of onset ranges from
ages 25 to 30. However, children have been diagnosed as early as the age of four years old (Cara,
2005; Birmaher et al., 2009). While bipolar disorder is difficult to diagnose in children, it is
estimated that 750,000 children in the United States are affected (Watling & Nielsen, 2010).
9
According to the U.S. Department of Health and Human Services (DHHS), an episode of
depressive symptoms is generally the first manifestation of bipolar disorder in children and
adolescents. The depressive symptoms will then be followed by a manic episode, which may
occur very rapidly following the depressive episode, or occur several months later (DHHS,
1999).
According to an article found in the Psychiatric Times, mania in children has been
diagnosed since 1980 using the DSM-IV-TR criteria for adults (Cogan, 1996). However there are
a number of obstacles that arise when identifying and diagnosing children with a disorder that is
most commonly known to affect an adult population. These obstacles include the disorder’s low
rate of occurrence, the change in presentation of symptoms throughout episodes, symptoms
resembling other disorders that occur in childhood, and developmental stages that mask the
outward expression of bipolar symptoms (Cogan, 1996).
In 2000, NIMH experts met to discuss issues concerning diagnosing children and
adolescents with bipolar disorder by using the DSM-IV-TR adult criteria (Beardslee et al., 2005).
It was concluded that children could be categorized into two groups. The first group included
children who fit within the DSM-IV-TR criteria for either bipolar I or II disorder. The second
group included children who did not exactly fit within the DSM-IV-TR criteria, but may have
bipolar disorder because they are presenting with symptoms of mania and depression. The
children who fall into the second group are not included in research studies because of the
“uncertainty of their diagnosis” (Beardslee et al., 2005, p.18).
Children who fall within the first group have, by definition, early-onset bipolar disorder,
or bipolar disorder diagnosed in childhood. Symptoms of early-onset bipolar disorder appear to
be more severe than those that first present in older teens and adults (DHHS, 2008). Children and
10
adolescents will experience frequent mood changes along with enduring mixed episodes (DHHS,
2008). Mixed episodes last for a duration of at least one week and involve manic episodes as
well as major depressive episodes (Beardslee et al., 2005). With these mixed episodes, children
and adolescents will experience significant impairments in their daily roles (such as being a
student), and are more likely to attempt suicide (DHHS, 2008).
Due to the scarce number of research studies conducted on bipolar disorder in
adolescents and the low rate of occurrences, risk factors for bipolar disorder in youth are
generally unknown (Beardslee et al., 2005). However, in the limited number of studies
conducted, there was one common risk factor found--family history (Beardslee et al., 2005). If
either a parent or sibling has the diagnosis of bipolar disorder, it is four to six times more likely
that the child or adolescent will develop the disorder than those children and adolescents whose
parents or siblings do not have the diagnosis (DHHS, 2008).
If bipolar disorder is left untreated, symptoms tend to worsen with time. “A person may
suffer more frequent and more severe episodes than when the illness first appeared” (DHHS,
2009, p. 5). Mania can cause adolescents to experience self-esteem inflation, racing thoughts, a
decrease in the ability or need to sleep, and an increase in distractibility as well as risky
behaviors (Kuwana, 2005). Depression can cause a loss of interest, changes in sleep and eating
habits, as well as decreased energy and concentration during tasks (Kuwana, 2005). As
symptoms worsen, those with bipolar disorder are likely to face disruptions within their day,
such as in school, work, or in their relationships with others.
According to the NIMH, common treatments for bipolar disorder include mood
stabilizing medications, atypical antipsychotic medications, antidepressant medications,
cognitive behavioral therapy (CBT), family-focused therapy (FFT), interpersonal and social
11
rhythm therapy (IPSRT), psychoeducation, electroconvulsive therapy (ECT), and sleep
medications (DHHS, 2009).
Occupational Therapy Practice Framework: Domain and Process, 2nd Edition
The Occupational Therapy Practice Framework: Domain and Process, 2nd Edition
(Practice Framework) outlines the scope of practice of occupational therapy and provides a
definition of occupational therapy as an area of practice that supports and promotes the health of
people and populations through engagement in meaningful activity (American Occupational
Therapy Association [AOTA], 2008). This official document developed by the AOTA contains
two main components: domain and process. During practice, it is essential that these two
components are considered and utilized by the occupational therapy practitioner. As defined
within the Practice Framework, the domain “outlines the profession’s purview and the areas in
which its members have an established body of knowledge and expertise” (AOTA, 2008, p. 226).
Process is defined as “the dynamic occupation and client-centered process used in the delivery of
occupational therapy services” (AOTA, 2008, p. 246). It is within these two components of the
document that the areas of occupation, client factors, context, activity demands, and the
application of services in the profession of occupational therapy are defined.
According to the Practice Framework, occupational therapy intervention is used to assist
the client in attaining well being physically, mentally, and socially (AOTA, 2008). Bipolar
disorder interrupts one’s ability to function effectively in many areas of daily life and
occupational performance such as initiating activity, attending to a task, participating in
interpersonal relationships, and coping (Cara, 2005). During depressive episodes, a child will
more likely become irritable, withdrawn, and lack the motivation to participate in daily activities
(Watling & Nielsen, 2010). During a manic episode, a child will have increased difficulties
12
attending to tasks, decreased ability to engage in interpersonal interactions, and may have
decreased judgment (Watling & Nielsen, 2010). By applying the principles outlined within the
Practice Framework during intervention, an occupational therapist can help a child improve his
or her ability to function in these areas and improve quality of life.
Intervention Strategies
In the literature, four specific approaches have been found that appear to be successful
when intervening with adults with bipolar disorder, and have also been described for intervening
with children and adolescents. These specific interventions are described below.
Family Focused Treatment. According to Morris, Miklowitz, and Waxmonsky (2007),
family focused treatment (FFT) was developed based on the concept of expressed emotion (EE),
which measures a relative’s attitude toward the client with bipolar disorder. It has been observed
that the higher the level of EE, the poorer the outcome for the individual with bipolar disorder
(Morris et al., 2007). FFT encompasses the use of medication as well as self-management and
skills training (Morris et al., 2007). FFT utilizes two approaches of intervention--education and
skills training. Health professionals use information to educate both the relatives and clients on
what the disorder is and how to cope with it, as well as skills training along with increased
communication to change negative family relations and to teach clients to advocate for
themselves (Morris et al., 2007). While this approach was first used by clinicians working with
people with schizophrenia, some researchers and clinicians found that, because of similar
symptomology, FFT had the potential to be effective for those with bipolar disorder as well (Rea
et al., 2003).
FFT focuses on six objectives that aim to assist people with bipolar disorder: (1) the
incorporation of the individual’s experiences with the disorder, (2) the identification of probable
13
susceptibility to relapses in the future, (3) the acceptance of mood-stabilizing medication as a
method to control symptoms, (4) the ability to discern between the individual’s true personality
and the symptoms of the disorder, (5) learning healthy coping mechanisms during events that
could potentially trigger relapses, and (6) restructuring interpersonal relationships after an
episode occurs (Morris et al., 2007). FFT uses collaborative care, in that it allows for those close
to the client, either family members, close friends, or significant others, to be a part of the
therapy session if the therapist and/or the client sees them as being a crucial aspect to therapy
(Morris et al., 2007). This approach has been shown to decrease hopelessness and improve
overall life functioning (Morris et al., 2007). In addition, studies with adult populations with
bipolar disorder have found that FFT has been effective in stabilizing moods, decreasing
depressive symptoms, promoting longer periods of time between relapses, and encouraging
positive communication within the family more so than other approaches, such as crisis
management interventions (Rea et al., 2003).
Cognitive Behavioral Therapy. Cognitive behavioral therapy (CBT) is an overarching
method of psychotherapy that focuses on the relationship between cognition and behavior, and
the effect dysfunctional cognitive beliefs and thoughts can have on one’s behavior (McCraith,
2011). It is now frequently used during occupational therapy and mental health intervention in
order to address a functional problem, and is considered to be one of the most widely used
psychotherapy approaches today (Alessandri, Cara, & MacRae, 2005; McCraith, 2011). CBT has
been molded and developed over time by four main psychotherapy models : the learning theory
and behaviorism, the social learning theory and social cognitive theory, behaviorally oriented
CBT models, and cognitively oriented CBT models (McCraith, 2011).

14
Each of these models introduces different aspects of CBT and their influences can be
seen in the development of the current CBT approach. Learning theory and behaviorism was
developed by B.F. Skinner in 1953 and focuses intervention on the use of external reinforcement
in order to cause a desired resulting behavior, with reinforcement continuing until the desired
behavior is learned. This theory is not as frequently used in current psychiatric or psychotherapy
intervention, as it did not effectively explain human behavior (McCraith, 2011).
The second theory influencing the current CBT model is the social learning model, or
social cognitive theory, developed by A. Bandura in 1977 (McCraith, 2011). This theory
emphasizes the importance of social and cognitive influences on one’s ability to learn. According
to McCraith (2011), the social learning model “provides the basis for many performance skill-
and occupation-based interventions used by occupational therapists” (p. 268). This model serves
as the foundation for occupational therapists, supporting their use of CBT as treatment for their
clientele.
The third set of models that are foundational to CBT are the behaviorally oriented CBT
models. These models, which were developed in the 1970’s, focus on equipping individuals with
cognitive and behavioral skills that they can generalize to their daily activity in order to increase
overall independence and success in areas that may otherwise be negatively affected by
unhealthy or “dysfunctional” cognitive beliefs and thoughts (McCraith, 2011).
The influence of the cognitively oriented CBT models is also seen in the current CBT
approach. These models focus directly on changing an individual’s thoughts and cognitive
beliefs in order to change his or her behaviors (McCraith, 2011). Falling within the cognitively
oriented CBT models is Cognitive Therapy, which was initially developed by psychiatrist Aaron
Beck in 1976. Using this therapy approach, a therapist works in collaboration with the client to
15
identify and change distorted thoughts and cognitive beliefs to more realistic beliefs in order to
decrease behavioral difficulties (McCraith, 2011).
Currently, there are two basic beliefs that are combined in CBT: the cognitive perspective
and the behavioral perspective. The cognitive perspective focuses on cognitive processes and the
effects of those processes on one’s behavior. Behavioral perspectives are commonly used with
adolescents and adults with mental illnesses and include principles of behaviorism, such as
reinforcement and reward systems, in order to improve positive behaviors and decrease negative
behaviors (Alessandri et al., 2005). CBT is considered to be effective with those who have
mental health disorders, including bipolar disorder (McCraith, 2011).
Dialectical Behavior Therapy. Dialectical behavior therapy (DBT), a type of CBT, is
another evidence-based approach used with bipolar disorder (Goldstein, Axelson, Birmaher, &
Brent, 2007). DBT was originally developed to treat borderline personality disorder in adults,
specifically in women who demonstrated self-injurious behavior (Goldstein et al., 2007; Stepp,
Epler, Jahng, & Trull, 2008). The term dialectic is used to describe the combination of facts or
ideas that contradict one another, and DBT attempts to resolve those contradictions. Change and
acceptance are the main dialectics of DBT. The focus is on accepting one’s current emotional
status and working towards changing one’s behaviors, skills, and thinking, which will in turn
positively affect emotional and functional state (Scheinholz, 2011). DBT focuses on emotional
regulation, making it an effective treatment for individuals with bipolar disorder.
In order to treat this population, an occupational therapist who is certified in DBT can
utilize two main intervention approaches, those being psychotherapy and skills training. Through
the use of psychotherapy and skills training an individual can develop mindfulness, emotional
regulation, distress tolerance, and interpersonal effectiveness (Scheinholz, 2011). Mindfulness is

16
the awareness of self and others, and one’s ability to observe one’s own life through a non-
judgmental lens. Emotional regulation and distress tolerance work in conjunction with one
another allowing a person to overcome and respond appropriately to emotional experiences.
Emotional regulation targets one’s ability to recognize one’s emotions, identify the obstacles that
inhibit the ability to change those emotions, and decrease the susceptibility to being influenced
by these emotions. Distress tolerance then works towards the ability to allow experiences to
occur without altering the natural outcome, and develop appropriate responses to tolerate and
survive the experience (Scheinholz, 2011).
Interpersonal Social Rhythms Therapy. Interpersonal Social Rhythm Theory (IPSRT)
is a type of psychotherapy, backed by empirical research that has been shown to be beneficial
when treating bipolar disorder in adults. IPSRT was developed from Interpersonal Psychotherapy
(IPT), which is a form of intervention that focuses on the difficulties that one is having within
interpersonal and social functioning in order to reduce and manage symptoms (Hlastala, Kotler,
McClellan, & McCauley, 2010; Spangler, 2011). IPSRT was based on the understanding that
bipolar disorder is “an interplay between biological and psychosocial factors” (Crowe et al.,
2008, p.142). In addition to IPT, IPSRT has the added component of having the client look at the
“loss of healthy self” in order to understand the bipolar disorder diagnosis and explore its effects
on the body and mind (Crowe et al., 2008, p. 142). IPSRT also incorporates social rhythm
therapy and an understanding of the circadian system.
IPSRT identifies three pathways through which symptoms can be made worse or
reappear for those with bipolar disorder. The pathways include (1) non-adherence of medication,
(2) interruptions to the circadian system, and (3) interpersonal stressors (Hlastala et al., 2010).
Overall, the goal of IPSRT is to disrupt each of these interconnected pathways in order to
17
improve the outcomes for a client with bipolar disorder (Hlastala et al., 2010). IPSRT addresses
interpersonal issues that are important to the client with bipolar disorder. For an adolescent,
IPSRT focuses on areas such as becoming independent, dating, and dealing with peer pressure
because these psychosocial stressors are often seen as the cause of exacerbation of symptoms
(Hlastala et al., 2010). IPSRT also looks at the biopsychosocial changes that happen during
adolescence and the effects of these changes on an adolescent’s sleep cycle, as sleep disruptions
also effect the exacerbation of symptoms (Hlastala et al., 2010). As times have changed,
adolescents’ sleep cycles have also changed due to occupations and social demands (Hlastala et
al., 2010). School starts earlier and adolescents stay awake later into the night. These changes
affect the sleep/wake cycles, especially when patterns of sleep are changed from the weekdays to
the weekends (Hlastala et al., 2010). Even in healthy adolescents, these changes have a negative
effect on “emotional, behavioral, and cognitive functioning” (Hlastala et al., 2010, p.458). The
last aspect that IPSRT looks at is the high rates of medication non-adherence seen in adolescents
and its correlation to relapse (Hlastala et al., 2010).
IPSRT focuses on the significance of the relationship between one’s life events and
moods, maintenance of consistent daily routines through the use of a Social Rhythm Matrix
(SRM), and the ability to identify and manage possible factors, particularly interpersonal factors,
that affect the regulation and balance of rhythm (Crowe et al., 2008). In addition, IPSRT
addresses the grief and mourning experiences that come with the loss of one’s healthy self and
methods for managing potential affective symptoms that are present in the individual (Crowe et
al., 2008).
In order to address symptoms, IPSRT progresses in four stages: initial, intermediate,
preventative, and termination (Frank et al., 2008). During the initial stage, the therapist gathers
18
information about the client’s medical history associated with his or her bipolar disorder,
educates the client about the disorder, and establishes an interpersonal problem area to focus on
during therapy (Frank et al., 2008). This stage is also when clients fill out the SRM, which is a
self-report of their daily schedule including when they wake, when they eat, when they return to
bed for the night and what their moods have been throughout the day (Crowe et al., 2008). Here,
education also involves the therapist explaining how the patterns of these activities combined
with the identified interpersonal issues affect the client’s mood (Crowe et al., 2008). In the
intermediate stage, the therapist provides strategies for stabilizing social rhythms and for dealing
with affective symptoms, and works with problem areas defined in the initial stage (Frank et al.,
2008). In the preventative stage, the therapist works to combine gains made by the client during
treatment and educates them on risk factors that could affect stability (Frank et al., 2008).
Finally, in the termination stage, the therapist reviews the client’s completed goals as well as
discusses areas that still need strengthening (Frank et al., 2008). In adults with bipolar disorders,
IPSRT has been found to decrease the time it takes to recover from depressive symptoms and
lengthens the time between episodes (Hlastala et al., 2010).
The interventions that are currently supported with evidence have primarily focused on
adults. In addition, one of the most prevalent interventions for those with bipolar disorder is
pharmacological treatment, which tends to have undesirable side effects. Occupational therapists
are working with adolescents with bipolar disorder, but there is little documented evidence of the
efficacy of their interventions in the occupational therapy literature. It is important that
occupational therapists provide interventions that fall within scope of practice as defined by the
Practice Framework and are shown to be effective through evidence-based research. The
purpose of this systematic literature review was to identify the current, evidence-based, non-
19
pharmacological interventions being used with adolescents with bipolar disorder. Through
awareness of occupational therapy’s role when working with this population, additional, more
holistic methods of intervention can be used. In order to increase the awareness of effective,
evidence-based interventions that fall within occupational therapy scope of practice, a review of
current literature was conducted to answer the question: what are the most effective evidence-
based occupational therapy interventions for adolescents with bipolar disorder?
Methodology
The goal of this systematic literature review was to identify the most effective evidence
based occupational therapy interventions for adolescents with bipolar disorder. Due to the
limited amount of research done on this topic, research evidence at levels I-V, and evidence
found in both peer-reviewed and non-peer-reviewed publications were included.
A search of the interprofessional health literature was conducted using PsychINFO,
MEDLINE Full Text, PsychARTICLES, and CINAHLplus with full text. A search was also
done using Google Scholar and SOLAR, The College of St. Scholastica’s integrated data search
engine. Secondary hand searches were conducted of the American Journal of Occupational
Therapy and American Journal of Psychiatry. Secondary hand searches were also conducted by
using reference lists from the selected primary articles in order to locate additional sources. The
primary search terms used to search the databases included: occupational therapy interventions
for adolescents with bipolar disorder, occupational therapy interventions for bipolar disorder,
social rhythm therapy, depression, and David Miklowitz. Advanced search terms used were:
bipolar disorder AND occupational therap*, social rhythm therapy AND bipolar, adolescent
AND bipolar treatment, therapy AND bipolar, adolescen* AND bipolar treatment, bipolar
disorder AND treatment, and occupational therap* AND bipolar.

20
Inclusion criteria were as follows. Treatment interventions needed to fall within the
occupational therapy domain as defined by the Practice Framework (AOTA, 2008). Participants
in the study had to fall within the age range of adolescence (9-18.11 years of age) and also had to
be diagnosed with bipolar disorder. Evidence at levels I-V, and evidence found in both peer-
reviewed and non-peer-reviewed publications were included. The literature was searched for
articles published from 2006 through the present in order to gather most recent data. Articles
selected in the search had to be written in the English language.
Studies were excluded if they were theoretical in nature, had no information on
intervention effectiveness, were conducted using adult populations, or the interventions fell
outside the occupational therapy domain of practice (e.g. psychopharmacology and
electroconvulsive therapy).
The interventions were analyzed in terms of their quality and effectiveness according to
criteria developed for the “AOTA Evidence-Based Practice Project” (Leiberman & Sherer,
2002). This methodology was chosen because of the emphasis the American Occupational
Therapy Association (AOTA) is placing on evidence-based practice. AOTA has determined that
this will be the methodology for evidence-based practice and we wanted to use an approach
consistent with the occupational therapy profession. The “AOTA Evidence-Based Practice
Project” criterion categorizes research articles into specific levels of evidence (I-V) according to
research design, sample size (A= n>20 per condition; B= n<20 per condition), and internal and
external validity (Trombley, Tickle-Degnen, Baker, Murphy, & Ma, 1999). The levels of
evidence are as follows: Level I: Randomized controlled trials (RCT) using experimental designs
with randomization to groups and repeated measure designs with randomization to sequence of
treatments; Level II: Non-RCT-2 group, two group (treatments) comparisons, repeated measures
21
but with two conditions; Level III: Non-RCT-1 group, one group pre- and post-test, cohort, case
control, or cross-sectional designs; Level IV: Single-subject design; Level V: Narratives, case
studies, qualitative designs, and expert opinion. Internal validity is measured based on the level
to which the studies outcomes can be explained by alternative variables. External validity is
measured based on the level to which the participants represent the general population and the
treatment represents the current practice (Leiberman & Sherer, 2002). (See Appendix B: Levels
of Evidence and Classification Scheme.)
In addition to the levels of rigor, we chose to focus on interventions that fall within the
occupational therapy domain of practice using the Practice Framework (AOTA, 2008). The
intended purpose of the Practice Framework is to outline the domain and process of
occupational therapy evaluation and intervention and is helpful in determining new applications
in emerging practice areas (i.e. effective evidence based interventions that fall under the
occupational therapy domain of practice for adolescents with bipolar disorder). In this study the
treatment intervention needed to be based around occupational therapy domains. These are
performance patterns (habits, roles, and rituals); client factors including social participation,
communication and problem solving, socialization and interpersonal skills, and emotional
regulation. They also needed to be considered occupational therapy process (i.e. interventions)
including cognitive behavioral therapy, self-management strategies and skills training, and
behavior modification. A column labeled “OT domain of practice” was added to the inclusion
table (Appendix C, Table 1: Inclusion Table) in order to relate each article back to the
occupational therapy scope of practice.
Articles for this study were reviewed independently by each author. The first reader read
for themes related to our research question, noted occupation based practice, determined whether
22
the study met the inclusion criteria, assigned the levels of rigor, and entered information into the
evidence table (Appendix C, Table 1: Inclusion Table). The second reader examined the articles
for additional information that the first reader may have missed and checked the accuracy of the
first reader’s data entered into the evidence table. Each reader had the equal opportunity to be
first reader. Any inconsistencies were discussed for consensus. Articles that were reviewed but
ultimately determined not to meet the inclusion criteria were recorded on an exclusion table
(Appendix C, Table 2: Exclusion Table).
Results
A total of seven articles describing quantitative studies ranging in levels of rigor from I-V
were found for the years 2006 through 2011. The articles identified effective interventions for
adolescents, ages 9-18.11 years, with bipolar disorder. The interventions found in these studies
fall within the scope of practice for occupational therapy as determined by the Practice
Framework and include Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy
(DBT), Interpersonal Social Rhythm Therapy (IPSRT), and Family-Focused Treatment (FFT).
Family Focused Treatment (FFT)
According to the literature we found, the most commonly used intervention for
adolescents with bipolar disorder was FFT, which was discussed in three of the seven studies.
Miklowitz et al. (2008) conducted a level I randomized controlled trial (RCT) that supported the
use of FFT-A to stabilize the depressive symptoms that are characteristic of bipolar disorder. The
study consisted of 21 50-minute sessions over a 9-month period of time, followed by a two-year
follow-up process. A sample of 58 adolescents engaged in psychoeducation and communication
and problem solving skills training. 36 participants completed the follow-up. The participants
varied in age, ranging from 12 to 17.11 years and were diagnosed with bipolar disorder I, bipolar
23
disorder II, or bipolar disorder not otherwise specified (NOS) according to the DSM-IV-TRS
criteria. The participants were diagnosed by a physician, as well as researchers of this study
using the Kiddie Schedule for Affective Disorders and Schizophrenia, Present and Lifetime
Version (K-SADS-PL), K-SADS Depression and Mania Rating Scales (DRS and MRS), and the
Child’s Global Assessment Scale (CGAS).
There were two treatment groups, one of which received only medications and family
psychoeducation for three sessions, and the other received medication and FFT-A intervention
for 9 months. As a treatment for those receiving FFT-A, the first portion of the study provided
psychoeducation to the participants and the families regarding the symptoms of BPD in
adolescents, the importance of medication management, and steps to take if there is a relapse.
Later in the treatment, the FFT-A intervention was used to assist in the development of
communication and problem solving skills for the participants as well as their families.
Researchers used the Adolescent Longitudinal Interval Follow-Up Evaluation (A-LIFE) and the
K-SADS DRS and the K-SADS MRS in order to identify participants’ symptom status at varying
points over the next two years.
Overall, Miklowitz et al. (2008) found that those who participated in FFT-A interventions
had less severe manic and depressive mood episodes (p = 0.006), shorter depressive episodes (p
< 0.001) and recovered from those depressive episodes more rapidly than those who only
received medication and psychoeducation (p = 0.04). According to the results of this study, FFT-
A is an effective intervention for treating adolescents with bipolar disorder. The study had some
limitations including the differing clinical statuses of the participants in regard to type and
frequency of episodes, unequal amount of treatment time between groups that impacted levels of
24
therapist-patient bond, and use of psychopharmacological treatment by the participants. These
limitations make it difficult to identify the extent to which the treatment outcome was affected.
Another research study that was conducted by Miklowitz et al. (2011) looked at a version
of FFT that was adapted for youth who are at higher risk for being diagnosed with bipolar
disorder (FFT-HR). This level III one-year treatment development trial provided twelve
treatment sessions in conjunction with medication, if needed, to 13 participants who met the
DSM-IV-TRS criteria for major depressive disorder, cyclothymic disorder, or bipolar disorder-
NOS. Evaluations of the participants were completed using the Washington University Version
of the Schedule for Affective Disorders and Schizophrenia for Children (WASH-U-KSADS) and
the K-SADS-PL. Sessions were broken down into three parts: psychoeducation, communication
enhancement training, and problem solving skills training, with each section spanning four
sessions totaling four months. Interviews were completed every four months for the duration of a
year. Interview outcome measures consisted of the Adolescent Longitudinal Interval Follow-up
Evaluation (A-LIFE), the Young Mania Rating Scale (YMRS), and the Children’s Depression
Rating Scale-Revised (CDRS-R). Results showed that over the course of one year, participants’
depression (p < 0.0001) and hypomania symptoms (p < 0.0001) had decreased while global
functioning increased (p < 0.0001). Limitations to this study, according to the researchers,
included the open trial design and the inability to rule out the effects of medications on the
outcome of the study. By using an open trial design versus a randomized control trial, they were
unable to “address whether family treatment is necessary to bring about symptoms reductions” in
adolescents with bipolar disorder or if “the passage of time would have accomplished the same
results” (Miklowitz et al, 2011, p.73).

25
The final research study was conducted by Morris et al. (2007). This level V case study
looked at the effects of FFT in conjunction with mood stabilizing medication for a 16-year-old
girl. Prior to the study, the participant was diagnosed with bipolar I disorder based on criteria
from the K-SADS-PL. Treatment consisted of 21sessions over a 9-month period including
education about the diagnosis, family communication skill training, problem solving skills
training, and application of learned skills. Morris et al. (2007) determined that FFT was effective
for the participant and her family based on the stabilization of depressive symptoms and
adherence to her medication routine. A major limitation to this study is its sample size. Because
there was only one participant, both the reliability and validity of this study are limited and
outcomes cannot be generalizable to other adolescents with bipolar disorder.
Three studies were conducted on the effectiveness of FFT. The interventions in all three
studies included problem solving and communication skills. Other skills addressed within the
studies were medication management and relapse planning. Despite limitations, the researchers
considered the approaches to be effective in treating adolescents with bipolar disorder.
Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT)
Feeny, Danielson, Schwartz, Youngstrom, and Findling (2006) conducted a level II pilot
study assessing the efficacy of CBT in conjunction with pharmacological treatment for
adolescents with bipolar disorder. This study consisted of 16 adolescents aged 10-17 years, each
of whom met the criteria for bipolar I, bipolar II, or cyclothymia. Of the 16 participants, eight
were given the CBT treatment, while the remaining eight made up the control group. In total, the
treatment consisted of 12 sessions where the participants received individual CBT treatment with
one of two clinical psychology graduate students or the students’ supervisor, a licensed clinical
psychologist. The participants’ treatment consisted of problem solving skill training, goal-
26
setting, medication management, communication and social skills, coping and relaxation, and
relapse prevention. Outcome measures administered with participants included The Young Mania
Rating Scale (YMRS) in interview format, the Inventory of Depressive Symptoms (IDS) also in
interview format, and the General Behavior Inventory (GBI) in self-report checklist format. The
YMRS and IDS were administered by the researchers to each participant, while the IDS was
completed by both the participants and the parents of the participants.
The results of the study conducted by Feeny et al. (2006) showed that the CBT
interventions, as found though parent report on the GBI, decreased both manic (p < 0.05) and
depressive (p < 0.05) symptoms in the participants, supporting the efficacy of CBT for
decreasing symptoms of bipolar disorder in adolescents. Researchers described two major
limitations to this study that should be addressed in further research. The first limitation was the
small, culturally homogeneous sample size and the use of a pilot study versus a randomized
control trial design. These limitations affect the significance of the outcomes as well as the
generalizability to other adolescents outside the Caucasian race and above or below the middle
class. The second limitation stated was that the control group’s data was collected from medical
chart review and collection was incomplete compared to the treatment group’s data. The control
group was also not assessed using the GBI and therefore their outcomes could not be compared
to treatment outcomes.
A level III one-year open trial was conducted by Goldstein et al. (2007) to assess the
efficacy of a combined family skills training and individual DBT treatment for adolescents with
bipolar disorder. Family skills training and individual DBT were done in conjunction with
pharmacological treatment. The study consisted of 10 participants ranging in age from 14
through 18 years who met the DSM-IV-TRS criteria for bipolar I disorder, bipolar II disorder, or
27
bipolar disorder-NOS and also had a history of attempted suicide. Weekly sessions were held
over the first six months (a total of 24 sessions), followed by 12 sessions during the last six
months of the study. The treatment sessions consisted of problem solving skills training,
behavior adaptations and compensatory techniques training, and symptom regulation training.
The skills were taught during the family focused training, and during the individual training the
participants were taught to apply what they had learned to their daily routine.
Prior to treatment, participants were administered several diagnostic evaluations
including the Schedule for Affective Disorders and Schizophrenia for School-Age Children-
Present and Lifetime Version (K-SADS-PL), K-SADS Mania Rating Scale (MRS) and criteria
from the Course and Outcome of Bipolar Youth Study (CABS). Outcome measures were
conducted every three months throughout the study, and included the K-SADS-P-DRS
(Depressive Rating Scale), K-SADS-P-MRS (Manic Rating Scale), the Modified Scale for
Suicidal Ideation (MSSI), and the Matson Evaluation of Social Skills with Youngsters (MESSY).
The parents of the participants also completed the Children’s Affective Lability Scale in order to
identify emotional dysregulation in the adolescent participant. Participants and parents also
completed a satisfaction questionnaire following the treatment.
Results of this open trial study conducted by Goldstein et al. (2007) showed that family
skills training and individual DBT intervention for adolescents in this sample with bipolar
disorder were effective in decreasing suicide attempts (p = 0.04) and non-suicidal self-injurious
behaviors (p = 0.06), increased emotional regulation (p = 0.02), and decreased depressive
symptoms (p = 0.03). Limitations identified by the researchers include that outcomes were
derived from a small sample size through an open trial versus a randomized control trial design
as well as that participants showed only mild manic symptoms prior to treatment, which limited
28
the ability to assess DBT’s influence on improving manic symptoms. A third limitation to this
study was the absence of DBT consultation staff, which could have resulted in an increase for
potential burnout for the primary therapist leading to a decrease in effectiveness. And finally,
many core elements of DBT can be found in CBT, IPSRT, and FFT, which could indicate that
the element of DBT that is effective in treating bipolar disorder could be found in other related
therapies.
Collectively, two studies were conducted on the effectiveness of CBT and DBT. The
interventions in the CBT study included problem solving skill training, goal-setting, medication
management, communication and social skills, coping and relaxation, and relapse prevention.
The interventions in the DBT study included problem solving skills training, behavior
adaptations and compensatory techniques training, and symptom regulation training. Despite
limitations, the researchers considered the approaches to be effective in treating adolescents with
bipolar disorder.
Interpersonal Social Rhythm Therapy (IPSRT)
A level III open trial was conducted by Hlastala et al. (2010) in order to determine the
feasibility of adapting IPSRT to use with adolescents with bipolar disorder. In this 20-week
study, 12 adolescent participants were provided with IPSRT-A intervention. Evaluations of the
participants were completed using the WASH-U-KSADS and the K-SADS-PL in order to
determine diagnoses. Participants took part in 12-16 weekly sessions as well as 2-4 biweekly
sessions over the course of 20 weeks. Although psychopharmacological intervention was not
included in the study’s treatment, participants were allowed to remain on prescribed medication.
During the first 4-6 sessions, the therapist reviewed each participant’s medical history and
important interpersonal relationships in order to understand his or her social routines, educated
29
each participant on the importance of medication management, and facilitated identification of a
primary interpersonal problem area. During the following 8-10 sessions, the therapist and
adolescent worked together to develop a structured daily routine that addressed the primary
interpersonal problem area. Lastly, during the final three sessions, the therapist emphasized the
conclusion of IPSRT sessions, reiterated each participant’s strengths and weaknesses, and
developed strategies to maintain current and improve future interpersonal relationships.
Outcome measures used during this study were conducted at baseline and every four
weeks and included the Brief Psychiatric Rating Scale for Children (BPRS-C), K-SADS MRS,
and the Beck Depression Inventory (BDI). In addition, the CGAS was given to each participant
at baseline and post-treatment. Every four weeks during treatment researchers administered the
Treatment Satisfaction Scale (TxSat). Results of this study showed increased scores on all
outcome measures in comparison to baseline scores, decreased depressive (p < 0.04) and manic
(p < .03) symptoms of bipolar disorder and increased global functioning (p < 0.001). Limitations
to this study, as described by Hlastala et al. (2010), include the use of an open trial design and
the lack of a control group to show the correlation between the outcomes and the effectiveness of
IPSRT. The subjects continued to use medication through the duration of the study and were
aware of the type of therapy that they were receiving, which could have also impacted the
outcome of the study.
A level V case study conducted by Crowe et al. (2008) also looked at how IPSRT could
be adapted for an adolescent with bipolar disorder. The participant was 15 years of age and
previously diagnosed with bipolar disorder, type unspecified in the literature. She participated in
30 sessions over 18 months, which included identifying current relationships and social routines,
psychoeducation on BPD and how mood symptoms effect normal development and patterns of
30
daily living, and developing strategies to stabilize mood during role transitions. No outcome
measures were noted by Crowe et al. (2008). Results show that the participant developed age-
appropriate self-identity, as well as increased ability to manage bipolar disorder symptoms. This
study supports the use of IPSRT with adolescents due to its ability to facilitate the development
of self-identity. A major limitation to this study is its sample size. With only one subject, both
the reliability and validity of this study are limited and outcomes may not be generalizable to
other adolescents with bipolar disorder.
Two studies were conducted on the effectiveness of IPSRT. The interventions in both
studies included interpersonal skill training, medication management, and routine building.
Another skill addressed during intervention within the study conducted by Crowe et al. (2008)
was symptom management during role transitions. Despite limitations, the researchers
considered the approaches to be effective in treating adolescents with bipolar disorder.
Discussion
The purpose of this systematic literature review was to find the most effective
occupational therapy interventions for adolescents with bipolar disorder. Bipolar disorder is a
mental health disorder that interferes with one’s ability to participate in and complete daily
activities as a result of manic and depressive symptoms. Mania and depression can cause
changes in sleeping and eating habits as well as decreased concentration, increased distractibility
and racing thoughts, and decreased involvement in activities of interest or increased risky
behaviors (Kuwana, 2005). These symptoms also disrupt an adolescent’s ability to successfully
engage in interpersonal and peer relationships, school activities, and personal areas of interest.
Each of these areas fall within the occupational therapy scope of practice, outlined by the
Practice Framework. The Practice Framework consists of the domain and process of
31
occupational therapy and defines occupational therapy as an area of practice that supports and
promotes the health of people and populations through engagement in meaningful activity
(AOTA, 2008). By applying the principles outlined within the Practice Framework during
intervention, an occupational therapist can help an adolescent improve his or her ability to
function in these areas and improve quality of life.
Four occupation-based interventions appear to be effective in the treatment of adolescents
with bipolar disorder, based on the outcomes of seven studies. Each of these studies described
intervention methods that increased occupational and global functioning, and decreased
symptoms of bipolar disorder in the adolescent participants. While there was at least one study
found that supported each intervention, there were a limited number of studies available that
discussed any type of occupation-based interventions with adolescents with bipolar disorder.
Therefore, none of the treatments identified in the seven studies can be adequately supported.
Due to this finding, the initial question “what is the most effective occupational therapy
intervention for adolescents with bipolar disorder?” could not be fully answered. However, the
outcomes of the studies provide support for the effectiveness of the four interventions found.
FFT focuses on the involvement of the family in the intervention process, while working
on occupational skills such as interpersonal skills, self-identification, coping skills, problem
solving, communication, medication management, and emotional regulation. Throughout the
intervention process, participants work towards increasing positive family relationships and
communication by incorporating techniques to improve self-management and training for
occupational skills. Each study included in this review found that adolescents participating in this
form of intervention experienced shortened length of depressive and manic episodes, decreased
depressive and hypomanic symptoms, and increased overall global functioning.

32
Although the FFT interventions were not carried out by an occupational therapist, the
skills taught in the psychoeducation sessions fit within the occupational therapy scope of practice
according to the Practice Framework. Communication skills, problem solving skills, and
underlying skills that assist with medication management and relapse planning are considered
performance skills and performance patterns, which are both domains of focus for occupational
therapy.
Although there were few studies included in this review, those that addressed CBT and
DBT found the approaches facilitated positive outcomes in this population. CBT is an approach
that focuses on the relationship between cognition and behavior through the use of skill building
in order to increase functional ability and reduce symptoms of bipolar disorder. DBT is a method
of CBT that also looks at the relationship between cognition and behavior, however focuses
treatment on emotional regulation, rather than skill building. In one study, CBT was combined
with psychopharmacological treatment and was shown to decrease both manic and depressive
symptoms in the adolescent participants. The study that used DBT was combined with family
skills training, which led to decreased suicidal behaviors and depressive symptoms, as well as
increased emotional regulation abilities. While CBT and DBT approaches appear promising for
this population, the two studies found were in conjunction with other approaches, such as family
skills training and psychopharmacology. Therefore, the efficacy of both CBT and DBT can not
be entirely determined.
Similar to FFT, these CBT and DBT focused studies did not include occupational therapy
in the interventions, nor do they mention the profession’s potential involvement in the future.
However, several of the intervention strategies and goals fall within occupational therapy scope
of practice, according to the Practice Framework, including problem solving, communication

33
and coping skills training, emotional regulation, behavioral adaptations, compensatory
techniques and symptom management. In addition, medication management and social
interaction are both skills that fall into the “areas of occupation” category. Roles and routines fall
within the “performance pattern” domain, while environmental modifications fall under the
domain of “activity demands.”
IPSRT focuses on improving social interaction, peer interaction, and medication
adherence through the use of psychoeducation, interpersonal skill building, and routine
development. The outcomes of the few studies analyzed for this review showed increased global
functioning, increased symptom management, as well as decreased overall symptoms of bipolar
disorder. Neither of the two studies using IPSRT included occupational therapy services in their
interventions, however social and peer interaction fall under the area of “performance skills”,
while routine development falls under the domains of “performance pattern” and “area of
occupation” according to the Practice Framework.
Although the interventions reviewed for this study fit with the occupational therapy scope
of practice, occupational therapy is not mentioned in any of the studies as a profession
contributing to the intervention being provided. Occupational therapy practitioners work within
the mental health field, as well as with the adolescent population, however because it is only
recently that a bipolar diagnosis is being given to adolescents, the amount of research currently
being conducted on this population within occupational therapy literature is limited.
Occupational therapy is guided by many models of practice and frames of reference. The
premises and perspectives of the models and frames of reference are reflected in the
interventions used by occupational therapists. A model of practice involves applying a
theoretical base to intervention while a frame of reference provides a structure that will guide an
34
intervention (Cole, 2007). FFT reflects the psychodynamic frame of reference as it focuses on
understanding the symptoms of bipolar disorder and how these symptoms affect one’s behavior,
the development of effective family communication in order to enhance the relationship
dynamics, and the implementation of strategies for more effective occupational performance.
CBT and DBT are interventions used within the behavioral/cognitive behavioral frame of
reference with their focus on utilizing behavioral adaptations, environmental modifications and
emotional regulation skills to enhance behavioral and occupational performance. IPSRT would
be an approach used by therapists influenced by the Model of Human Occupation in that it
focuses on sleep habits, social roles, and the interpersonal issues that arise due to disruption in
these areas of occupation. Although only three frames of references were identified, each of
these interventions could fall within a number of occupational therapy frames of references.
Overall, the most effective evidence based occupation therapy interventions for treating
adolescents with bipolar disorder that were found in the literature were CBT, DBT, IPSRT, and
FFT. By addressing the functional areas or areas of occupation that are negatively affected in
adolescents with bipolar disorder, these interventions appear to be effective in decreasing manic
and depressive symptoms. In turn, the reduction in symptoms enabled an increase in participants’
ability to participate in functional, daily activities. It appears that applying techniques that focus
on aspects of occupational development is a successful approach for treating this population.
Occupational therapists are able to play a large role in providing this form of intervention, as
occupation and independence in daily activity is a main element of their scope of practice.
Currently, occupational therapists are not only working with the mental health population, but
are seeking to be identified in our licensing regulations as primary providers. Evidence gathered
35
on the use of these four interventions by occupational therapists would help support these
techniques being implemented into occupational therapy practice.
Limitations
Both researchers are graduate level students and have limited research experience. Our
limited level of skills in data gathering, interpretation, and analysis may have impacted the
results. However, we were able to access library personal and experienced faculty to help us with
the process, and through the completion of this systematic literature review our knowledge of the
research process has increased greatly. In addition, time allotted for this study was limited due to
academic obligations and a one-year timeline. Scheduled meetings within and outside of class
periods allowed for adequate time to be spent researching and composing this systematic
literature review. Data was also limited, as some resources were unable to be included in this
study due to cost or accessibility. We reached saturation with the resources we had available.
The researchers have also found that resources available through the College of St. Scholastica,
such as databases, information accessible through inter-library loans, and research professionals,
have been greatly beneficial to the research process.
Future Research. Mental health and interventions with youth are recognized as
emerging areas of practice, as outlined in the AOTA’s Centennial Vision. As of now, there are a
limited number of studies conducted with adolescents with bipolar disorder. For this reason it is
important to increase the amount of literature supporting the involvement of occupational
therapy with persons, especially children and adolescents, with mental health disorders. The
majority of the research found used an adult population and highlighted interventions that were
found effective only for adults. As noted in the background literature review, CBT, DBT, FFT,
and IPSRT are most frequently used when working with the adult population with bipolar
36
disorder. Because adolescents have only recently been diagnosed with bipolar disorder, this may
also contribute to the lack of research available.
In addition to the limited amount of current research in this area, all of the studies that
were found allowed participants to continue using pharmacological treatment throughout the
duration of the study. Because of this, it is not possible to know the extent to which the
medications or the treatment being provided affected the adolescents’ treatment outcomes. It
would be beneficial to develop and conduct research that supports the use of only occupational
interventions, in order to identify the true effects of the interventions.
A final concern with the literature found for this study was the low rigor of many of the
studies and small sample sizes of most studies. Levels of rigor of the studies found ranged from I
through V, with the majority of the studies being levels III and V, non-randomized control trials
and case studies. Because most studies had small sample sizes, this impacts the validity of the
studies, with the potential that the studies may not be an accurate depiction of the general
population of adolescents with bipolar disorder and limits the generalizability of the outcomes
across this population. Finally, because the studies had low rigor and there were so few studies
found in the literature, we can’t claim the efficacy of any of the approaches, and our research
question cannot be answered with assurance.
In the future, more rigorous studies, such as RCTs, need to be conducted in order to
support the involvement of occupational therapy in the intervention of adolescents with bipolar
disorder. Studies also need to be conducted on occupation-based interventions alone, without the
use of pharmacological treatment. There is a great need for occupational therapists to expand
their evidence-based practice in the field of mental health in general, as well as with this specific
population. In order to provide the most effective interventions for this population, more research
37
must be conducted that includes occupational therapy. Occupational therapy can provide
intervention that develops problem solving skills, communication skills, medication
management, ADL training, social skills, and coping skills for adolescents with bipolar disorder,
which falls under the Practice Framework. Each of the interventions discussed in this literature
review that were found to be effective with this population incorporate some of these skills,
which in turn places these intervention techniques into the occupational therapy scope of
practice. More rigorous research on these interventions that includes the use of occupational
therapy will greatly benefit this population, as well as provide recognition of occupational
therapy’s contributions in this area.

38
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Morris, C. D., Miklowitz, D. J., & Waxmonsky, J. A. (2007). Family-focused treatment for
bipolar disorder in adults and youth. Journal of Clinical Psychology, 63(5), 433-445.
National Alliance on Mental Illness. (2010). Mental illness: Child and adolescent bipolar
disorder. Retrieved from
http://www.nami.org/Template.cfm?Section=By_Illness&template=/ContentManagement
/ContentDisplay.cfm&ContentID=13107
Rea, M. M., Miklowitz, D. J., Tompson, M. C., Goldstein, M. J., Hwang, S., & Mintz, J. (2003).
Family-focused treatment versus individualized treatment for bipolar disorder: Results of
a randomized clinical trial. Journal of Counseling and Clinical Psychology, 71, 482-492.
doi: 10.1037/0022-006X.71.3.482
41
Spangler, N. W. (2011). Mood disorders. In C. Brown, V. Stoffel, & J. Munoz (Eds.),
Occupational therapy in mental health: A vision for participation (pp.155-166).
Philadelphia: F. A. Davis.
Stepp, S. D., Epler, A. J., Jahng, S., & Trull, T. J. (2008). The effect of dialectical behavior
therapy skills use on borderline personality disorder features. Journal of Personality
Disorders, 22(6), 549-563.
Trombley, C., Tickle-Degnen, L., Baker, N., Murphy, S., & Ma, H. (1999). Levels of
evidence for occupational therapy outcomes research. Unpublished table, Boston
University.
U.S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon
general. Rockville, MD: U.S. Department of Health and Human Services, Substance
Abuse and Mental Health Administration, Center for Mental Health Services & National
Institute of Mental Health. Retrieved from
www.surgeongeneral.gov/library/mentalhealth/home.html
U.S. Department of Health and Human Services, National Institutes of Health, National Institute
of Mental Health. (2009). Bipolar Disorder (NIH Publication No. 09-3679). Retrieved
from http://www.nimh.nih.gov/health/publications/bipolar-disorder/nimh-bipolar-
adults.pdf
U.S. Department of Health and Human Services, National Institutes of Health, National Institute
of Mental Health. (2008) Bipolar disorder in children and teens: a parent’s guide (NIH
Publication No. 08-6380). Retrieved from
http://www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-teens-a-
parents-guide/nimh_bipolar_children_parents_guide.pdf
42
Watling, R. & Nielsen, S. (2010). Occupational engagement of children and youth with mental
illness. In M. Kavanahaugh Scheinholtz (Ed.), Occupational Therapy in Mental Health:
Considerations for Advanced Practice (pp. 66-67). Bethesda, MD: AOTA Press.
43
Appendix A
Bipolar I Disorder
Diagnostic criteria for
296.0x Bipolar I Disorder, Single Manic Episode

● Presence of only one Manic Episode and no past Major Depressive Episodes.
● Note: Recurrence is defined as either a change in polarity from depression or an interval
of at least 2 months without manic symptoms.
● The Manic Episode is not better accounted for by Schizoaffective Disorder and is not
superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or
Psychotic Disorder Not Otherwise Specified.
296.40 Bipolar I Disorder, Most Recent Episode Hypomanic

● Currently (or most recently) in a Hypomanic Episode.
● There has previously been at least one Manic Episode or Mixed Episode.
● The mood symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
● The mood episodes in Criteria A and B are not better accounted for by Schizoaffective
Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder,
Delusional Disorder, or Psychotic Disorder Not Otherwise Specified.
296.40 Bipolar I Disorder, Most Recent Episode Hypomanic

● Currently (or most recently) in a Hypomanic Episode.
296.4x Bipolar I Disorder, Most Recent Episode Manic

● Currently (or most recently) in a Manic Episode.
● There has previously been at least one Major Depressive Episode, Manic Episode, or
Mixed Episode .
296.6x Bipolar I Disorder, Most Recent Episode Mixed

● Currently (or most recently) in a Mixed Episode.
● There has previously been at least one Major Depressive Episode, Manic Episode, or
Mixed Episode.
44
296.5x Bipolar I Disorder, Most Recent Episode Depressed

● Currently (or most recently) in a Major Depressive Episode
296.7 Bipolar I Disorder, Most Recent Episode Unspecified

● Criteria, except for duration, are currently (or most recently) met for a Manic, a
Hypomanic, a Mixed, or a Major Depressive Episode.
● The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective
● The mood symptoms in Criteria A and B are not due to the direct physiological effects of
a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical
condition (e.g., hyperthyroidism).
296.89 Bipolar II Disorder (Recurrent Major Depressive Episodes With Hypomanic

Episodes)
Diagnostic criteria for:
296.89 Bipolar II Disorder

● Presence (or history) of one or more Major Depressive Episodes.
● Presence (or history) of at least one Hypomanic Episode.
● There has never been a Manic Episode or a Mixed Episode.
● The mood symptoms in Criteria A and B are not better accounted for by Schizoaffective
● The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
(American Psychiatric Association, 2000, p. 382-400)

45
Appendix B
QUANTITATIVE Levels of Evidence for Occupational

Therapy Outcomes Research
Level of evidence for design
I Randomized control trial (RCT)—compared 1 or more
groups/conditions in experiment with random assignment to
group (or sequence in repeated measures design)
II Non-randomized control trial—two or more
groups/treatments in quasi-experimental with no
III randomization
Non-randomized control trial—one group (one treatment),
IV pre-test and posttest
V
Single-study design—one subject studied at intervals
throughout treatment
Narratives, case studies
Level of evidence for sample size

A n > 50 per condition, group, or observation
B n > 20 per condition, group, or observation
C n < 20 per condition, group, or observation
Level of evidence for internal validity

1 High internal validity; no alternative explanation for
outcome, no obvious threats such as attrition, unblinded
2 evals, unequal treatment, or spontaneous recovery
Moderate internal validity; attempt to control for lack of
3 randomization, no strong alternative explanation for outcome
but 1-2 threats to validity
Low internal validity; two or more serious alternative
explanations for outcome
Level of evidence for external validity

a High external validity; participants represent population and
treatments represent current practice OR strong theoretical
support and research was done in a natural (home/clinic)
b setting
c Moderate external validity; between high and low (has 2-3 of
the criteria for a)
Low external validity; heterogeneous sample without being
able to understand whether effects were similar for all
diagnoses or treatment does not represent current practice
Adapted by Dr. Erica Stern from Lieberman, D. & Scheer, J.

(2002). AOTA’s evidence-based literature review project: An
overview. American Journal of Occupational Therapy, 56(3),
344-359.
46
Appendix C
Table 1
Inclusion Table
Author, Year Level of # of Sub. Treatment Measures Data Analysis Results Framework
Evidence Sub age
Hlastala, S.A., IIIC3c 11 13.9- Interpersonal and Brief Psychiatric Statistical “At the conclusion of Performance
Kotler, J.S., 17.8 Social Rhythm Rating Scale for Package for the the treatment (20 skills,
McClellan, J.M., & Therapy for Children (BPRS-C) Social Sciences weeks), the pilot performance
McCauley, E.A. Adolescents (IPSRT- Version 15 sample of adolescents patterns and
(2010) A) Children’s Global (SPSS) demonstrated areas of
Assessment Scale significant occupations.
(C-GAS) T-tests improvements on all
four clinical outcome
The Mania Rating measures compared to
Scale (MRS) their baseline score.”
(p.461)
Beck Depression
Inventory (BDI)
Treatment
Satisfaction Scale
(TxSat)
Goldstein, T.R., IIIC3b 9 12.0- Dialectical Behavior Schedule for Statistical “Significant Performance
Axelson, D.A., 18.11 Therapy (DBT) Affective Disorders Package for the improvement from pre- skills
Birmaher, B., & and Schizophrenia Social Sciences to posttreatment was
Brent, D.A. (2007) for School-Age Version 13 evident in suicidality,
Children-Present (SPSS) nonsuicidal self-
and Lifetime version injurious behavior,
(K-SADS-PL) T-tests emotional
dysregulation, and
CABS Pre/post depressive symptoms.”
treatment (p.828)
Depression Rating
Scale (DRS) section
of K-SADS-P
Mania Rating Scale

47
(MRS) section of K-
SADS-P
Modified Scale for

Suicidal Ideation
(MSSI)
Child’s Affective
Lability Scale
Matson Evaluation
of Social Skills with
Youngsters
(MESSY)
Crowe, M., Inder, VC3c 1 15 Interpersonal and Social Rhythm Pattern “IPSRT can be an Performance
M., Joyce, P., Moor, Social Rhythm Matrix-II-Five Item matching effective treatment for skills,
S., Carter, J., & Therapy (IPSRT) Version (SRM-II-5) adolescents with performance
Luty, S. (2009) Explanation bipolar disorder by patterns and
Specialist support care Matching facilitating an area of areas of
(SSC) development around occupations.
sense of self into its
therapeutic techniques”
(p.148)
Feeny, N., IIIC3c 16 10-17 Cognitive Behavioral The Young Mania T-Tests “A comprehensive Area of
Danielson, C., years Therapy (CBT): Skill- Rating Scale cognitive-behavioral occupation,
Schwartz, L., based training in (YMRS) ANOVA manualized treatment performance
Youngstrom, E., & problem solving, goal for adolescents with skills,
Findling, R. (2006) setting, medication Inventory of BP who are currently performance
compliance, Depressive being treated with patterns, and
communication and Symptoms (IDS) medication is feasible activity
social skills, coping The General and potentially demands.
and relaxation and Behavior Inventory efficacious.” (p. 513)
relapse prevention. (GBI)
Miklowitz, D.J., IIIC3c 13 9-17 Family Focused Adolescent Mixed effects FFT-HR promising Performance
Chang, K. D., years Treatment-High Risk Longitudinal regression intervention for youth skills and areas
George, E. L., (FFT-HR) Interval Follow-Up modeling with at high risk for BPD. of occupations.
48
Singh, M. K., Evaluation (ALIFE), random

Schneck, C. D., Youth Mania Rating slope/random
Dickinson, L. M., Scale (YMRS), intercept
Howe, M. E., and Children’s assumptions
Garber, G. (2011) Depression Rating
Scale, Revised
(CDRS-R)
Miklowitz, D. J., IA3b 58 12-17 Family Focused ALIFE, Kiddie Mixed-effects FFT is an effective Performance
Axelson, D. A., years Treatment Schedule for regression intervention for skills and areas
Birmaher, B., Affective Disorders model adolescents with BPD of occupations.
George, E. L., and Schizophrenia in conjunction with
Taylor, D. O., Depression and medications, in order
Schneck, C. D., Mania Rating Scales to stabilize depressive
Beresford, C. A., (KSADS-DRS and symptoms.
Dickinson, L. M., MRS)
Craighead, W. E.,
and Brent, D. A.
(2008)
Morris, C. D., VC3c 1 16 Family Focused Self-report NA Participant experienced Performance

Miklowitz, D. J., years Treatment clinical stability of skills and areas
and Waxmonsky, J. subsyndromal syptoms of occupations.
A. (2007) of depression and
continued medication
regimine.
49
Table 2
Exclusion Table
References Reason for
exclusion
Frank, E., Soreca, I., Swartz, H.A., Fagiolini, A.M., Mallinger, A.G., Thase, M.E.,...Kupfer, D.J. Adult
(2008). The role of interpersonal and social rhythm therapy in improving occupational functioning in population
patients with bipolar 1 disorder. American Journal of Psychiatry, 165, 1559-1565.
doi:10.1176/appi.ajp.2008.07121953
Rea, M. M., Miklowitz, D. J., Tompson, M. C., Goldstein, M. J., Hwang, S., and Mintz, J. (2003). Adult
Family-focus treatment versus individualized treatment for bipolar disorder: Results of a randomized population
clinical trial. Journal of Counseling and Clinical Psychology, 71, 482-492. doi: 10.1037/0022-
006X.71.3.482
Pavuluri, M. N., Graczyk, P. A., Henry, D. B., Carbray, J. A., Heidenreich, J., & Miklowitz, D. J. Child
(2004). Child- and family-focused cognitive-behavioral therapy for pediatric bipolar disorder: population
Development and preliminary results. Journal of American Academy of Child and Adolescent
Psychiatry, 43(5), 528-537. doi:10.1097/01.chi.0000116743.71662.f8

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Running head: ADOLESCENTS WITH BIPOLAR DISORDER 1

The Most Effective Evidence-Based Occupational Therapy Interventions

for Adolescents with Bipolar Disorder:

A Systematic Literature Review

A Graduate Research Project Submitted in Partial Fulfillment of the Requirements

I, the undersigned, approve the final copy of the thesis:

___ ______________ ____May 11, 2012_____________

___ ___ ____May 11, 2012_____________

All rights reserved

INFORMATION TO ALL USERS

Diane Anderson, PhD, MPH, OTR/L

Gerald Henkel-Johnson, Psy.D., L.P.

achieve her goal to become an occupational therapist.

to benefit this population by incorporating routine development, problem solving,

treatment in order to achieve optimal occupational success.

Key Words: Occupational therapy, bipolar disorder, adolescents

Appendix A-Bipolar Disorder Diagnostic Criteria……………………..…………………... 43

Appendix B-Level of Evidence……………………………………………………………... 45

antidepressants, and anticonvulsants (National Alliance on Mental Illness [NAMI], 2010).

serious side effects, non-psychopharmacological therapy such as occupational therapy should be

Background Literature Review

Bipolar disorder, sometimes known as manic-depressive disorder, is described by the

others may have lingering symptoms (DHHS, 2009).

biochemical, neuroendocrine, genetic, socioenvironmental, psychosocial, and

to the child or adolescent population.

rate of occurrence, the change in presentation of symptoms throughout episodes, symptoms

outward expression of bipolar symptoms (Cogan, 1996).

“uncertainty of their diagnosis” (Beardslee et al., 2005, p.18).

or bipolar disorder diagnosed in childhood. Symptoms of early-onset bipolar disorder appear to

student), and are more likely to attempt suicide (DHHS, 2008).

Due to the scarce number of research studies conducted on bipolar disorder in

parents or siblings do not have the diagnosis (DHHS, 2008).

such as in school, work, or in their relationships with others.

stabilizing medications, atypical antipsychotic medications, antidepressant medications,

rhythm therapy (IPSRT), psychoeducation, electroconvulsive therapy (ECT), and sleep

medications (DHHS, 2009).

Occupational Therapy Practice Framework: Domain and Process, 2nd Edition

people and populations through engagement in meaningful activity (American Occupational

application of services in the profession of occupational therapy are defined.

According to the Practice Framework, occupational therapy intervention is used to assist

occupational performance such as initiating activity, attending to a task, participating in

or her ability to function in these areas and improve quality of life.

Family Focused Treatment. According to Morris, Miklowitz, and Waxmonsky (2007),

susceptibility to relapses in the future, (3) the acceptance of mood-stabilizing medication as a

management interventions (Rea et al., 2003).

Cognitive Behavioral Therapy. Cognitive behavioral therapy (CBT) is an overarching

CBT models, and cognitively oriented CBT models (McCraith, 2011).

intervention, as it did not effectively explain human behavior (McCraith, 2011).

unhealthy or “dysfunctional” cognitive beliefs and thoughts (McCraith, 2011).

decrease behavioral difficulties (McCraith, 2011).

mental health disorders, including bipolar disorder (McCraith, 2011).

Dialectical Behavior Therapy. Dialectical behavior therapy (DBT), a type of CBT, is

regulation, making it an effective treatment for individuals with bipolar disorder.

regulation, distress tolerance, and interpersonal effectiveness (Scheinholz, 2011). Mindfulness is

another allowing a person to overcome and respond appropriately to emotional experiences.

survive the experience (Scheinholz, 2011).

Interpersonal Social Rhythms Therapy. Interpersonal Social Rhythm Theory (IPSRT)

therapy and an understanding of the circadian system.

and its correlation to relapse (Hlastala et al., 2010).

In order to address symptoms, IPSRT progresses in four stages: initial, intermediate,

lengthens the time between episodes (Hlastala et al., 2010).

efficacy of their interventions in the occupational therapy literature. It is important that

based occupational therapy interventions for adolescents with bipolar disorder?

_ May 11, 2012_

_ _ May 11, 2012_________