This conceptual analysis synthesizes patient-level participation barriers described in the bipolar disorder CBT literature and considers ketogenic metabolic therapy (KMT) as a candidate adjunct within a delivery-focused framework. CBT is an evidence-based adjunctive psychotherapy for bipolar disorder, but its clinical value depends on whether patients initiate treatment, sustain session continuity, and complete between-session practice that supports skill use in daily life. In routine care, psyc