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Reviewers searched Medline, Best Evidence, PsychLit, CINAHL, Embase, Cochrane Database of Systematic Reviews to 2000 and Pre-Medline in January 2001. Reference lists were hand searched and researchers contacted.
Eligible studies were those describing early prodromal symptoms of relapse of depression or mania, and duration of such symptoms in people with bipolar or unipolar disorder. Single case reports, papers including patients with diagnoses other than mania or depression, or describing prodromes of the first episode of the illness, or relapses due to reduction in therapy, or residual symptoms from a previous episode, or including no data or only qualitative data were excluded.
Data were extracted on population, sample size and, where available, the proportion of people who were able to identify early symptoms and duration of prodromes.
17 studies met inclusion criteria (1191 participants). Most studies were small and relied on retrospective recall of symptoms.
Bipolar depression – depressive relapse: 8 studies reported on early symptoms of bipolar depressive relapse. Most people with bipolar depression identified early symptoms (70–100%, median 82%). 5 studies reported on the prevalence of early symptoms. Median prevalences were: mood change - 48%; psychomotor change - 41%; increased anxiety - 36%; appetite change - 36%; suicidal ideation - 29%, and sleep disturbance - 24%. Mean duration of depressive prodromes was 11–19 days.
Bipolar depression – manic relapse: 11 studies reported on early symptoms of manic relapse. Prodromal symptoms were identified by 75% to 100% (median 93%) of people. 5 studies reported on the prevalence of early symptoms. Median prevalences were: sleep disturbance - 77%; psychotic symptoms - 47%; mood change - 43%; psychomotor change - 34%; appetite change - 20%, and increased anxiety - 36%. Duration of manic prodromes ranged from 1–120 days.
Unipolar depression: 5 studies reported on early symptoms for relapse. Prevalence data are lacking, but the main early symptoms of unipolar depression were anxiety (87% of people) and irritability (60% of people). Duration of the prodromal period ranged from 7–133 days.
There are limited data on the prevalence and nature of prodromes of affective disorders, especially unipolar disorder. Although findings are limited by heterogeneity of methods, outcome reporting and participants, it appears that people with unipolar or bipolar disorder can identify some prodromal symptoms, which could prompt early intervention.
After decades of relative neglect, the management of bipolar disorder is now going through a very exciting period of rapid development that promises real benefits for patients. There have been recent advances in the drug treatment of acute manic and depressive phases of the disorder and in relapse prevention with both drugs and new psychological treatments including cognitive behaviour therapy and family focused psychotherapy.1 At the heart of current management strategies is the recognition of the central importance of self-monitoring by the patient themselves.2 Clinicians are increasingly working with the patient to identify prodromal symptoms and to devise effective strategies to treat emerging symptoms of mania and depression before they reach full syndromal level. This approach can lead to a very fruitful collaboration between patient and clinician which, together with a clear explanation of the benefits and risks of medicines, promises to improve adherence and outcomes. A key task is the identification of specific symptoms that appear to herald the onset of a mood episode in each patient’s case. This review has usefully synthesised the literature on the prodromes of bipolar depression and mania to help identify the commonest symptoms.
The findings demonstrate that a limited number of symptoms seem to be common in the prodrome and confirm the clinical impression that sleep disturbance is one of the key indicators of manic disturbance. The duration of the prodromal period varied substantially, especially in the case of depressive episodes. However the mean durations are long enough to indicate that there may be the possibility of effective early intervention in many patients. At the same time, for some patients, prodromes are extremely brief, lasting only a day or so. Furthermore, early symptom recognition and intervention may be more effective in the prevention of manic than depressive relapses.3 This highlights the need for further trials on the effectiveness of self-monitoring and early intervention either as an alternative or add-on to long-term drug treatment to prevent relapse. It may be that optimising long-term treatment is especially important when a very brief duration of prodrome makes early intervention difficult, or when the main pattern of illness is depressive.
Source of funding: This work was funded by a Legacy from the Searle Foundation.
For correspondence: J Scott. Division of Psychological Medicine, Institute of Psychiatry, PO Box 96, De Crespigny Park, Denmark Hill, London, SE5 8AF, UK. E-mail:
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