A systematic review of manic and depressive prodromes

Abstract

Background: This paper explores whether individuals with a mood disorder can identify the nature and duration of depressive and manic prodromes. Methods: Seventy-three publications of prodromal symptoms in bipolar and unipolar disorders were identified by computer searches of seven databases (including medline and Psyclit) supplemented by hand searches of journals. Seventeen studies (total sample=1191 subjects) met criteria for inclusion in a systematic review. Results: At least 80% of individuals with a mood disorder can identify one or more prodromal symptoms. There are limited data about unipolar disorders. In bipolar disorders, early symptoms of mania are identified more frequently than early symptoms of depression. The most robust early symptom of mania is sleep disturbance (median prevalence 77%). Early symptoms of depression are inconsistent. The mean length of manic prodromes (>20 days) was consistently reported to be longer than depressive prodromes (<19 days). However, depressive prodromes showed greater inter-individual variation (ranging from 2 to 365 days) in duration than manic prodromes (1–120 days). Limitations: Few prospective studies of bipolar, and particularly unipolar disorders have been reported. Conclusions: Early symptoms of relapse in affective disorders can be identified. Explanations of the apparent differences in the recognition and length of prodromes between mania and bipolar depression are explored. Further research on duration, sequence of symptom appearance and characteristics of prodromes is warranted to clarify the clinical usefulness of early symptom monitoring.

Introduction

Prodromes are described as cognitive, affective, and behavioural early symptoms of a disorder that appear before an episode of depression or mania (*Altman et al., 1992, *Keitner et al., 1996). Fava and Kellner’s (1991) review stated that the duration of a prodrome is defined as the interval from the time that the first symptom is recognised to the time when the symptoms of an episode reach maximum severity. Detection of early symptoms could facilitate early intervention to prevent or reduce the impact of relapse on the individual (*Joyce, 1985, *Molnar et al., 1988, *Smith and Tarrier, 1992, Perry et al., 1995, Basco and Rush, 1996, Lam et al., 1999).

Recent research on psychological interventions for recurrent unipolar and bipolar disorders has utilised the identification and early management of prodromes as a core strategy (Scott, 1995, Scott, 2001, *Perry et al., 1999, Lam et al., 2001, *Katon et al., 2001). Likewise, user groups such as the Manic Depression Fellowship in the UK are trying to teach individuals to identify prodromes in order to employ self-management techniques.

A systematic literature search was conducted to identify what early symptoms of depression and mania have been described; to determine prodrome duration and any differences in duration between depression and mania; and to explore which early warning symptoms are most commonly identified.