Early warning signs checklists for relapse in bipolar depression and mania: Utility, reliability and validity

Abstract

Background

Recognising early warning signs (EWS) of mood changes is a key part of many effective interventions for people with Bipolar Disorder (BD). This study describes the development of valid and reliable checklists required to assess these signs of depression and mania.

Methods

Checklists of EWS based on previous research and participant feedback were designed for depression and mania and compared with spontaneous reporting of EWS. Psychometric properties and utility were examined in 96 participants with BD.

Results

The majority of participants did not spontaneously monitor EWS regularly prior to use of the checklists. The checklists identified most spontaneously generated EWS and led to a ten fold increase in the identification of EWS for depression and an eight fold increase for mania. The scales were generally reliable over time and responses were not associated with current mood. Frequency of monitoring for EWS correlated positively with social and occupational functioning for depression (beta = 3.80, p = 0.015) and mania (beta = 3.92, p = 0.008).

Limitations

The study is limited by a small sample size and the fact that raters were not blind to measures of mood and function.

Conclusions

EWS checklists are useful and reliable clinical and research tools helping to generate enough EWS for an effective EWS intervention.

Introduction

Bipolar Disorder (BD) is a common and severe mental health problem characterised by repeated relapses of mania or depression. Recurrence rates are high at around 50% at one year and 70% at four years (Altshuler et al., 2002, Gitlin et al., 1995, Perlis et al., 2006, Yatham et al., 2009). Surveys of patient organisations in the US and UK reveal a strong wish by patients for both self-help and psychological treatments in addition to pharmacotherapy (Hill et al., 1996, Lish et al., 1994, Morselli et al., 2004). Evidence shows that teaching people to recognise and manage Early Warning Signs (EWS) of relapse can increase time to recurrence, decrease hospitalisation and improve functioning (Morriss et al., 2007). Accurate and early detection of warning signs is crucial to the effectiveness of such interventions. The rationale for EWS interventions relies on sufficient warning signs being detected early enough in the prodromal phase to allow action to be taken to prevent further escalation. Evidence suggests that a minimum of three or four early signs can be used but more than six is likely to be necessary for an effective intervention (Morriss, 2004). EWS must be distinguishable from ongoing inter-episode symptoms (which are not specific indicators of relapse), and consistent over subsequent relapses as markers for these events within an individual, resulting in a “relapse signature” (Molnar et al., 1988).

Previous research suggests that 70–80% of people with bipolar disorder can identify one or more prodromal symptoms (Goossens et al., 2010, Jackson et al., 2003) and early symptoms of mania are identified more frequently than early symptoms of depression. Whilst research suggests that there is inter-individual variation, studies have found some consistency between individuals in their reporting of EWS of mania and depression (Goossens et al., 2010, Lam and Wong, 1997, Molnar et al., 1988, Smith and Tarrier, 1992), with the most common EWS for mania being “changes in sleep” and for depression “loss of interest”. Smith and Tarrier (1992) asked people to generate their own EWS and found a number of idiosyncratic ones (e.g. ‘getting very angry with my ex-wife’; ‘increased sensitivity to racism’; ‘cutting face’) emphasising the need to allow for individuality. However, within each individual, there is evidence for consistency in warning signs over time (Molnar et al., 1988), suggesting that individual “relapse signatures” are applicable to bipolar disorder.

A tool to help people identify their own EWS would be beneficial clinically and key to research aiming to identify mechanisms of effective psychosocial and pharmacological interventions involving the recognition of EWS (Morriss et al., 2007). It is important that this tool is flexible enough to pick up idiosyncratic EWS as well as prompting for more common EWS, and that it can be used by people experiencing mood changes, and those close to them who are often the first to notice early signs.

In this study we report on the development and evaluation of the first EWS checklists for depression and mania. This paper will describe the development of the measures and present data on test–retest reliability, and construct validity. Importantly, clinical utility of the measures as assessed by the extent to which the measures can improve on spontaneous recall of EWS will be reported.