Early Monitoring of Prodromal Symptoms in Bipolar Disorder

Early Monitoring of Prodromal Symptoms in Bipolar Disorder

Luke Fullagar

RMIT University

Early monitoring of prodromal symptoms has been included in numerous efficacious adjunctive psychosocial approaches to the treatment of bipolar disorders (e.g.  Family Focused Treatment (FFT) (Simoneau et al., 1999); Cognitive Behavioural Therapy (CBT) (Lam et al., 2000) (in both one-on-one (Lam et al., 2000; 2003; 2005) and group settings (Castle et al., 1997)); Interpersonal and Social Rhythm Therapy (IPSRT) (Frank et al., 1999); and Psychoeducation (Colom et al., 2003).

Prodromal symptoms emerge during the time between when symptoms are first recognised and when they reach an apex of severity (Molinar et al., 1988).  Because bipolar disorders involve a characteristic fluctuation in mood, behavior, and cognition, detecting and managing these symptoms during the early prodromal phase is critical and has been shown to assist in both preventing and reducing the severity of bipolar episodes (Joyce, 1985; Perry et al., 1999).  Moreover, psychosocial interventions that include early symptom monitoring have also been shown to positively assist in: relapse prevention, increasing time to relapse, decreasing rate of hospitalisation, lowering symptom severity and episode length, and enhancing quality of life (Gitlin et al., 1995; Lam et al., 2003; Morriss et al., 2002; Scott et al., 2001).

Patients with chronic conditions including bipolar disorders report a need for both self-help and psychosocial treatments in conjunction with pharmacotherapy (Hill, Hardy & Shepard, 1996; Lish et al., 1994), in which they are an active partner in the management of their condition. Psychosocial interventions that include early monitoring of prodromal symptoms meet this need by assisting patients to become aware of symptomatic changes in mood, cognition and behavior; to categorise these symptoms and processes with their clinicians and to use this information and skill set to develop coping strategies for prodromal symptoms (e.g. strategic and responsive lifestyle alterations, behavioral modification or seeking assistance) (Lam et al., 1999).  Research has demonstrated that patients with bipolar disorders can effectively recognise and report prodromal symptoms of a behavioral, mood and cognitive nature (Lam et al., 2001; Mantere et al., 2008) and can distinguish between both elevated and depressed symptoms (Jackson et al., 2003) – findings which lend weight to the appropriateness of this approach in treating bipolar patients in active and remission phases.

The Early Symptom Monitoring Inventory provides a simple, low time investment method for patients to report daily mood states (both high and low, and with a measure of severity) and critical preventative behaviors (sleep, exercise, medication adherence and existence of life stress). It is tailored to be a general inventory, and is therefore able to be usilied in any of the relevant therapies noted above where early monitoring of prodromal symptoms is prescribed by the treating clinician.

Why complete the Early Symptom Monitoring Inventory (ESMI)?

Early symptom monitoring and management is an important part of many collaborative psychological treatments for bipolar disorders. It has been shown to be beneficial in preventing relapse.

Bipolar symptoms fluctuate, and early recognition of their direction, their severity, their cycle and their relationship to other factors like medication levels and life stress, is essential in accurately diagnosing and successfully treating the disorder.  

Regularly completing the ESMI lets you monitor your symptoms and warning signs over time. The ESMI collates daily information of your moods, medication, sleep patterns and stressful events, and produces a chart which you and your clinician can use to monitor whether you are recovering or whether you are experiencing a worsening of symptoms which require early action to reduce the chance of relapse.  Attempting to remember this information over time can be difficult, and especially when you are unwell. Understanding this information can help you see important relationships and patterns that could otherwise be undetected.

How do I complete the ESMI?

The ESMI is conveniently contains a whole month on one sheet.  You can print it out and complete by hand, or complete the file electronically.

After entering your name and the relevant month and year, complete the form each day as follows:

• Mood: At the same time each day tick the column for that day twice – one for the highest elevation of mood, and one for the lowest dip in mood for that day. 

o If you experienced a particular symptom you believe important to record in detail, additionally enter the date and details of that symptom in the Detailed Notes sheet.

• Sleep: At the same time each day enter the length of time you slept in that day in hours. 

• Medication: 

o Medication Name: Enter the name of each of your medications at each line in the document provided.

o Daily Medication Dose Taken: At the same time each day enter in the column for that day the dose in mg of the medication you have used.

• Stressful Life Event: If you have experienced a stressful life event in a particular day, tick the box for that day, and then enter the date and details of that event in the Detailed Notes sheet.

• Exercise: At the same time each day tick the column for that day if you have exercised in a way that you believe reflects the exercise discussed in your treatment sessions.

What should I do if I notice an increase in symptom severity?

To ensure the best chances of avoiding relapse, it is important that you contact people in your designated support network and your psychologist if you notice any increase in symptom severity.

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