Prodrome in Childhood and Adolescent Mania

Abstract Objectives: This study was conducted to find the average duration of prodrome in childhood and adolescent mania, to ascertain the symptoms, and to assess the difference in duration of prodromes on the basis of sex, mood, and age. Patients and Methods: This was a prospective study of 30 consecutive patients aged 19 years or younger who had had a manic episode or bipolar affective disorder, manic type according to the International Classification of Diseases-10. A checklist was applied for symptoms of mania and other associated symptoms. The duration between the first symptom and the manic episode was taken as the prodrome. Results: The mean duration of prodrome was 14.9 days. A significantly longer prodromal period was found for the age group 12 to 16 years than for the age group 17 to 19 years (mean, 22.9 days vs 7.9 days). Decreased sleep and increased self-esteem were among the most common prodromal symptoms. Conclusion: Caregivers can be sensitised to early warning symptoms so that treatment can be initiated early to prevent a full-blown manic episode and/or admission to hospital, thereby influencing the course and prognosis of the manic episode. Key words: Adolescent, Bipolar disorder, Child Introduction The term prodrome indicates a forerunner of an event. (1) In other words, a prodrome is the period that elapses between the occurrence of the first symptoms and the fully developed illness. The appearance of prodromal symptoms has been important in clinical medicine for many progressive and treatable diseases in which early detection and timely treatment are crucial. Except for schizophrenia, research into prodromal symptoms in psychiatry has been largely anecdotal. (1-5) Recent studies have concentrated on identifying symptoms of mania early in the evolution of the episode. (6-8) Social workers have been encouraged to detect early relapses and refer such patients to minimise the undesirable consequences of career damage, financial loss, unwanted pregnancy, and impaired relationships. (9) In one study, 40 adult patients with mania and depression were interviewed on the prodromes for mania and depression and how these prodromes were managed. (10) The authors reported that, for patients with bipolar disorder, their level of functioning in the areas of work, marital relationships, parenting abilities, and social functioning was related to how well they managed the prodromes of mania. The recognition of prodromal symptoms is becoming more important, as highlighted by the emergence of psychoeducational programmes for partners of patients with bipolar mania. (11) The National Institute of Mental Health working parties highlighted the need for research and the development of methods for psychological intervention in bipolar affective disorder, (12,13) an obvious candidate being early intervention during the prodrome. Several methodological problems are involved in the exploration of prodromes in affective disorders. (1,2) Studies have equated hospital latency--the time of onset of the first symptom to the point of admission to hospital--as that of evolution or prodrome. (14,15) In 1988, Molnar et al defined prodrome as the period from onset of the first symptom to maximum intensity--a definition that is consistent with the concept of evolution. (6) Meanwhile Keitner et al asked the patients and guardians to list the symptoms before the onset of the manic episode--a concept consistent with prodrome. (8) There have been many methods of eliciting symptoms during evolution. Studies have asked the patients to report symptoms of prior episodes (6,8) or have used a symptom checklist. (7) Other methods include dating the symptoms using the Present State Examination (15) and longitudinal Brief Psychiatric Rating Scale administration. (16) Use of a symptom checklist might facilitate recall by the informant but would result in missed symptoms not included in the checklist. …