PRODROMAL SYMPTOMS of RECURRENT MAJOR DEPRESSIVE EPISODES: a Qualitative Analysis

Arriericun Jouniul o/Orthop.vychiutty,6-(2). April IYY7

PRODROMAL SYMPTOMS OF RECURRENT MAJOR DEPRESSIVE EPISODES: A Qualitative Analysis

Bonnie M. Hagerty, Ph.D., R.N., Reg A Williams, Ph.D., R.N., Michelle Liken, M.S., R.N.

In four focus groups, I6 people with major depressive or bipolar disorder were asked to describe the onset of an acute depressive episode. Findings indicate that those entering a major depressive episode often have diflculty identihing prodromal symptoms, although they experience early warning phases. These phases and described, and implications for clinical intervention are outlined.

pisodes of major depression, whether terns can be identified early as prodromes E as a component of major depressive of reemerging depression, it may be possi- disorder or a bipolar disorder, are now rec- ble to intervene so as to prevent or mini- ognized as a public-health problem causing mize the episode. Thus, the purpose of this untold personal suffering and socioeco- qualitative study was to explore the experi- nomic costs. These episodes are recurrent ence of individuals in the prodromal phase for most individuals with bipolar disorder of recurrent MDE. and for 50%85% of those with major de- The prodromal stage of an illness is usu- pressive disorder (MDD) (Consensus De- ally considered a time period during which velopment Panel, 198.5)).Clinicians treat signs and symptoms of a particular disorder more patients for recurrent than first-time begin to be manifested. These early indica- episodes (Thase, 1992). Recurrence is asso- tions may be quantitatively or qualitatively ciated with increased severity of episodes, different than symptoms evident during the increased duration of episodes, and shorter acute stage of the illness. They may be periods of wellness between episodes (Kup- fewer, less intense, or different than the fer, 1991; Thase, 1992). symptoms that define the full-blown clini- Yet, little is known about the clinical cal manifestation of the illness. Prodromal phenomenology of the prodromal phase of phases of illness vary in duration and may a recurrent major depressive episode (MDE). last for only several minutes or hours to It is unclear what patients begin to experi- many weeks or months. ence that later becomes identified as the be- In general care, assessment and identifi- ginning of the depressive episode, how cation of the prodrome of an illness usually they come to label this as another episode allow for timely intervention with the pa- of depression, and why and when they initi- tient that can facilitate prevention of the ate self-care or seek help. If symptom pat- acute episode, a less protracted course, and

A revised version of a paper submitted to the Journal in May 1995 Authors are at the School of Nursing, Universiry of Michigan, Ann Arbor 308 0 1997 American Orthopsychiatric Association. Inc HAGERTY ET AL 309 less invasive and costly treatment. In psy- include generalized anxiety, sadness, irri- chiatry, much of the research on identify- tability, impaired work, decreased initia- ing and understanding the prodromal phase tive, loss of interest, fatigue, and initial and has focused on schizophrenia. To date, this delayed insomnia (Fava, Grandi, Canes- research has demonstrated that detection trari, & Molnar, 1990). and recognition of the early signs and Unfortunately, much of the information symptoms of schizophrenia, prior to onset about prodromal symptoms of depressive of the acute phase, allows for more timely episodes has been gathered retrospectively, and effective intervention that can prevent from small numbers of patients, utilizing or minimize acute psychosis (Herz, 1985; checklists and instruments that list primar- 0 'Connor, 1991). ily the key symptoms of the acute phase of There is, however, a paucity of research the disorder. If, indeed, the prodromal about the prodromal phase of MDD. Sev- phase of MDE might be qualitatively as eral early studies demonstrated that there well as quantitatively different, research was a rapid onset of depressive symptoms should take into account the possibility that when episodes were associated with bipo- symptoms, other than those used as the lar disorder and endogenous subtype of de- standard criteria for depression, could por- pression (Hays, 1964; Hays & Steinert, tend a depressive episode. Additionally, 1969). In a more recent study, Young and ways in which patients experience the re- Grabler (1985) reported that rapid onset of emergence of the depression, including symptoms was associated with endogenous temporality of types and severity of symp- subtype, absence of past or current affec- toms, and the manner in which they inter- tive disorders, older age of first depressive pret the symptoms, label them as depres- episode, less stressful events before the sion, and initiate self-care or help-seeking, episode, and shorter hospitalization. How- remain undocumented. ever, the small number of subjects (N=l l) To address this gap, the following re- and the retrospective design of the study search questions were posed in this study: may limit the generalizability of the find- I) What are the signs and symptoms, and ings. Terao (1993) presented a two-case re- their order and time of occurrence, that pa- port in which lithium was self- tients experience in the prodromal phase of administered when prodromal symptoms recurrent depression? 2) How do patients appeared, thus preventing a recurrent epi- with recurrent episodes of major depres- sode of depression. This is consistent with sion respond to prodromal symptoms of re- Fava and Kellner's (1991) premise that currence? early recognition of prodromal symptoms could be valuable. Kupfer, Frank, and METHODS Perel (1989) agreed that early intervention This study was qualitative, using focus during the prodromal stage of the illness is groups and grounded theory methods (Glas- important in preventing or minimizing re- er & Strauss, 1967). A series of four focus lapse and recurrence. groups took place over the course of one There is evidence to suggest that the du- year. The first three groups were conducted ration and symptoms of successive pro- via a semistructured interview schedule dromes of depressive disorders are some- based on the research questions; responses what consistent within individuals (Young were then analyzed and hypotheses formu- Fogg, Scheftner, & Fawcett, 1990). In ad- lated. In the fourth focus group, the hy- dition, it appears that patients generally potheses were discussed with the members have at least one psychiatric symptom prior (two of whom had been present at previous to the onset of depressed mood. Prodromal focus groups) to assure reliability of find- symptoms of MDE have been reported to ings from the first three groups. Data satu- 31 0 PRODROMAL SYMPTOMS OF DEPRESSIVE EPISODES ration was evident in that responses were forced by the fact that depressed or sad repeatedly present or notably absent in all mood was usually not the first symptom descriptions of prodromal experiences pro- people experienced. For example, one par- vided by participants. ticipant said: I really didn’t want to admit it. I never do want to Sample and Procedure admit this depression. A total of 16 participants who had been Participants described initial negative, treated for either bipolar disorder or MDD uncomfortable feelings that were vague and had had at least two episodes of de- and nondescript, such as fatigue and feel- pression participated in the focus groups. ing overwhelmed. These early symptoms Participants ranged in age from 29 to 65 tended to be different, both quantitatively years. Forty-four percent were women. All and qualitatively, than those used as stan- participants had been or were in treatment dard criteria for diagnosing depression. At for their disorder. Two were in the midst of the time they experienced these symptoms, an episode of major depression, one was the subjects attributed them to external fac- hypomanic, and the remaining participants tors. Only two participants, at the time of were at various stages of recovery. All ex- their symptoms, were able to identify these cept one had experienced MDEs within the as possible precursors to a depressive epi- past year. The focus groups were led by sode. As one subject put it: two doctoral-prepared psychiatric nurse At first, the symptoms can just be ignored. I can say, clinicians and were audiotaped and video- “It isn’t that serious-like oversleeping or skipping taped. Audiotapes were transcribed and an- meals or whatever.” I can justify it somehow. alyzed using ATLASTI (Muhr, 1994), a Participants also described expending computer-aided text interpretation and the- energy to put up a front. They stated that ory-building software program. they behaved normally, although they were feeling stressed, exhausted, and unwell. RESULTS One subject said The following recurrent themes were Well, there’s a certain amount of guilt associated identified: I) “something’s not right,” 2) when you feel a little bit phony because you are act- “something’s really wrong,” 3) “the crash,” ing [like] the normal person, your normal state, but you’re not feeling the same. and 4) “getting connected.” These themes also could be considered progressive stages Participants were quick to point out that, within the prodromal phase of a depressive in this first stage, symptoms would remit at episode. certain times but not at others. In other words, they did not necessarily experience, Something’s Not Right in each incident, a recurrent depressive This theme related to participants’ com- episode subsequent to this first stage. ments about the way in which they experienced initial symptoms of recurrent depres- Something’s Really Wrong sion. The duration of this early stage var- After the initial period of not feeling ied, ranging from days to months both be- well, participants described more standard, tween and within individuals across epi- focused symptoms. The variety of symp- sodes. Within this theme, the following toms mentioned during this early phase of subthemes were identified: a) denial of recurrence included alterations in sleep and symptoms; 6) attributing symptoms to ex- appetite, lack of energy, changes in cogni- ternal factors (stredweather); and c) put- tion, withdrawal and isolation, general anx- ting up a front. iety, and suicidal ideation. These symp- All participants described denial of early toms were all linked to one general out- depressive symptoms. The denial was rein- come, the inability to experience congru- HAGERTY ET AL 31 1 ence, harmony, or synchrony with the en- as a rapid spiraling down, from which there vironment. This experience, which we la- was no relief. beled as “desynchrony,” was disturbing to all participants. They described being on Getting Connected different schedules than those around them, The fourth theme identified by partici- experiencing differences in sleepwake cy- pants was the need to seek help. Most cles, having reduced cognitive clarity to focus-group members discussed their expe- match their everyday tasks, and function- riences in this regard with anger, fiustra- ing and feeling out of tune with others. tion, urgency, and disappointment. All de- These symptoms often led to avoidance of scribed a critical need at this stage to find a interpersonal interactions. One participant person who would listen to them, someone described it as follows: who could provide feedback about their The first symptom I experienced was I just started status and assistance with active interven- waking up early. You know, wake up at two in the tion. This was usually a family member, a morning, wide awake-not to where you’re going to go back to sleep again-and you start worrying about friend, or a therapist who was able to vali- the next day, and then, if you’re not sleeping, you date their symptoms. The account of one of worry about not sleeping. It’s a vicious cycle. the men in the group was typical: I usually think I’m at the end of my rope and 1’11 talk The Crash to my wife. She’ll say, “Well, you’re no different The disturbing experience of desyn- than you were this other time. You don’t remember chrony was followed by the occurrence of how bad you were sounding then. You sound the one to three specific symptoms that sig- same now; you don’t sound any worse.” So there’s some comfort in that. naled the beginning of the acute episode of depression to all participants. Each of the Participants also described the impor- focus-group members experienced these tance of finding assistance that they felt “pivotal symptoms,” which generally en- was beneficial to them. Focus-group mem- compassed difficulties with sleep, cogni- bers told of positive experiences that as- tion, interpersonal relationships, and safety. sisted them in reaching out to others, but Although these symptoms were different they spoke as well of experiences that for individuals, they generally remained served to maintain, or even exaggerate, consistent for each person across episodes, their disconnection. When those who had although not all occurred with each epi- sought help, advice, or validation from sode. For example, one participant reported: family, friends, or health-care providers felt My sleep is not the usual. When I am depressed, I that it was not forthcoming, the resulting oversleep. disappointment and uncertainty often con- Another noted: tributed to the severity and duration of the depressive episode. One participant poign- For me, it’s the sleeping and the withdrawing [that] are a key that something’s wrong. antly recalled an early incident of this sort: The first time I was ever put on medicine, an antide- Yet another stated: pressant, the person that prescribed the medicine did And my mental acuity also went. I worked as a health a lackadaisical job of monitoring progress. I did not care professional and it just scared the bee-gee-bees have much improvement in symptoms at the time. out of me, the lack of concentration I had at work. I You know, you usually wait for the symptoms to im- knew I could make a mistake that could really hurt prove. The person did not raise the dose at all, no someone. blood level monitoring. It was almost as though the All participants agreed that once the piv- person was giving me medicine to make me think I otal symptoms were experienced, the acute had something legitimately wrong with me and even shades of that perception from the person that’s sup- episode was inevitable. Pivotal symptoms posed to be helping me is rather infuriating because were the key in alerting them to the onset you get that enough from the people in your daily of MDE. Many described this experience life. 312 PRODROMAL SYMPTOMS OF DEPRESSIVE EPISODES

DISCUSSION symptoms of a previous episode. While The findings of this qualitative study such symptoms may interfere with assess- suggest that people with recurrent depres- ment of prodromal occurrence, all focus- sion often experience a specific prodromal group participants in the present study re- phase before the onset of acute depression. ported that they perceived their status to be This phase varies in duration from episode changing at this early stage (“something’s to episode, ranging from days to weeks, not right”). and differs in intensity as well. It appears Thus, clinically, the classification of that the prodromal phase may be resolved these experiences may be less relevant than without the person ever experiencing an the fact that: I) they are perceived by the acute episode of depression. This seemed patient to be uncomfortable and disturbing; to be the case when the individual was 2) they frequently herald the early phase of able, early on, to mobilize assistance or a recurrent depression; and 3) patients have self-care, although at times the rationale for great difficulty identifying and assessing absence of a subsequent acute episode was these symptoms as warnings of depression not clear. Some early signs may have been reemergence, but tend instead to attribute symptom flurries, ordinary responses to them to external causes such as stress at stress, or exacerbation of underlying resid- work or lack of sleep. The exact mecha- ual symptoms. If, however, a depressed in- nisms (e.g., psychodynamic, cognitive, neu- dividual reached the point of experiencing roregulatory, or neuroendocrine) that inter- pivotal symptoms, a rapid downward spiral fere with a patient’s ability to identify and signaled the initiation of the acute phase of label this early stage of the prodrome re- the illness. quire further investigation. investigation of Recent longitudinal studies on the course potential biological markers of prodromal of depression reveal that 20% or more of signs of relapse may provide additional those who experience MDD will not have useful information about this stage. recovered after one year (Keller et al., During the second stage of the prodrome 1992). Ongoing residual or dysthymic (“something’s really wrong”), patients be- symptoms signal poor prognoses for per- gin to associate their symptoms with de- sons with MDD (Wells, Burman, Rogers, pression. This stage is characterized by de- Hays, & Camp, 1992). The purpose of the synchrony and the symptoms involved present study was not to compare specific tend to be the more standard symptoms of differences between participants who expe- MDD, including those affecting mood, rienced low-level depressive symptoms sleep, appetite, cognition, social function- over time and those who did not, but rather ing, energy, and suicidal ideation. These to examine symptomatic change, that is, symptoms are consistent with those identi- description of the prodromal phase in fied by Fava and associates (1990) as in- which the patient experienced change in dicative of a depressive prodrome. Symp- severity or type of symptomatology. toms that promote the experience of desyn- Initial prodromal symptoms appear to be chrony seem to be especially important in qualitatively different than standard de- promoting recognition of the oncoming depression criteria, resulting in descriptions pression. of vague, diffuse difficulty, but not severe While the symptoms contributing to the impairment, in one or more spheres of experience of desynchrony may vary functioning. Fava and Kellner (1991) noted widely from episode to episode, an individ- that other kinds of symptoms may con- ual’s pivotal signs, usually one to three found depressive prodromal research, in- symptoms, tend to remain consistent across cluding premorbid traits, normal subclini- episodes, although all may not appear in cal fluctuation of symptoms, and residual the same episode. These pivotal symptoms HAGERTY ET AL 31 3 are indicative of “the crash” and signify choate feelings” and the inability to label that the acute phase of the depression has the experience as depression, attributing occurred. their bad feelings to an external situation It is in these second and third stages that rather than to themselves. The “something patients actively acknowledge symptoms is really wrong” phase is consistent with and may initiate action to address them, ei- Karp’s description of a “self-working-bad- ther through self-help strategies or help- ly” stage in which patients come to recog- seeking behavior. Those in the present nize their symptoms as depression. Karp’s study who did not immediately attribute crisis phase, the point at which patients go their symptoms to depression, and who did public with their disorder and seek help, is not take action, subsequently went on to analogous to “the crash” and “getting con- experience their pivotal symptoms and spi- nected” phases identified in this study. ral into the acute phase of the episode. Indi- While the focus of this research was on de- viduals who had supportive others, includ- scribing and understanding the prodromal ing family, friends, or professionals, who phase of recurrent depression, Karp sought were able to point out their symptoms at to explore the issues involved in coming to this stage and encourage helping behavior, grips with an illness identity over time. Un- tended to report a greater degree of control derstanding the need to reconstruct and over their emerging episodes. In spite of reinterpret one’s past in terms of the cur- this general pattern, some episodes with rent situation-constructing a theory of the rapid onsets were perceived by participants nature of depression as life-long and estab- as uncontrollable. lishing modes of coping+an help to clar- Getting connected, having someone lis- ify the work involved in identifying and la- ten, and having symptoms validated as de- beling symptoms of recurrent depression. pression appear to be important elements While subjects were asked to recall in- of symptom relief. Once individuals “go formation retrospectively, the consistency public” with their symptom difficulties and of responses from all participants, includ- reach out for assistance, it is important to ing those with bipolar diagnoses, was strik- maintain that connection and focus on the ing. The findings of this study are a step factors that patients view as critical at that toward identifying specific characteristics point. Often, these may be basic needs such of the prodromal phase of recurrent depres- as activities of daily living, assistance orga- sion and patient responses, and toward a nizing and setting priorities, and getting more comprehensive phenomenological de- questions answered. All participants description of the experience and characteris- scribed the need to feel as though they had tics of this phase, which can inform further support and options available to fight the investigations of the course of recurrent de- depression and achieve relief. They em- pression. phasized the importance of mental health The present findings also suggest that professionals listening to them, acknowl- specific clinical interventions can be devel- edging their symptoms, and giving them oped to identify early warning signs and information about their illness and their initiate actions that can help minimize or medications. prevent a major depressive episode. Such The findings of this study support Karp’s interventions may include psychoeduca- (1994) exploration of the ways in which tion about recurrent depression and the in- depression as a chronic illness requires an dividual’s specific prodromal patterns and ongoing definition of self. The “something pivotal symptoms; monitoring techniques isn’t right” phase, identified in the present using standardized tools; involvement of study, is similar to a phase described by significant others in monitoring and re- Karp in which patients experienced “in- sponding to early depressive symptoms; 314 PRODROMAL SYMPTOMS OF DEPRESSIVE EPISODES

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For reprints. Bonnie M. Hagerty. PI1 D . R.N , School of Nursing, University of Michigan. 2352NIB. Aim Arbor, MI 48109