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PRODROMAL SYMPTOMS of RECURRENT MAJOR DEPRESSIVE EPISODES: a Qualitative Analysis

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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 pro- dromal 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
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