Context: Development of early intervention strategies and identification of high risk subjects may improve outcome in psychosis. While prodrome to manic relapse has been extensively studied, little is known about prodrome to the initial manic episode.
Aims: Description of symptoms and behaviours characterising the 12 months period preceding a first manic episode (proximal markers) and identification of possible pre-morbid risk factors (distal markers).
Method: Retrospective assessment of the 12 months preceding an initial manic episode with psychotic features in a cohort of 18 subjects with a semi-structured questionnaire and assessment of premorbid functioning, psychiatric history and life events with standardised scales. If possible, collection of collateral information from family or partners.
Results: During the mean 22 weeks proximal prodromal period, patients presented mainly with disrupted sleep, mood lability, elevated mood, concentration difficulties, and to a lesser extend irritability, disinhibition and increased energy. While suggestive of a mood problem, these symptoms may prove insufficiently specific to identify high risk patients in a general population. The presence of other characteristics in subjects presenting with such symptoms may however increase their significance: Progressive decrease in functional level starting during early adolescence, first degree relative with history of mood disorder or psychosis (observed in 61% of patients), history of substance use disorder, history of significant life event.
Conclusions: Observation of a certain symptomatic profile in the context of risk factors should raise the suspicion of a possible impending first manic episode. These elements apply however only to the proximal prodrome to a first manic episode. The observation of a progressive deterioration in functioning staring about 8 to 10 years before onset of the first manic episode is in keeping with previous data and suggests more work needs to be done in order to identify a more distal prodrome.