Are we missing opportunities for early intervention in bipolar disorder?

Abstract

Clinical staging informs the assessment, prognosis and choice of therapies in a diverse range of medical specialities, such as cardiac disorders and oncology. However, it is only relatively recently that psychiatry has begun to explore staging as a conceptual framework to understand the progression of psychiatric disorders, and how this may inform prognosis and man-agement choices. However, a substantial body of new data is available to inform this topic. Therefore, it appears timely to examine some of the evidence regarding early intervention and the staging of clini-cal approaches, specifically as they relate to bipolar disorder.Considerable evidence has emerged in recent years for a staging model in medi-cine, particularly for disorders such as cancer, HIV and liver disease. According to this model, disorders progress in identi-fiable phases, which have specific features and require specifically adapted interven-tions. There is recognition that while pro-gression through various phases may not be applicable to all patients with a particu-lar disorder, this concept can nevertheless reflect an aggregate picture. The staging model has also attracted interest in psychiatry as it provides the opportunity for specialized and stage-appropriate interventions that may mini-mize the risk for further illness progression, and facilitate recovery early in the course. Specifically, recent models developed for psychotic disorders and later adapted to bipolar disorders, have described categories ranging from stage 0 (describing and iden-tifying risk factors for a disorder in the absence of any clear symptoms), through to stages 1a and 1b (comprising mild, non-specific identifiable prodromal symptoms, respectively), stage 2 (comprising the first episode), stages 3a, 3b and 3c (compris-ing subthreshold, threshold and persistent relapse, respectively), to stage 4 (referring to persisting unremitting symptoms that may have been nonresponsive to treatment)