A Review of the Efficacy and Role of the Card Sort Exercise in the Treatment of Bipolar Disorder.

The current card sort exercise described by Agius et al. in 2006 provides a tool for patients and their families to characterise the temporal pattern of occurrence of both stereotyped and idiosyncratic prodromal symptoms that serve as early warning signs predicting a relapse. This 'individual relapse signature' is highly specific for bipolar relapse, and aids identification of a relapse such that patients can be channeled into appropriate early intervention pathways. This review examines the role of the card sort exercise in the treatment of bipolar disorder, and evaluates the evidence for its efficacy. Few studies involve the card sort exercise, and those that do paired it with other early therapeutic interventions, such that it was difficult to assess the true contribution of the card sort exercise alone to outcome measures such as time-to-relapse or hospitalisation avoidance. We went back to first principles and evaluated the literature concerning various factors necessary for the card sort exercise to be useful. We concluded that there is good evidence that replicable relapse signatures exist as early warning signs for bipolar relapse, and that a certain subgroup of patients and their families can reliably use these signs to seek help and activate therapeutic interventions to abort the relapse episode. Early intervention is both possible and efficacious, which makes early identification of relapse yet more important. The card sort is of less use for depressive relapses, where prodromal symptoms are harder to pinpoint. The card sort exercise is useful in elucidating the relapse signature for each patient, which can then be used in psychoeducation or identification of future relapse episodes. However, more research is needed directly assessing the usefulness of the card sort exercise in helping patients and their families gain insight into the possibility of an imminent relapse.