LAUSR

In his review of staging prior to bipolar disorder (BD) onset, Parker raises many important points about gaps in the literature and potential perils of introducing “staging” into clinical practice (e.g., overtreatment). Before launching into specifics, it is first critical to ask: What are the primary goals of clinical staging? How can staging contribute to our understanding of BD, and ultimately to the development of strategies to delay progression? First, the identification of early stages can facilitate a timely diagnosis of BD. This is critical, given that delays of 5– 10 years between threshold bipolar symptoms and appropriate diagnosis and treatment are common. Second, improved recognition of antecedent symptoms may inform the treatment of individuals with a family history of BD who are already in distress and presenting for treatment. For clinicians, the question is not if to treat these youth, but rather how to treat them (e.g., avoid treatments that may exacerbate the illness). It is also imperative to consider the methodology by which symptoms prior to BD diagnosis are ascertained. We agree with Parker that current staging models are often based on retrospective data in adults and are thus limited. In this Commentary, we highlight empirical findings from prospective, longitudinal studies (e.g.,1– 3), integrating these findings with clinical experience and the staging model by Berk and colleagues; we begin with the stage closest to diagnosis (Stage 1b) and work backward.