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Am J Psychiatry 1995; 152:967-972
Copyright © 1995 by American Psychiatric Association
Prodromes and precursors: epidemiologic data for primary prevention of disorders with slow onset
WW Eaton, M Badawi and B Melton
Department of Mental Hygiene, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
OBJECTIVE: The concepts of prodrome and precursor are used to show how
epidemiologic data on age at onset can be used in timing preventive
interventions and selecting target populations. METHODS: Data concerning
onset of DSM-III major depression and panic disorder were taken from the
Epidemiologic Catchment Area Program. Cumulative distributions of ages at
onset of diagnosis and onset of precursors are presented, and the concept
of attributable risk is introduced. Attributable risk is the maximum
proportion of cases that would be prevented if an intervention were 100%
effective in eliminating a specific precursor. RESULTS: Illustrative
results for depression and panic are presented. Precursors vary in the
degree to which they predict onset of the full disorder; 2 or more weeks of
sad mood in the year before full-blown depression is a better predictor
(relative odds, 7.0) than weight loss or gain (relative odds, 3.0). The
formula for population attributable risk was applied to the precursor
relative risks and prevalences to estimate the potential success of
interventions for specific precursors in preventing the disorder. The
precursor attributable risks indicate that sleep problems would identify
47% of the new cases of major depression occurring in the following year,
and the question "Are you a nervous person?" would identify 60% of persons
with onset of panic disorder in the following year. CONCLUSIONS: This
conceptual framework links the early natural history of disorders with the
search for syndromes. Knowledge of precursor prevalence and attributable
risk, combined with other host characteristics and environmental risk
factors, can be used in screening and prevention.
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