Development of an Online EWS Symptom Card Sort

The Early Warning Signs (EWS) card sort is a task commonly used by mental health professionals to help develop Staying Well Plans with patients*.

These Staying Well Plans are often developed towards the end of therapy, and include a number of elements, one of which is a plan of action should a person start to notice warning signs that they might be becoming unwell. This might mean being at risk of becoming depressed, becoming manic or developing escalating symptoms of psychosis.

Screenshot from card sort demo video.

The standard card sort is a physical sorting task used to help patients and therapists quickly and effectively select symptoms from a set of common symptoms, and arrange them into early, mid and late signs of becoming unwell. In my experience most patients find the card sort to be an engaging and useful activity.

A video example of a card sort can be seen here.

During the covid-19 pandemic, it became difficult to do the card sort in person. As a result I have developed a digital version. I have shared locally, but perfectionism (and time pressure) prevented me from sharing more widely.

I’ve looked into a wide range of more or less sophisticated options for replicating the face to face task in a way that could be shared for collaborative access over platforms such as Microsoft Teams / Zoom. I have settled for the moment on using presentation software such as Powerpoint (which most NHS professionals have by default).

Instructions for Use

Profesional Use

The tool is designed for use by appropriately qualified and supervised mental health professionals. If that’s you, you should know!

You use the tool in much the same way as the physical version. It’s not just something that’s done by rote, but individual to the person you are working with. It’s really important to map out the characteristics and meaning of each symptom/experience to each person.

As the tool develops it will be more interactive. For the moment I tend to use it while screen sharing. It can also be shared collaboratively with the patient if they have a copy of Powerpoint – or used in a face to face session on a big screen, for some covid safe card shuffling!

Non Professional Use.

Individuals who struggle with symptoms of depression, mania and psychosis are very welcome to try out the tool themselves as a self-help tool. For the moment I have incorporated some basic instructions in the tool. I will update the instructions and this blog article in due course.

Download and Feedback.

The Powerpoint version is available for download and use, click here. I would appreciate feedback and ideas if you find it useful (or not!). You can find a feedback form here.

Google Slides Version is available here. This is probably better for realtime collaboration than the Microsoft Powerpoint option. The patient will need a google account.

I have a few other versions which I intend to make available soon(ish!), check back for updates.

Powerpoint Card Sort: Mania Symptom Select

Development Plans

I hope to continue with the digitisation of the card sort and develop an easy to use tool that will help patients and professionals quickly and easily develop accessible staying well plans. Together with a few others, I already have a number of ideas that, if we can implement them, should make a really useful tool.

Card Sort Literature.

A very brief, not at all systematic, dip into the literature:

The earliest published use of the EWS card sort I’m aware of is in a paper, published in 2000, by Max Birchwood, Elizabeth Spencer and Dermot McGovern, which details how the card sort can be used in identifying a person’s ‘relapse signature’.

Two more recent papers review the literature on the card sort task. Agius et al, 2006, describe the literature and report on a pilot study, but I only have access to the abstract. A 2017 by Tern et al (last author Agius), follows up on the 2006 paper with a review of the card sort for people with bipolar disorder, but again, only an abstract is available to me right now. The message of the abstract is that there is not much of a literature and that the card sort 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.

They also suggest that the card sort may be ‘less use for depressive relapses, where prodromal symptoms are harder to pinpoint’.

*As always, it’s hard to know whether to use patients, clients, people. Evidence is mixed as to patients’ preference.

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