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.

“When I stopped hearing the voices in my head”

In today’s Guardian there is a lovely short article by ‘Anonymous’ about what it is like to hear voices.  Well worth a read for those struggling with the same issues, or those trying to understand the experience of voice hearing.

The author’s story is very familiar to me, the stress of going university seemingly bringing on a severe depression while later, with the added stress of exams, the voices appear.  I’ve been told this story many times, often by people who I interviewed for the Maudsley Bipolar Twin Study, and then more recently by my clients.  My recollection is that the majority of those who’ve related this particular sequence of events were women, but perhaps this was random or recall bias.

The author, via some combination of medication and therapy reports that she no longer hears voices, and that she has found a way to cultivate a supportive inner voice in their place.  No point in me saying more, read what she has to say!

(I assumed the author was a woman from the photo, but it’s just a stock image, so who knows).


“Up/Down” Bipolar Disorder Documentary

A film produced by Matt Stockalper and Kyle Gehring

The following is the first contribution to my attempts to provide a resource for those searching for mental health media for use in therapeutic settings (or indeed more generally).

“Up/Down” is a full length documentary (1h23m) about the diagnosis of bipolar disorder.  It is a well produced and well shot film, which involves interviews with the general public, psychiatric professionals, people with a diagnosis of bipolar disorder and family members.  For me, the strength of this film is very much the latter two sets of people.  The film begins by briefly surveying what bipolar disorder means to the general public and providing an introduction to bipolar disorder, before  progressing on to more detailed interviews.  For these later interviews, the producers have chosen a format whereby they ask each participant a number of set questions, and hence we get a variety of responses, reflecting the peoples’ diverse experiences of the bipolar spectrum.  The questions broadly cover each person’s experience of bipolar generally, as well as more specifically in the manic and depressive stages.

All the participants are US American, and this is perhaps reflected in the number of medications each participant is taking, the upsides and downsides of which are explored in a later section of the film.  One of the people interviewed also describes her experiences of ECT, with the pros (being shocked out of depression) and cons (very severe complications of memory loss).  Towards the end of the documentary, relatives of people with bipolar are interviewed and they discuss how it is to have a relative with bipolar disorder.

Overall I liked this documentary.  Although one never knows what has been lost or emphasised in the production and editing, the film appears to give space for each participant to express their own experience.   I feel that the film could be of interest/use to professionals, patients and relatives.

Some reservations.  I have some concerns  with regard to the introduction to bipolar disorder.  Primarily, it is perhaps too ‘factual’ in nature, when what is presented as fact is often actually rather controversial.

Diagnosis is always a difficult topic to deal with and in this film the validity and utility of  diagnosis are taken for granted; this is always going to be an issue for those, who like me, have concerns about the way in which diagnoses are used.  The film continues the tradition of treating disorders such as bipolar and schizophrenia as unitary and separable conditions, when the evidence for this is limited.   For example the brief history of bipolar disorder at the beginning of the film gives the impression (as many believe) that the distinction made by Kraepelin was a clear scientific progression (previously the disorders were ‘confused’).   It is an irony that although we know that there is little evidence for a clearcut distinction between these diagnoses, it is hard to talk about the experience of people who have these symptoms without using their diagnoses and we thus reinforcing the impression that we are discussing two independent, valid diagnoses.   On the other hand, the film clearly shows one of the benefits of diagnoses, by using the diagnosis of bipolar disorder, the filmmakers were not only able to easily select a group of people with similar (but not the same) symptoms and experiences, but also enabled me and others to easily find their film.

There is also a very controversial statement that ‘children as young as three have displayed signs of the [bipolar] disorder’, again perhaps reflecting that this is an US film, where very very early diagnosis and medication is not unheard of (very extreme examples include the treatment and subsequent treatment related death of a four year old).  The narrator also states that ‘Most psychologists and psychiatrists believe that it [bipolar disorder] is genetic’, which is far from the full story, and is to my mind, misleading.  Most of us may accept that the diagnosis bipolar disorder is highly heritable (and has a shared genetic component with schizophrenia among other diagnoses), but many of us are aware that the full story is much more complicated and that  heritability is a very misunderstood topic.

Documentary Timeline. For my own purposes, I’ve detailed some questions/points in the documentary along with the appropriate times (not at all complete)

Introductory Topics

  • History of bipolar disorder:  07.00
  • Childhood bipolar 8.30
  • Symptoms 09.00
  • Diagnoses, depression to mania ratios 10.00


  • ‘Could you give me a general explanation of how you felt before you were diagnosed?’  0h14
  • ‘And how long have you felt the symptoms of bipolar’  0h16.55
  • ‘What was this person like in a depressive episode and how did you react to it?’  1h06
  • ‘What was this person like in a  manic episode and how did you react to that?’  1h07.30
  • ‘How do you view bipolar disorder now after having been exposed to it personally?’  1h09
  • ‘Have you accepted the disorder as part of your life?’  1h12
  • ‘What are your thoughts and hopes for the future?’ 1h13
  • ‘What would you like the general public to know about bipolar disorder’  1h13.30
  • In your own words, try to sum up what it’s like to have bipolar disorder’  1h16.30


  • A lovely description of bipolar disorder at 1h18.00.  Boat, anchor and kite metaphor.