Abstract
A significant minority of people presenting with a major depressive episode (MDE) experience co-occurring subsyndromal hypo/manic symptoms. As this presentation may have important prognostic and treatment implications, the DSM-5 codified a new nosological entity, the "mixed features specifier," referring to individuals meeting threshold criteria for an MDE and subthreshold symptoms of (hypo)mania or to individuals with syndromal mania and subthreshold depressive symptoms. The mixed features specifier adds to a growing list of monikers that have been put forward to describe phenotypes characterized by the admixture of depressive and hypomanic symptoms (e.g., mixed depression, depression with mixed features, or depressive mixed states [DMX]). Current treatment guidelines, regulatory approvals, as well the current evidentiary base provide insufficient decision support to practitioners who provide care to individuals presenting with an MDE with mixed features. In addition, all existing psychotropic agents evaluated in mixed patients have largely been confined to patient populations meeting the DSM-IV definition of "mixed states" wherein the co-occurrence of threshold-level mania and threshold-level MDE was required. Toward the aim of assisting clinicians providing care to adults with MDE and mixed features, we have assembled a panel of experts on mood disorders to develop these guidelines on the recognition and treatment of mixed depression, based on the few studies that have focused specifically on DMX as well as decades of cumulated clinical experience.
Highlights
The recent addition of the mixed features specifier in the latest edition of the Diagnostic and Statistical Manual (DSM–5) codifies a new nosological entity characterized by subthreshold hypomanic or manic symptomsDownloaded from https://www.cambridge.org/core
Since the release of the DSM–5 in 2013, it has been suggested that clinicians follow existing guidelines written for the treatment of major depressive disorder (MDD) or bipolar disorder (BD) without any particular reference to individuals presenting with depressive episodes with mixed (DMX) features
∙ These alternative diagnostic criteria for depressive mixed states (DMX) stress how critical it is to assess the patient for any family history of bipolar spectrum disorders:33–35 ➢ Always inquire about family history of bipolar symptoms or ANY symptoms ofmania in patients presenting with a major depressive episode ➢ Inquire about common bipolar comorbidities
Summary
A significant minority of people presenting with a major depressive episode (MDE) experience co-occurring subsyndromal hypo/manic symptoms. As this presentation may have important prognostic and treatment implications, the DSM–5 codified a new nosological entity, the “mixed features specifier,” referring to individuals meeting threshold criteria for an MDE and subthreshold symptoms of (hypo)mania or to individuals with syndromal mania and subthreshold depressive symptoms. Toward the aim of assisting clinicians providing care to adults with MDE and mixed features, we have assembled a panel of experts on mood disorders to develop these guidelines on the recognition and treatment of mixed depression, based on the few studies that have focused on DMX as well as decades of cumulated clinical experience. Received 7 January 2017; Accepted 24 January 2017; First published online 28 February 2017 Key words: Mixed, bipolar, depression, unipolar, guidelines
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