![]() Current data suggest that patients with MDD who meet criteria for mixed features may be at elevated risk for the development of bipolar I and II disorders, thus requiring specific monitoring over the course of their illness. The mixed features specifier, it was decided, would define clinical entities present during common clinical practice that could have an impact on the course of illness and that merited clear and more precise definition-especially in order to establish clear entities for future outcome studies. The DSM-5 committee took into account all of these concerns in examining whether to revise the concept and criteria for mixed feature presentations. 6 These symptoms were sufficiently severe that intervention was indicated, so a new entity was warranted. The reality is that mixed episodes in bipolar disorder, as strictly defined in DSM-IV, are much less common in clinical practice than are complex presentations in which subsyndromal symptoms of depression are present during periods of mania or hypomania, or subsyndromal symptoms of mania are present during episodes of depression, even in patients without a lifetime history of bipolar disorder. The clinical problem was that, other than for the most severely ill patients with bipolar I disorder who met full criteria for a mixed episode, the previous diagnostic categories for mood disorders ignored the presence of symptoms of hypomania or mania during depression (and depression during mania). The clinical understanding of “mixed symptoms” or “mixity” has been in the clinical consciousness with respect to the bipolar patient and less so (or not at all) with respect to the patient with MDD. ![]() The narrow definition of “mixed episode” is gone, replaced by the mixed features specifier, a specifier that can now be used in both major depressive disorder (MDD) and bipolar disorder and that acknowledges, in terms of symptoms and course, the overlap between bipolar disorder and major depression. While eliminating the Mood Disorders section and placing bipolar and other disorders in one chapter and depressive disorders in another, DSM-5 in practical terms appears to be shifting from a categorical approach to diagnosis to a more dimensional one. DSM-5 partially addresses this gap between practice and criteria. Like the proverbial unicorn, mixed episodes in actual practice are hard to find-although the term mixed has been used in practice for concurrent symptoms of depression and mania whether they meet criteria or not. ![]() 4, 5 Mixed episode criteria in DSM-IV required that full criteria for manic episode and major depressive episode be met concurrently for at least 1 week. 3 DSM, of course, has been categorizing and deconstructing mood disorders through DSM-IV-TR, leaving the mixed episode as the only formal category with mixed symptoms of mania and depression. Kraepelin 1, 2 famously described “manic depressive insanity,” within which he included all affective states, leading some, such as Adolf Meyer, to complain that he had created a “startling condensation” of all mood syndromes into one. The intermixed presentation of depressed and manic symptoms has existed longer than any modern diagnostic schema. In this brief article, we will describe the historical development of the mixed features specifier, the specific criteria for the diagnosis, and the dilemma clinicians face given the current state of the evidence for the treatment of patients who meet the criteria. Ostacher, MD, MPH, MMSc, a, * and Trisha Suppes, MD, PhD aįor those of us who treat and study patients with mood disorders, perhaps the most dramatic recent change in how we diagnose those patients is the addition in DSM-5 of the mixed features specifier for major depressive episodes. ![]() By downloading this file, you are agreeing to the publisher’s Terms & Conditions.ĭepression With Mixed Features in Major Depressive Disorder: This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. ![]()
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