The Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) incorporated a "mixed features" specifier that recognizes the idea of mood disorders as lying on a spectrum and acknowledges the coexistence of subthreshold symptoms of (hypo)mania during a major depressive episode (or of subthreshold symptoms of depression co-occurring with a manic episode). Although this revision to the DSM-5 was a welcome indication of progress in our understanding of mood disorders, there was little guidance in terms of how to recognize and treat such mixed depressive states. Until now.
A panel of 20 leading mood disorder experts from around the world have recently published a set of guidelines to aid clinicians in the diagnosis and treatment of major depressive episodes with mixed features (DMX). These DMX guidelines stress the importance of screening for indicators of mixed features (including any hint of mania or positive family history of bipolar disorder) in all patients who present with symptoms of depression…and before antidepressant monotherapy is prescribed. Given that there are currently no medications FDA-approved for the treatment of DMX, the authors' recommendations are based on decades of accumulated clinical experience, existing guidelines for the treatment of bipolar depression, and the relatively few clinical trials that have shown some efficacy of psychotropic agents in ameliorating symptoms of DMX. The bottom line of the treatment recommendations put forth in these guidelines is that antidepressants may be inappropriate, and possibly harmful, when it comes to DMX.
Compelling editorials written by two of the authors of the DMX guidelines bring home the salient points and importance of implementing the DMX guidelines in all clinical practices where antidepressants are prescribed.
>> Guidelines for the recognition and management of mixed depression
Stahl SM, Morrissette DA, Faedda G et al. Guidelines for the recognition and management of mixed depression. CNS Spectr 2017; Epub ahead of print. https://doi.org/10.1017/S1092852917000165
Stahl SM. Mixed-up about how to diagnose and treat mixed features in major depressive episodes. CNS Spectr 2017; Epub ahead of print. https://doi.org/10.1017/S1092852917000207
Morrissette DA. Do no harm: a paradigm shift in the unchecked use of antidepressants. CNS Spectr 2017; Epub ahead of print. https://doi.org/10.1017/S1092852917000086