In a long-overdue development, the DSM-5 of 2013 widened “mixed states” to include depressive episodes with some manic or hypomanic features. Last weekend, at the Psychiatric and Mental Health Congress in San Diego, an all-star panel comprising Gary Sachs of Harvard, Joseph Calabrese of Case Western Reserve, and Michael Thase of the University of Pennsylvania explained the ins and outs.
Going off my notes …
Since before the twentieth century, clinical observers have been aware of mixed states. For instance, Emil Kraepelin back in 1899 recognized “depressive mania,” “excited depression,” and “depression with flight of ideas."
But in the mid-twentieth century came a spilt between unipolar and bipolar that was incorporated into the DSM-III of 1980. With the split, mixed states officially just about disappeared.
The DSM-5 of 2013 essentially brought back Kraepelin by recognizing “major depressive order with mixed features.” Thus, according to Dr Sachs, clinicians “can diagnose patients based on what they really have.”
Back in the old days, doctors would have ignored various anomalies such as a patient laughing while depressed. But this type of behavior may be a tip-off that something more than simple depression may be going on.
Traditionally, depression was associated with low mood and energy and loss of pleasure while mania was identified with euphoria and increased energy and various over-the-top behaviors.
But how do we account for symptoms doctors see in their patients all the time, such as agitation and irritability? The most credible explanation is that mixed states are part of an overlapping spectrum between “pure” depressions and manias. In bipolar disorder, where mixed states are a common feature, they seem to indicate a transition between the “pure” states.
But even if you never experienced mania or hypomania (mania lite), it is still possible to have some of its symptoms. Moreover, mixed features may indicate a gradual conversion from depression to bipolar. Some 20 percent of patients originally diagnosed with depression eventually receive a bipolar diagnosis.
This, of course, suggests different treatments than for plain vanilla depression. A major red flag is a patient who no longer responds to antidepressants.
The doctors on the panel also recommended that clinicians screen for mania in depressed patients, taking a family history (such as a first degree relative who has bipolar), having a family member in on the consultation, and having regard for when the patient’s first depression occurred (a first outbreak during teen or early adulthood points to potential bipolar).
All three members of the panel acknowledged that taking this extra information poses a major challenge in an era where doctors are expected to accomplish more in less time. In this day and age, a good clinician may not wait for you to ramble through your story, and instead prompt you with precise questions.
You can help by by doing your homework in advance. If you suspect that your depression may be more than just a depression, please make an effort to recall behavior out of character with the depression you are in, such as laughing or experiencing bursts of energy or experiencing racing thoughts.
The implications are enormous. All three doctors mentioned that, left untreated, mixed features place the patient at greater risk of suicide and other complications. Don’t be afraid to speak up.