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Guidelines for the recognition and management of mixed depression

  • Stephen M. Stahl (a1) (a2) (a3), Debbi A. Morrissette (a3), Gianni Faedda (a4) (a5), Maurizio Fava (a6), Joseph F. Goldberg (a7), Paul E. Keck (a8), Yena Lee (a9) (a10), Gin Malhi (a11), Ciro Marangoni (a5), Susan L. McElroy (a8), Michael Ostacher (a12) (a13), Joshua D. Rosenblat (a9) (a10), Eva Solé (a14), Trisha Suppes (a12) (a13), Minoru Takeshima (a15), Michael E. Thase (a16), Eduard Vieta (a14), Allan Young (a17), Mark Zimmerman (a18) and Roger S. McIntyre (a9) (a10)...
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.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
*Address correspondence to: Stephen M. Stahl, Department of Psychiatry, University of California–San Diego, Neuroscience Education Institute, 1917 Palomar Oaks Way, Suite 200, Carlsbad, California 92008, USA. (Email: smstahl@neiglobal.com)
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