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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.
The balance of national and state powers has undergone continuous readjustment since 1790, without a constitutional amendment by means of numerous congressional preemption statutes superseding completely or partially certain regulatory powers of the states and thereby effectuating a major transformation in the federal system. Congress since 1978 has increased its regulation of subnational governments as polities by enacting preemption statutes containing mandates and restraints (Zimmerman 1994) while simultaneously enacting other statutes providing for extensive deregulation of the banking and communications industries and complete economic deregulation of the air, bus, and rail transportation companies.
The United States Constitution incorporated elements of the unitary and confederate systems of government to form simultaneously a compound republic, the world's first federal governance system, and a unitary government with complete control over the District of Columbia and territories. Specific powers were delegated to Congress and all other powers were reserved to the states and the people unless prohibited.
It is with the deepest regret that I report the death on January 15, 2004, of Wilma L. Rule who collaborated with me on a number of research projects relating to the election of women and members of certain minority groups to elective office in the United States and other nations. She was a long-time member and secretary-treasurer of the Section on Representation and Electoral Systems of The American Political Science Association whose members continue to appreciate her research and service to the profession.