Hostname: page-component-7dd5485656-j7khd Total loading time: 0 Render date: 2025-10-30T15:15:28.944Z Has data issue: false hasContentIssue false
  • English
  • Français

Measures of the DSM–5 mixed-features specifier of major depressive disorder

Published online by Cambridge University Press:  12 January 2017

Mark Zimmerman
Mark Zimmerman*
Affiliation:
Department of Psychiatry and Human Behavior, Brown Medical School, Rhode Island Hospital, Providence, Rhode Island, USA
*
*Address for correspondence: Mark Zimmerman, 146 West River Street; Providence, Rhode Island 02904, USA. (Email: mzimmerman@lifespan.org)
Get access Rights & Permissions [Opens in a new window]

Abstract

During the past two decades, a number of studies have found that depressed patients frequently have manic symptoms intermixed with depressive symptoms. While the frequency of mixed syndromes are more common in bipolar than in unipolar depressives, mixed states are also common in patients with major depressive disorder. The admixture of symptoms may be evident when depressed patients present for treatment, or they may emerge during ongoing treatment. In some patients, treatment with antidepressant medication might precipitate the emergence of mixed states. It would therefore be useful to systematically inquire into the presence of manic/hypomanic symptoms in depressed patients. We can anticipate that increased attention will likely be given to mixed depression because of changes in the DSM–5. In the present article, I review instruments that have been utilized to assess the presence and severity of manic symptoms and therefore could be potentially used to identify the DSM–5 mixed-features specifier in depressed patients and to evaluate the course and outcome of treatment. In choosing which measure to use, clinicians and researchers should consider whether the measure assesses both depression and mania/hypomania, assesses all or only some of the DSM–5 criteria for the mixed-features specifier, or assesses manic/hypomanic symptoms that are not part of the DSM–5 definition. Feasibility, more so than reliability and validity, will likely determine whether these measures are incorporated into routine clinical practice.

Keywords

Bipolar disordermixed featuresself-reportinterviewDSM–5specifier

Information

Type
Review Articles
Information
CNS Spectrums , Volume 22 , Issue 2: Theme: Mixed features in major depressive episodes , April 2017 , pp. 196 - 202
Copyright
© Cambridge University Press 2017 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

1. Kraepelin, E. Manic-Depressive Insanity and Paranoia. Edinburgh: Livingstone; 1921.Google Scholar
2. Bauer, MS, Wisniewski, SR, Marangell, LB, et al. Are antidepressants associated with new-onset suicidality in bipolar disorder? A prospective study of participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP–BD). J Clin Psychiatry. 2006; 67(1): 48–55.Google Scholar
3. Goldberg, JF, Perlis, RH, Bowden, CL, et al. Manic symptoms during depressive episodes in 1,380 patients with bipolar disorder: findings from the STEP–BD. Am J Psychiatry. 2009; 166(2): 173–181. http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2008.08050746.Google Scholar
4. Judd, LL, Schettler, PJ, Akiskal, H, et al. Prevalence and clinical significance of subsyndromal manic symptoms, including irritability and psychomotor agitation, during bipolar major depressive episodes. J Affect Disord. 2012; 138(3): 440–448; Epub ahead of print Feb 6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3677770/pdf/nihms468685.pdf.CrossRefGoogle ScholarPubMed
5. Swann, AC, Moeller, FG, Steinberg, JL, Schneider, L, Barratt, ES, Dougherty, DM. Manic symptoms and impulsivity during bipolar depressive episodes. Bipolar Disord. 2007; 9(3): 206–212. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723749/pdf/nihms128564.pdf.Google Scholar
6. Dodd, S, Kulkarni, J, Berk, L, et al. A prospective study of the impact of subthreshold mixed states on the 24-month clinical outcomes of bipolar I disorder or schizoaffective disorder. J Affect Disord. 2010; 124(1–2): 22–28. Epub ahead of print Nov 27, 2009.Google Scholar
7. Goldberg, J, Perlis, R, Ghaemi, S, et al. Adjunctive antidepressant use and symptomatic recovery among bipolar depressed patients with concomitant manic symptoms: findings from the STEP–BD. Am J Psychiatry. 2007; 164(9): 1348–1355. http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2007.05122032.Google Scholar
8. Masi, G, Toni, C, Perugi, G, Mucci, M, Millepiedi, S, Akiskal, HS. Anxiety disorders in children and adolescents with bipolar disorder: a neglected comorbidity. Can J Psychiatry. 2001; 46(9): 797–802.Google Scholar
9. Olgiati, P, Serretti, A, Colombo, C. Retrospective analysis of psychomotor agitation, hypomanic symptoms, and suicidal ideation in unipolar depression. Depress Anxiety. 2006; 23(7): 389–397.Google Scholar
10. Perugi, G, Angst, J, Azorin, JM, et al. Mixed features in patients with a major depressive episode: the BRIDGE–II–MIX Study. J Clin Psychiatry. 2015; 76(3): e351–e358.Google Scholar
11. Smith, DJ, Forty, L, Russell, E, et al. Sub-threshold manic symptoms in recurrent major depressive disorder are a marker for poor outcome. Acta Psychiatr Scand. 2009; 119(4): 325–329. Epub ahead of print Dec 16, 2008.Google Scholar
12. Benazzi, F. Intra-episode hypomanic symptoms during major depression and their correlates. Psychiatry Clin Neurosci. 2004; 58(3): 289–294 http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1819.2004.01234.x/pdf.Google Scholar
13. Sato, T, Bottlender, R, Schroter, A, Möller, HJ. Frequency of manic symptoms during a depressive episode and unipolar “depressive mixed state” as bipolar spectrum. Acta Psychiatr Scand. 2003; 107(4): 268–274.Google Scholar
14. Benazzi, F. Suicidal ideation and bipolar–II depression symptoms. Hum Psychopharmacol. 2005; 20(1): 27–32.Google Scholar
15. Benazzi, F. Reviewing the diagnostic validity and utility of mixed depression (depressive mixed states). Eur Psychiatry. 2008; 23(1): 40–48. Epub ahead of print Aug 30, 2007.Google Scholar
16. Koukopoulos, A, Sani, G, Koukopoulos, AE, Manfredi, G, Pacchiarotti, I, Girardi, P. Melancholia agitata and mixed depression. Acta Psychiatr Scand Suppl. 2007; 11(433): 50–57. http://onlinelibrary.wiley.com/resolve/doi?DOI=10.1111/j.1600-0447.2007.00963.x,Google Scholar
17. Vieta, E. The treatment of mixed states and the risk of switching to depression. Eur Psychiatry. 2005; 20(2): 96–100.Google Scholar
18. Perlis, RH, Cusin, C, Fava, M. Proposed DSM–5 mixed features are associated with greater likelihood of remission in out-patients with major depressive disorder. Psychol Med. 2014; 44(7): 1361–1367. Epub ahead of print Mar 15, 2012.CrossRefGoogle ScholarPubMed
19. Benazzi, F. Bipolar disorder: focus on bipolar II disorder and mixed depression. Lancet. 2007; 369(9565): 935–945.CrossRefGoogle ScholarPubMed
20. Berk, M, Dodd, S, Malhi, GS. “Bipolar missed states”: the diagnosis and clinical salience of bipolar mixed states. Aust N Z J Psychiatry. 2005; 39(4): 215–221.Google ScholarPubMed
21. Swann, AC, Lafer, B, Perugi, G, et al. Bipolar mixed states: an international society for bipolar disorders task force report of symptom structure, course of illness, and diagnosis. Am J Psychiatry. 2013; 170(1): 31–42. http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2012.12030301.CrossRefGoogle ScholarPubMed
22. Koukopoulos, A, Sani, G, Ghaemi, SN. Mixed features of depression: why DSM–5 is wrong (and so was DSM–IV). Br J Psychiatry. 2013; 203(1): 3–5. http://bjp.rcpsych.org/content/203/1/3.long.CrossRefGoogle ScholarPubMed
23. Malhi, GS, Das, P, Gessler, D, Outhred, T, Fritz, K. The mixed features of DSM–5. Aust N Z J Psychiatry. 2015; 49(9): 842–843.Google Scholar
24. Koukopoulos, A, Sani, G. DSM–5 criteria for depression with mixed features: a farewell to mixed depression. Acta Psychiatr Scand. 2014; 129(1): 4–16. Epub ahead of print Apr 19, 2013.Google Scholar
25. Kim, W, Kim, H, Citrome, L, et al. More inclusive bipolar mixed depression definitions by requiring fewer non-overlapping mood elevation symptoms. Acta Psychiatr Scand. 2016; 134(3): 189–198. Epub ahead of print May 2.Google Scholar
26. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. 3rd ed. Washington, DC, American Psychiatric Association; 2010. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf.Google Scholar
27. Kroenke, K, Spitzer, R, Williams, J. The PHQ–9: validity of a brief depression severity measure. J Gen Intern Med. 2001; 16(9): 606–613. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/pdf/jgi_01114.pdf.Google Scholar
28. Rush, A, Trivedi, M, Ibrahim, H, et al. The 16-item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS–C), and self-report (QIDS–SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003; 54(5): 573–583.CrossRefGoogle ScholarPubMed
29. Zimmerman, M, Chelminski, I, McGlinchey, JB, Posternak, MA. A clinically useful depression outcome scale. Compr Psychiatry. 2008; 49(2): 131–140. Epub ahead of print Dec 20, 2007.Google Scholar
30. Ghaemi, SN, Boiman, EE, Goodwin, FK. Diagnosing bipolar disorder and the effect of antidepressants: a naturalistic study. J Clin Psychiatry. 2000; 61(10): 804–808.Google Scholar
31. Ghaemi, SN, Ko, JY, Goodwin, FK. “Cade’s disease” and beyond: misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum disorder. Can J Psychiatry. 2002; 47(2): 125–134.Google Scholar
32. Hantouche, EG, Akiskal, HS, Lancrenon, S, et al. Systematic clinical methodology for validating bipolar–II disorder: data in mid-stream from a French national multi-site study (EPIDEP). J Affect Disord. 1998; 50(2–3): 163–173.Google Scholar
33. Birnbaum, HG, Shi, L, Dial, E, Oster, EF, Greenberg, PE, Mallett, DA. Economic consequences of not recognizing bipolar disorder patients: a cross-sectional descriptive analysis. J Clin Psychiatry. 2003; 64(10): 1201–1209.Google Scholar
34. Shi, L, Thiebaud, P, McCombs, JS. The impact of unrecognized bipolar disorders for patients treated for depression with antidepressants in the fee-for-services California Medicaid (Medi-Cal) program. J Affect Disord. 2004; 82(3): 373–383.Google Scholar
35. Matza, LS, Rajagopalan, KS, Thompson, CL, de Lissovoy, G. Misdiagnosed patients with bipolar disorder: comorbidities, treatment patterns, and direct treatment costs. J Clin Psychiatry. 2005; 66(11): 1432–1440.CrossRefGoogle ScholarPubMed
36. Depue, RA, Krauss, S, Spoont, MR, Arbisi, P. General Behavior Inventory identification of unipolar and bipolar affective conditions in a nonclinical university population. J Abnorm Psychol. 1989; 98(2): 117–126.CrossRefGoogle Scholar
37. Hirschfeld, R, Williams, J, Spitzer, R, et al. Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. Am J Psychiatry. 2000; 157(11): 1873–1875. http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.157.11.1873.Google Scholar
38. Angst, J, Adolfsson, R, Benazzi, F, et al. The HCL–32: towards a self-assessment tool for hypomanic symptoms in outpatients. J Affect Disord. 2005; 88(2): 217–233.Google Scholar
39. Ghaemi, SN, Miller, CJ, Berv, DA, Klugman, J, Rosenquist, KJ, Pies, RW. Sensitivity and specificity of a new bipolar spectrum diagnostic scale. J Affect Disord. 2005; 84(2–3): 273–277.Google Scholar
40. Graham, RK, Parker, GB. The status of screening measures for bipolar disorder. Curr Opin Psychiatry. 2015; 28(1): 18–23.Google Scholar
41. Wang, HR, Woo, YS, Ahn, HS, Ahn, IM, Kim, HJ, Bahk, WM. The validity of the Mood Disorder Questionnaire for screening bipolar disorder: a meta-analysis. Depress Anxiety. 2015; 32(7): 527–538.Google Scholar
42. Zimmerman, M, Galione, J. Screening for bipolar disorder with the Mood Disorder Questionnaire: a review. Harv Rev Psychiatry. 2011; 19(5): 219–228.Google Scholar
43. Rush, AJ, First, MB, Blacker, D. Handbook of Psychiatric Measures, 2nd ed. Washington, DC: American Psychiatric Association; 2008.Google Scholar
44. Altman, EG, Hedeker, D, Peterson, JL, Davis, JM. The Altman Self-Rating Mania Scale. Biol Psychiatry. 1997; 42(10): 948–955.Google Scholar
45. Cooke, RG, Kruger, S, Shugar, G. Comparative evaluation of two self-report Mania Rating Scales. Biol Psychiatry. 1996; 40(4): 279–283.Google Scholar
46. Braunig, P, Shugar, G, Kruger, S. An investigation of the Self-Report Manic Inventory as a diagnostic and severity scale for mania. Compr Psychiatry. 1996; 37(1): 52–55.CrossRefGoogle ScholarPubMed
47. Shugar, G, Schertzer, S, Toner, BB, DiGasbarro, I. Development, use, and factor analysis of a self-report inventory for mania. Compr Psychiatry. 1992; 33(5): 325–331.Google Scholar
48. Bauer, MS, Crits-Christoph, P, Ball, WA, et al. Independent assessment of manic and depressive symptoms by self-rating: scale characteristics and implications for the study of mania. Arch Gen Psychiatry. 1991; 48(9): 807–812.Google Scholar
49. Zimmerman, M, Chelminski, I, Young, D, Dalrymple, K, Martinez, JH. A clinically useful self-report measure of the DSM–5 mixed features specifier of major depressive disorder. J Affect Disord. 2014; 168(Oct): 357–362. Epub ahead of print Jul 22.Google Scholar
50. Goodwin, F, Jamison, K. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd ed. New York: Oxford University Press; 2007.Google Scholar
51. Vieta, E, Bobes, J, Ballesteros, J, et al. Validity and reliability of the Spanish versions of the Bech–Rafaelsen’s mania and melancholia scales for bipolar disorders. Acta Psychiatr Scand. 2008; 117(3): 207–215. Epub ahead of print Dec 13, 2007.CrossRefGoogle ScholarPubMed
52. Shansis, FM, Reche, M, Capp, E. Evaluating response to mood stabilizers in patients with mixed depression: a study of agreement between three different mania rating scales and a depression rating scale. J Affect Disord. 2016; 197: 1–7. Epub ahead of print Mar 3.Google Scholar
53. Young, RC, Biggs, JT, Ziegler, VE, Meyer, DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry. 1978; 133(5): 429–435.Google Scholar
54. Bech, P. The Bech–Rafaelsen Mania Scale in clinical trials of therapies for bipolar disorder: a 20-year review of its use as an outcome measure. CNS Drugs. 2002; 16(1): 47–63.CrossRefGoogle ScholarPubMed
55. Altman, EG, Hedeker, DR, Janicak, PG, Peterson, JL, Davis, JM. The Clinician-Administered Rating Scale for Mania (CARS–M): development, reliability, and validity. Biol Psychiatry. 1994; 36(2): 124–134.CrossRefGoogle ScholarPubMed
56. Endicott, J, Spitzer, RL. A diagnostic interview: The Schedule for Affective Disorders and Schizophrenia. Arch Gen Psychiatry. 1978; 35(7): 837–844.Google Scholar
57. Spitzer, RL, Endicott, J, Robins, E. Research diagnostic criteria: rationale and reliability. Arch Gen Psychiatry. 1978; 35(6): 773–782.Google Scholar
58. Swann, AC, Steinberg, JL, Lijffijt, M, Moeller, GF. Continuum of depressive and manic mixed states in patients with bipolar disorder: quantitative measurement and clinical features. World Psychiatry. 2009; 8(3): 166–172. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758583/pdf/wpa030166.pdf.Google Scholar
59. Bowden, CL, Singh, V, Thompson, P, et al. Development of the Bipolar Inventory of Symptoms Scale. Acta Psychiatr Scand. 2007; 116(3): 189–194.Google Scholar
60. Gonzalez, JM, Bowden, CL, Katz, MM, et al. Development of the Bipolar Inventory of Symptoms Scale: concurrent validity, discriminant validity and retest reliability. Int J Methods Psychiatr Res. 2008; 17(4): 198–209.Google Scholar
61. First, MB, Spitzer, RL, Williams, JBW, Gibbon, M. Structured Clinical Interview for DSM–IV (SCID). Washington, DC: American Psychiatric Association; 1997.Google Scholar
62. Zimmerman, M, McGlinchey, JB, Chelminski, I. An inadequate community standard of care: lack of measurement of outcome when treating depression in clinical practice. Prim Psychiatry. 2008; 15: 67–75.Google Scholar
63. Trivedi, M, Rush, A, Wisniewski, S, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D implications for clinical practice. Am J Psychiatry. 2006; 163(1): 28–40. http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.163.1.28.Google Scholar
64. Akiskal, HS, Benazzi, F. Family history validation of the bipolar nature of depressive mixed states. J Affect Disord. 2003; 73(1–2): 113–122.Google Scholar
65. Angst, J, Azorin, JM, Bowden, CL, et al. Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: the BRIDGE Study. Arch Gen Psychiatry. 2011; 68(8): 791–798. http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1107421.Google Scholar
66. Benazzi, F, Akiskal, HS. Psychometric delineation of the most discriminant symptoms of depressive mixed states. Psychiatry Res. 2006; 141(1): 81–88. Epub ahead of print Nov 28, 2005.Google Scholar
67. Serretti, A, Olgiati, P. Profiles of “manic” symptoms in bipolar I, bipolar II and major depressive disorders. J Affect Disord. 2005; 84(2–3): 159–166.CrossRefGoogle ScholarPubMed
68. Benazzi, F. Bipolar II depressive mixed state: finding a useful definition. Compr Psychiatry. 2003; 44(1): 21–27.Google Scholar