Robert J. Haight, PharmD, BCPP
Program Committee Vice Chair
Michael Thase, MD presented on the development of the mixed features specifier and medication treatment options during his presentation, Mixed Opinions? Recognition and Management of Depressions with Mixed Features. Dr. Thase is a Professor of Psychiatry at Perelman School of Medicine of the University of Pennsylvania and also practices at the Philadelphia VA Medical Center.
After he reviewed the differential diagnosis of depressive disorders. Dr. Thase provided additional details on the “with mixed features” specifier. In general, the mixed features specifier applies to any episode in which at least three symptoms are unique to the opposite pole are present. In patients with a major depressive diagnosis, this could include additional symptoms of euphoric or expansive mood, flight of ideas, racing thoughts, grandiosity, and increased energy. These symptoms must be present nearly every day.
He focused on the impact of each patient’s presenting symptoms and “History taking in the age of DSM-5.” Dr. Thase emphasized the importance of assessing for symptoms of depression and hypomania/mania during every patient encounter, especially asking about mood changes immediately prior to and after depressive episodes. He reminded attendees about the importance of obtaining collateral symptom histories from significant others or other family members, specifically regarding fluctuating or episodic changes. When identifying mixed features, certain “clues” in the patient’s history may be relevant, including early age of onset (<30 years), presence of suicidal ideation, history of traumatic brain injury, substance use, multiple prior episodes, and a family history of bipolar disorder.
Patients with MDD with mixed features have additional burdens including higher rates of suicide attempts, greater risk of comorbidities (anxiety, impulse control, and substance abuse disorders), a higher likelihood of coexisting heart disease, and a greater chance of converting to bipolar disorder. Potential consequences of not correctly diagnosing patients with mixed features include:
Current clinical practice usually includes the initiation of an SSRI or buproprion. If the patient experiences little or no response, switching to a different antidepressant or augmentation with an atypical antipsychotic is recommended. Unfortunately, randomized, placebo-controlled studies of antidepressants for patients with MDD mixed features are lacking. Atypical antipsychotics which have been found to be effective in patients with MDD with mixed features and/or bipolar disorder with mixed features include lurasidone, ziprasidone, and olanzapine.
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