Are manic symptoms that ‘dip’ into depression the essence of mixed features?

Malhi, Gin S; Fritz, Kristina; Allwang, Christine; Burston, Nicole; Cocks, Chris; Devlin, Jill; Harper, Margaret; Hoadley, Benjamin; Kearney, Brian; Klug, Peter; Meagher, Linton J.; Rowe, Mark; Samir, Hany; Way, Raymond; Wilson, Craig M.; Lyndon, William

doi:10.1016/j.jad.2015.12.009

Cited by 30 publications

(26 citation statements)

References 16 publications

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“…This suggests that our present obsession with mood is misguided, and that pure mania and depression are relatively uncommon, such that they should not be accorded such prominence in diagnostic manuals. This is an important point that warrants careful consideration and, although our data is once again limited in this regard, recent research does lend support to both the traditional perspectives of mixed state prevalence and the importance of cognition and activity domains 25-27…”

Section: Introductionmentioning

confidence: 75%

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Modelling mood disorders: An ACE solution?

et al. 2018

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Objectives The treatment of mood disorders remains sub‐optimal. A major reason for this is our lack of understanding of the underlying pathophysiology of depression and bipolar disorder. A core problem is the lack of specificity of our current diagnoses. This paper discusses the history of this problem and posits a solution in the form of a more sophisticated model. Method The authors review the notable historical works that laid the foundations of mood disorder nosology; discuss the more recent influences that shaped modern diagnoses; and examine the evidence that mood disorders are characterised by multidimensional and longitudinal symptom profiles. Results The ACE model considers mood disorders as a combination of symptoms across three domains: Activity, Cognition, and Emotion; that vary over time. This multidimensional and longitudinal perspective is consistent with the prevalence of complex clinical presentations, such as mixed states, and highlights the importance of recurrence in mood disorders. Conclusions The ACE model encourages researchers to characterise patients from a number of equally important perspectives and, by doing so, add specificity to the treatment of mood disorders.

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Section: Introductionmentioning

confidence: 75%

“…This is an important point that warrants careful consideration and, although our data is once again limited in this regard, recent research does lend support to both the traditional perspectives of mixed state prevalence and the importance of cognition and activity domains. [25][26][27]…”

Section: Indeed Two Thirds Of Patients Seen Across 7 Years At Kraepementioning

confidence: 99%

Modelling mood disorders: An ACE solution?

et al. 2018

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“…The lack of association between irritability and mixed states at baseline should not be confused with prevalence studies that have shown that irritability is common in mixed states . If we look at the proportion of participants who were irritable within the mixed BCOS subsample, a reasonably high percentage (66%; n=22) were irritable – true for both mixed mania (n=33) and mixed depression (n=33).…”

Section: Discussionmentioning

confidence: 99%

“…Given its common occurrence as a nonspecific factor, however, irritability in the DSM 5 is not included as a mixed specifier of major depressive episodes (MDEs) in adults . Even when conceptualized independently of other manic symptoms, irritability commonly co‐occurs with episodes of bipolar depression . In both the Systematic Treatment Enhancement Program for Bipolar Disorder study (STEP‐BD) (n=1180) at baseline and the long‐term prospective Collaborative Depression Study (CDS) (n=142), which involved participants with bipolar depression, irritability occurred far more often than other common intradepressive manic symptoms .…”

Section: Introductionmentioning

confidence: 99%

Impact of irritability: a 2‐year observational study of outpatients with bipolar I or schizoaffective disorder

Berk

Hallam

Venugopal³

et al. 2017

Bipolar Disorders

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“…In conclusion, although the combinatory approach may have favored empirical research, it seems to represent an obstacle to the identification and definition of specific criteria for the diagnosis of mixed episode. Any evidence‐based definition of mixed states must include core mixed features for the different subtypes . Clinical research has underlined how overlapping symptoms, such as psychomotor agitation, mood lability, irritability and distractibility may actually represent the core features of mixed depression .…”

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confidence: 99%

ICD‐11 mixed episode: Nothing new despite the evidence

Perugi

2019

Bipolar Disorders

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The modern concept of mixed state was introduced by Kraepelin 1 to identify "phases" characterized by the contemporary presence of manic and depressive features, in patients with manic-depressive insanity. He formulated the hypothesis that each of the domains of mood, cognition, and activity would change at a different pace over time, thereby leading to selective increases or decreases of each of these three domains. In this model, different types of mixed states reflected the instability of underlying brain mechanisms governing the three fundamental domains of psychic life and are not considered just a complication of mania and depression, but the most common clinical manifestation and the most important unifying core feature of manic-depressive insanity.In DSM-III, -IV, and -5 mixed episode has not received specific criteria characterization and is basically defined as the combination of mania and major depression "co-occurring or rapidly alternating" in the same period. This approach, which in part reflects the recent empirical Zeitgeist of descriptive psychiatry, shaped the kind of research that was conducted in recent years and mixed state has been mainly considered as a subtype of manic or depressive episodes, rather than in Kraepelinian terms of specific features or episode components.The inclusion of symptoms of the opposite polarity in depressive and manic episode implicitly recognizes the existence of a mood spectrum, suggesting a continuum ranging from pure major depression to pure mania. The DSM-5 definition of mixed features reflects this spectrum approach and captures subthreshold non-overlapping symptoms of the opposite pole using a "with mixed features" specifier to be applied to manic, hypomanic, and major depressive episodes, experienced in bipolar I, II, and major depressive disorder. The criteria are in part data-driven and overcome the problems derived from the extremely narrow definition of the previous editions of the manual. The possibility of classifying depression "with mixed features" represents another major improvement. However, the DSM-5 definition is based on the speculative wish to avoid "overlapping" manic and depressive symptoms, such as psychomotor agitation, irritability, and mood lability, the most common features of mixed depression across the literature. This opinion-based aspect of the DSM-5 definition is very restrictive, allowing the diagnosis of mixed depression only in 1 out of 4 cases. 2 Certainly, these symptoms may be nonspecific, but to exclude them entirely may be not justified, in the absence of any evidence that the remaining criteria are sufficiently sensitive. Without empirical evidence, the theoretical wish to avoid over-diagnosis cannot be considered a criterion of validity in itself.Fortunately, in the ICD-11 a specific diagnostic category for mixed episode has been preferred to a "specifier" for depressive and manic episodes. A diagnostic category is obviously more likely to improve diagnostic sensitivity and to ensure specific treatment strategy than a sim...

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Are manic symptoms that ‘dip’ into depression the essence of mixed features?

Cited by 30 publications

References 16 publications

Modelling mood disorders: An ACE solution?

Modelling mood disorders: An ACE solution?

Impact of irritability: a 2‐year observational study of outpatients with bipolar I or schizoaffective disorder

ICD‐11 mixed episode: Nothing new despite the evidence

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