When the diagnostic criterion for MD was applied to depressed patients, the prevalence of DMX was estimated as about one-third of MDE, which was 5 to 10 times higher than that diagnosed by MF of the DSM-5 criteria Thus, categorically diagnosed DMX has been still a target of argument, because of large variability in their prevalence without any assessment of DMX severity. “Mixed depression (MD)” proposed by Benazzi has covered these excluded nonspecific symptoms as core mixed symptoms and has extended the definition of DMX (at least 3 mixed symptoms for a week and more during MDE). Other studies have criticized that exclusion of nonspecific symptoms like distractibility, irritability, and agitation common for both manic and depressive psychopathology causes underdiagnosis of MF and have stressed that such overlapping symptoms are rather important as the core symptoms of DMX. However, contrary to our expectations, studies using the DSM-5 criteria used to demonstrate relatively low prevalence of MF (3.2–7.5%) or rather show considerably wide range of the prevalence according to the latest meta-analysis (7.2–42.5%). The new diagnostic criteria, DSM-5, more broadly defined DMX as “mixed features specifier (MF)”, at least three typical hypomanic/manic symptoms during a major depressive episode.
ED DMX MIXES FULL
Mixed episode used to be a rare diagnosis only for bipolar I disorder, because the DSM-IV-TR criteria defined mixed episode as a mixture of both full depressive and full manic episodes. Moreover, DMX often requires prompt treatment including urgent admission and cautious medication different from those used for pure depression like vigorous antidepressant monotherapy. However, patients rarely express their mixed depressive symptoms, whereas clinicians tend to focus on typical depressive manifestations and overlook DMX during MDE. Core Symptoms of DMX have been regarded as distractibility, psychomotor agitation, irritability, and racing/crowded thoughts, which are apparently different from static and internalized manifestations of pure depression. The abovementioned 8 symptoms seem to be helpful for primary screening and negative check of DMX with considerable severity during MDE.ĭepressive mixed state (DMX) as a mixture of subthreshold manic components during major depressive episodes (MDE) remains underdiagnosed although clinicians do not rarely encounter potential DMX in usual clinical settings. The AUC of ROC curve and sensitivity/specificity were well balanced together with sufficient negative predictive values. By using these 8 symptoms, 40.5% of the overall patients were screened as positive at the same cut-off value (≥13) for both MD and MF. Eight symptoms (overreactivity, inner tension, racing/crowded thought, impulsivity, irritability, aggression, risk-taking behavior, and dysphoria) with their AUC > 0.6 for ROC curves were specially focused on distinguishing patients with MF or MD from non-mixed patients.
The rate of MF was 4.2% while that of MD was 22.6%.
Associations between symptomatological combinations of the DMX-12 and MF or MD were analyzed using receiver operating characteristic (ROC). Subjects were 190 consecutive cases with major depressive episode (MDE) who visited our clinic. For simultaneous screening of mixed features (MF) by DSM-5 and mixed depression (MD) by Benazzi, useful symptoms were extracted from our 12-item dimensional scale for depressive mixed state (DMX-12).
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