An Overview of Depressive Disorder With Mixed Features

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Depressive disorder with mixed features (also referred to as mixed episode, mixed state, or agitated depression) is a mood disorder where a person has symptoms of both depression and mania or hypomania at the same time

When it was first introduced, the diagnosis of major depressive disorder with mixed features (MDD-MX) was met with skepticism and remains controversial among some researchers and clinicians. 

However, in 2013 MDD-MX was included in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and has begun to gain acceptance.


The specific causes of depression with mixed features are unclear and not well understood. As with other types of depression, researchers suspect there are a number of different factors that contribute to the development of the MDD-MX, including an individual’s family history, genetics, environment, and other health conditions. 

While MDD-MX can be difficult to diagnose, research has suggested it’s fairly common: as many as 25% of people with unipolar depression may have mixed episodes.

Since the condition can easily be misdiagnosed as bipolar disorder, the number of people who have depression with mixed features may, in fact, be much higher. 

In the past, differentiating between depression with mixed episodes and bipolar disorder was much more challenging for clinicians. Recent updates to diagnostic guidelines that consider the subtleties of each condition have been helpful.

Continued research into the factors that contribute to depression, such as environmental exposure and genetics, are also giving researchers a better understanding.


Researchers have come to believe that mood disorders exist on a continuum from depression to mania (pure depression is thought to be much less common and some researchers consider it rare). In general, a person who has one of these conditions experiences symptoms across the spectrum but tends to lean more toward one end than the other. 

As they are trying to make a diagnosis, your doctor will ask you about where your symptoms typically fall on the spectrum. This will help them distinguish between depression and bipolar disorder.

People who have depression with mixed features usually experience mostly depressive symptoms, but may have certain manic symptoms (such as racing thoughts) as well. 

To be diagnosed with major depressive disorder, you must have experienced certain symptoms every day for at least the past two weeks or longer. 

Classic features of depression include low mood and decreased interest or pleasure in activities you typically enjoy. However, to be diagnosed with depression, you must also have at least four of the following symptoms:

  • Fatigue, loss of energy and motivation
  • Feeling worthless, ashamed, or guilty
  • Inability to fall asleep or sleeping too much
  • Troubling thinking, focusing, and concentrating
  • Losing or gaining weight, eating more or less than usual
  • Psychomotor agitation (pacing, restlessness) or retardation (sluggish thought or movement)
  • Recurrent thoughts of death/dying, suicidal ideation or attempts

If your doctor feels you meet the criteria for a diagnosis of depression, the next step will be to determine whether you are also experiencing symptoms of hypomania or mania, such as:

If you have experienced at least three of symptoms of hypomania or mania almost every day for the past two weeks of your current depressive episode, your doctor will add the specifier with mixed features to your depression diagnosis. 


It can be very challenging to diagnose depression with mixed features. For a long time, mental health professionals were taught that the presence of manic symptoms meant a person had bipolar, rather than unipolar, depression. 

While mania or hypomania is still part of the fundamental diagnostic criteria for bipolar disorder, it is now also understood that people with depression may experience these symptoms—albeit to a lesser degree. 

The classic signs and symptoms of major depression may be relatively easy to spot, but subtle episodes of mania or hypomania may go undetected—both by the person with the condition and the doctors treating them.

A person with symptoms of hypomania or mania and depression may initially be misdiagnosed with bipolar disorder. While the conditions may look (and at times feel) the same, there are some important distinctions—especially when it comes to treatment. A correct diagnosis is necessary to ensure someone with either condition is able to access the most effective type of treatment. 

Obvious similarities between mixed episodes of depression and bipolar disorder, such as shared symptoms, might be clear to doctors and researchers but these conditions may also share risk factors (like a family history of mental illness). 

Doctors must carefully consider all the information as they are formulating a diagnosis, as only looking at symptoms can be misleading. The consequences of being diagnosed with the wrong mood disorder can have a major impact on someone’s life. 

According to the DSM-5, the "with mixed features" specifier can be added to a diagnosis of major depressive disorder to indicate a person has symptoms of both depression and mania but doesn’t quite meet the diagnostic criteria for a diagnosis of bipolar disorder.

Though there are similarities between depression with mixed features and bipolar disorder, the two conditions can differ quite a bit in how they respond to treatment—especially medications (see: Treatment). 

It’s also important to know that a diagnosis of depressive disorder with mixed features in and of itself is a significant risk factor for eventually developing bipolar disorder. When you and your doctor are creating a treatment plan, you will need to consider this risk. 

Research has indicated that compared to those with depression, people who experience mixed episodes are more likely to misuse substances and are at an increased risk for suicide—yet another reason why getting a correct diagnosis is important. 


After being diagnosed with depressive disorder with mixed features, your doctor or psychiatrist will discuss treatment options with you. The first option may be therapy, medication, or both.

It’s important to know that this form of depression may not respond well—or at all—to treatment with antidepressant medications alone.

To help with manic symptoms, your doctor may also prescribe an atypical antipsychotic such as: 

You may also be given a mood stabilizer like lithium or Depakote (Divalproex) instead of, or in addition to, an antidepressant. Small studies in patients with depression and mixed episodes have demonstrated these medications may be helpful when given in doses lower than would be used for bipolar disorder. 

Some people who have depression with mixed features have trouble sleeping or feel especially agitated during periods of mania/hypomania. Your doctor may prescribe sedatives to help with these symptoms, such as:

Even if you are taking more than one medication, it may not be enough to effectively help manage symptoms of depression with mixed features. You may need to implement other types of treatment, such as psychotherapy, cognitive behavioral therapy, or electroconvulsive therapy (ECT). 


For people who have MDD-MX, both the process of getting diagnosed and the demands of managing symptoms can become frustrating and overwhelming.

If you have recently been diagnosed or are working with a doctor/mental health professional because you suspect you may have MDD-MX, it’s important that you have the support you need. 

Begin to build your network of support with those around you at home, such as family members and friends, then reach out to your community (such as a church group or volunteer organization). 

You may want to find specific support groups (in-person, online, or both) for people with depression, bipolar disorder, and other mood disorders. 

If you’re not sure where to start, ask your doctor, psychiatrist, or therapist if they can point you toward local resources. You can also use the internet to search for social networks, forums, and patient advocacy networks.

A Word From Verywell

If you have depression with mixed features, you may share some experiences with someone who has been diagnosed with bipolar disorder. However, the conditions have some key differences that both you and your mental health care team need to be aware of—especially when deciding on treatment. 

If you have depression with mixed episodes, you may not respond well (or at all) to the antidepressants usually prescribed for depression. You may need a different combination of medications (such as mood stabilizers) as well as other therapeutic interventions to manage the condition effectively. 

The process can be frustrating, particularly if you are initially misdiagnosed with another mood disorder and not given a treatment that works well for you. That’s why it’s important to do your best to create and maintain a network of support around you. 

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