Depressive Disorder With Mixed Features

Causes, Symptoms, and Diagnosis

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Depressive disorder with mixed features, also known as a mixed episode, a mixed state, or agitated depression, is a term used in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to describe a condition in which the symptoms of both depression and mania exist at the same time. If you have this condition, you experience mostly depressive symptoms, but you also have certain manic symptoms, such as racing thoughts.

Another type of mixed state would be bipolar disorder with mixed features, in which you have mainly manic symptoms, but you also have certain depressive symptoms, such as crying.


While the causes of this condition are not well understood, some researchers suggest that mood disorders exist on a continuum, ranging from depression to mania.

While you may suffer from symptoms that fall mainly at one end or the other of the scale, pure depression is likely quite rare. However, clinicians do still make a diagnostic distinction between depression and bipolar disorder.


In order to be diagnosed with major depressive order, you must have had feelings of depression and/or decreased interest or pleasure in activities you've normally enjoyed, PLUS at least four of the following symptoms almost every day for the past two weeks or longer:

  • Fatigue or loss of energy
  • Feelings of worthlessness or guilt
  • Weight or appetite changes (losing or gaining weight, having no appetite or eating more than you normally do)
  • Inability to fall asleep or sleeping too much
  • Psychomotor agitation or retardation (pacing or feeling restless; sluggish thoughts or not feeling like moving)
  • Decreased ability to think or concentrate
  • Recurrent thoughts of death or suicide

If you meet the specific criteria for a diagnosis of major depressive disorder, your doctor will then consider whether you have also had any of the following symptoms of mania or hypomania:

  • Elevated mood
  • Inflated self-esteem
  • Pressured speech and increased talking
  • Decreased need for sleep
  • Flight of ideas or racing thoughts
  • Increased energy or goal-directed activity
  • Greater participation in activities that are pleasurable but that have the potential to have bad consequences, such as excessive use of alcohol or risky sex

If you have had at least three of the preceding symptoms almost every day for the past two weeks of your current depressive episode, then a specifier of "with mixed features" will be added to your diagnosis of depression.


Under the DSM-5, the specifier "with mixed features" may be added to a diagnosis of major depressive disorder to indicate that you have symptoms of both depression and mania, but that you don't quite meet the criteria for a diagnosis of bipolar disorder.

Being diagnosed with depressive disorder with mixed features is a fairly significant risk factor in developing bipolar disorder in the future, so your treatment plan should be adjusted accordingly.


If you are diagnosed with a depressive disorder with mixed features, you will probably need an antidepressant. However, this type of depression doesn't generally respond well to antidepressants alone and sometimes doesn't respond well to them at all.

Your doctor may prescribe an atypical antipsychotic like Saphris (asenapine), Latuda (lurasidone), Zyprexa (olanzapine), Seroquel (quetiapine), or Geodon (ziprasidone), and/or a mood stabilizer like lithium or Depakote (divalproex) to help with your manic symptoms along with or instead of the antidepressant. You may also be prescribed a sedative like Valium (diazepam), Xanax (alprazolam), Ativan (lorazepam), or Klonopin (clonazepam) to help you sleep.

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