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. A person with this condition would primarily be experiencing depressive symptoms, but they might also have certain manic symptoms, such as racing thoughts.

Another type of mixed state would be bipolar disorder with mixed features, in which a person who has mainly manic symptoms might also have certain depressive symptoms, such as crying.


While the causes of this condition are not well understood, some researchers suggest that mood disorders may exist on a continuum, ranging from depression to mania. While an individual may suffer from symptoms that fall mainly at one end or the other of the scale, pure depression is probably quite rare. At the present time, however, clinicians do still make a diagnostic distinction between depression and bipolar disorder.


Under the DSM-5, the specifier "with mixed features" may be added to a diagnosis of major depressive disorder to indicate that a person has symptoms of both depression and mania, but falls short of being able to receive 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.


In order to be diagnosed with major depressive order, you must first of all have had at least five of the following nine symptoms of major depressive disorder almost every day for at least the past two weeks. The first two symptoms on the list must be among those symptoms.

  • Feelings of depression
  • Decreased interest or pleasure in activities
  • Fatigue or loss of energy
  • Feelings of worthlessness or guilt
  • Significant unintentional weight loss or a change in appetite
  • Inability to fall asleep or sleeping too much
  • Psychomotor agitation or retardation
  • 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, the clinician 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 distractibility
  • Increased energy or goal-directed activity
  • Greater participation in activities which are pleasurable but have the potential to have bad consequences

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.


People who have a depressive disorder with mixed features do not generally respond well to antidepressants alone. Treatment with mood stabilizers or antipsychotic medications may be necessary in order to control their manic symptoms.


Dilsaver, Steven C. "Mixed States in Their Manifold Forms." Psychiatric Times. March 30, 2011. UBM Medica, LLC.

Grohol, John M.  "DSM-5 Changes: Depression & Depressive Disorders. " PsychCentral Professional. May 18, 2013. Psych Central.

McManamy, John.  "DSM-5 Changes to Mixed States - A Report from the 9th International Bipolar Conference." HealthCentral. June 12, 2011.  Remedy Health Media, LLC.

"Mixed Features Specifier."  American Psychiatric Publishing. 2013. American Psychiatric Association.

Vieta, E. and M. Valenti. "Mixed states in DSM-5: implications for clinical care, education, and research." Journal of Affective Disorders. 148.1 (2013):28-36.