Support for DSM-5 mixed features specifier

By Lucy Piper, Senior medwireNews Reporter

Study findings uphold the value of the DSM-5 mixed features specifier of at least three depressive symptoms (DS) during a manic episode for diagnosing and classifying patients with mixed mania.

Of 700 patients with bipolar I disorder who responded to an online questionnaire about their diagnosis, symptoms, and treatment, 275 (39%) had experienced DS during a past manic episode.

This was in agreement with results reported using broader criteria and close to the prevalence based on clinician judgment, the researchers, led by Eduard Vieta (University of Barcelona Hospital Clinic, Spain), note.

The patients with DS, compared with the 435 who experienced fewer than three depressive symptoms, were more likely to have been diagnosed less than 5 years ago, at 80.4% versus 71.3%. This could be due to mixed mania being more complex and therefore hard to recognize and classify, says the team.

Indeed, 39% of patients with DS were initially misdiagnosed, most commonly with insomnia, at 46.7%. Misdiagnosis was also common in patients without DS, affecting 43%, with major depressive episode or major depressive disorder the most frequent misdiagnoses.

Patients with DS had primarily depressive symptoms at diagnosis and a lower prevalence of typical manic manifestations than those without DS.

Vieta et al comment in the Journal of Affective Disorders that of the six new DSM-5 criteria for mania with mixed features, all four assessed in their study (prominent depressed mood, diminished interest or pleasure in all activities, feelings of guilt, and lack of energy) were significantly overrepresented in the group with DS, confirming the discriminatory value of the DS criteria.

The remaining two criteria (presence of suicidal thoughts and behaviors, and psychomotor retardation) were not assessed.

Also, two manic symptoms – physical aggression and being abusive toward others – were significantly more frequent in those with mixed features, as were the non-mood symptoms anxiety and irritability, making the combination of anxiety and irritability or agitation possible relevant discriminators.

“[T]he results of the survey preliminarily show that a threshold of 3 depressive symptoms during a manic episode as operationalized in the new DSM-5 can be used to identify mixed versus non-mixed patients,” the researchers conclude.

“The 3-symptom threshold should now also be validated for depressive episodes with mixed features, as proposed in DSM-5.”

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