What Is Depression With Mixed Features?

When the diagnosis of major depressive disorder with mixed features (MDD-MX) was introduced, experts met it with skepticism . Even now, it 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 gained acceptance.

Symptoms of MDD-MX

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.

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

Classic features of depression include low mood and decreased interest or pleasure in activities you typically enjoy. However, a depression diagnosis also requires at least four of the following:

• Fatigue, loss of energy and motivation
• Feeling worthless, ashamed, or guilty
• Inability to fall asleep or sleeping too much
• 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
• Troubling thinking, focusing, and concentrating

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:

• Being talkative or "chatty," pressured speech
• Decreased need for sleep
• Elevated mood
• Increased energy or goal-directed activity
• Inflated self-esteem
• Participation in activities that may feel good at the moment but can have potentially serious consequences (i.e., excessive alcohol use, risky sexual behaviors, impulsive spending, etc.)
• Racing thoughts or flight of ideas

If you have experienced at least three 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. 

Causes of MDD-MX

The specific causes of depression with mixed features are unclear. As with other types of depression, researchers suspect that other factors contribute to the development of MDD-MX, including family history, genetics, environment, and other health conditions. 

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.

The Diagnosis of MDD-MX

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

The classic signs and symptoms of major depression can be relatively easy to spot, but subtle episodes of mania or hypomania often 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. 

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. 

Treatment of MDD-MX

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. 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.

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. 

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

• Abilify (aripiprazole)
• Geodon (ziprasidone)
• Latuda (lurasidone)
• Rexulti (brexipiprazole)
• Saphris (asenapine)
• Seroquel (quetiapine)
• Zyprexa (olanzapine)

You may also be given a mood stabilizer like lithium or Depakote (divalproex) instead of, or in addition to, an antidepressant. Small studies in people with depression and mixed episodes have demonstrated that 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:

• Ativan (lorazepam)
• Klonopin (clonazepam)
• Xanax (alprazolam)

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 as well, such as psychotherapy or electroconvulsive therapy (ECT).

Coping With MDD-MX

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 or mental health professional because you suspect you may have depressive disorder with mixed features, 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. 

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.

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.