Over the past several days, we’ve lifted the masks of many MDD presentation variations. Before we move onto specifiers of onset, we’ll round out presentation specifiers with Mixed Features. Historically, a mixed presentation was only recognized as applied to Bipolar Disorder Type 1 when a patient simultaneously met criteria for Mania and Major Depression. This was called a Mixed Episode. This stringent criteria always puzzled me, as it didn’t seem unusual to witness someone with just a few depressive symptoms superimposed on a full hypomanic/manic (hy/manic) episode, or, more relevant here, some hy/manic symptoms superimposed on a full MDD episode. The DSM-5 now recognizes the presence of such presentations, and we have the Mixed Features specifier.

As for how common it is, there again is minimal research. McIntyre et al. (2015) wrote that Mixed Features for MDD episodes ranged between 11 and 54%. This depended on the number of symptoms researchers believed were required to constitute Mixed Features. Currently, the DSM-5 sanctioned number is at least 3. It is likely that the DSM threshold is 3 because a cluster of hy/manic symptoms makes an undeniable case it is indeed a mixed mood state. Otherwise, there could be confusion because other specifiers share some symptoms similar to hy/manic ones. For example, the restlessness of Anxious Distress, the inability to focus many depressed patients experience in general, or the fact that it is not unusual for depressed people to simultaneously experience sadness and irritability, which could be mistaken for the “expansive” affective experience of hy/mania. Taken together, these three items are more likely a hy/manic experience; individually, they could simply represent a characteristic of another specifier.

Mixed features is interesting because, not surprisingly, it can lead into full manic or hypomanic episodes, indicating a Bipolar 1 or 2 diagnosis. If people with Bipolar Disorders experience Mixed Features during their MDD phases, it is often correlated to more severe and longer duration of the depression, and higher rates of suicidality have been noted across researchers.

Despite the tendency for many with Mixed Features to develop Bipolar conditions, there are some MDD sufferers whose Mixed Features never seem to evolve that far (Suppes & Ostacher, 2017). This is not to say that these patients’ lives are more easily endured than someone with distinct mood cycling.

The presentation:

A good metaphor for mixed presentations could be “spinning in the darkness.” Seeing a patient not only depressed, but who is experiencing racing thoughts and impulsivity can be challenging for clinicians. Imagine what it is like for the patient! Kelly’s case helps illustrate:

Kelly began graduate school with a bang. She did really well in undergrad, and was slated to finish her master’s degree ahead of schedule. After the first month of the semester, Kelly began losing her appetite and had insomnia. She figured that full time graduate school and working two jobs, coupled with trying to keep up a relationship was wearing on her. As the semester wore on, her overall mood felt “gray” and often irritable. Friends noticed she lost her spunk and didn’t hang out as much. She pushed through to finals, thankful to have made it. Kelly planned to slow her pace and only go part-time next semester if this was what stress would do to her. During finals week, Kelly continued to feel gray and irritated, and didn’t eat much, but seemed to be running on adrenaline. She felt the few hours of sleep she got was sufficient. However, her mind raced from subject to subject, and she couldn’t focus to study well. Normally an A student and someone who handled stress well, she barely passed her exams, and was very concerned. Hoping the Holiday break would relax her mind, Kelly went home to rest. After a week at home, her symptoms stayed the same. Kelly’s parents phoned Dr. H for an evaluation.

DSM-5 diagnostic criteria for MDD with Mixed Features is as follows:

  • The presence of an MDD episode during which there are at least 3 symptoms of hy/mania present (see below for symptoms) for the majority of the episode.*

Kelly’s “stress” turned out to be a lot more than an adjustment to graduate school life. Can you identify what Kelly exhibited that would lead to an MDD with Mixed Features diagnosis? Feel fre to share in Comments!

*Returning to the 3 symptom threshold, it’s my experience that we should use clinical judgement. If only one or two symptoms are clearly present (i.e., the restlessness or affective alterations normally seen in some depression presentations become extreme, as if an energy is behind them) it’s safe to be considering a Mixed Features specifier, and to certainly be vigilant for additional evolving symptoms.

Treatment implications:

As noted above, the concern with mixed symptoms is the potential for patients to spin into full hy/manic episodes and enter full Bipolar territory. Thus, developing a skilled eye for emerging Mixed Features is key. At first, it may be difficult to differentiate Mixed Features from someone with the agitation and intense trouble focusing due to Anxious Distressor Melancholic Features. There are some key points to help differentiate these and to identify superimposed hy/manic symptoms in general:

  1. Most people with depression have slowed thinking and thus their trouble focusing. If the patient’s thought process and speech are pressured/tangential (just can’t stop talking) despite being depressed, that is a good indicator of a Mixed Feature.
  2. Another matter of thought process is flights of ideas where the person is jumping from topic to topic, as someone with ADHD might do.
  3. Depressed patients with agitation and anxiety often seem fatigued by their restlessness. Therefore, if it is noticed the patient has an energetic, or hyperactive, “flavor” about them, this is indicative of a Mixed Feature. Another tip-off is despite not sleeping much, they may not seem tired.
  4. Poor impulse control/pleasure-seeking behavior, such as breaking things, uninhibited purchasing, sex, gambling, substance use, etc. is also quite different from the average depressed patient, and another sign of a Mixed Feature.
  5. If the person’s demeanor shifts from poor self-esteem to thinking highly of themselves in some capacity.
  6. Lastly, if the person’s depressed mood is seasoned with elevated/euphoric periods or periods of expansive mood (i.e. alterations between brightness, irritation, and sadness), that is a clear indicator of Mixed Features.

Given patients with Mixed Features have one and a half feet in the realm of Bipolar spectrum conditions, it is no surprise that they need referral for psychiatry. This is not depression that will likely resolve via talk therapy alone. Some MDD patients with Mixed Features seem prone to become fully hy/manic if treated with an anti-depressant alone. Therefore, like Bipolar patients, they may be prescribed a mood stabilizer such as lamictal, lithium, or an atypical antipsychotic medication. This will help them become less energetic and able to think more clearly, helping them focus on therapy.

Talk therapy with someone prone to Mixed Features is similar to the work we do with Bipolar Disorders. Once again, for the therapist, it is not only important to get the patient stable in the current episode, but to work towards episode relapse prevention. This of course begins with a plan, if they stabilize and are discharged from therapy, to have them immediately reconnect if they or friends/loved ones notice any onset of mood symptoms. It should also include stress management, because for people prone to hy/mania, there is a correlation between hy/manic episode onset and environmental stressors. Since the person is indeed prone to some hy/manic features, and there is the possibility that could evolve into full hy/mania, keeping stress down is key. This often includes family therapy since this is where a lot of the stress burden is rooted for many. Lastly, poor sleep is another significant correlate to unlocking hy/manic presentations in people prone, so sleep hygiene is also of utmost importance.

Mixed Features has been described as a “natural bridge” between MDD and Bipolar Disorders and, to some researchers, might constitute a distinct diagnostic category (Suppes & Ostacher, 2017). This remains to be seen, and if that would bring about new treatment approaches, which would likely be of a biological nature. For now, such patients may do well if therapists remain vigilant for such presentations and approach treatment similarly to Bipolar presentations.


Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association, 2013.

McIntyre, R. S., Cucchiaro, J., Pikalov, A., Kroger, H., & Loebel, A. (2015). Lurasidone in the treatment of bipolar depression with mixed features (subsyndromal hypomanic) features: post hoc analysis of a randomized placebo-controlled trial. Journal of Clinical Psychiatry, 76 (4), 398-405

Suppes, T., & Ostacher, M. (2017). Mixed features in major depressive disorder: diagnoses and treatments.CNS Spectrums, 22 (2), 155160