The April 2017 theme issue of CNS Spectrums offers guidelines on how to approach patients with mixed feature diagnoses.

The issue is edited by psychiatrist Dr Stephen M. Stahl, who also co-authored an article in the issue, “Guidelines for the Recognition and Management of Mixed Depression.”

Stahl and colleagues recommend all patients who receive antidepressants for a major depressive episode (MDE) are carefully monitored for signs of abnormal behavioral activation or psychomotor acceleration. While there are as yet no approved treatments for the mixed-feature category of mental disorders, the article describes that the nature of depression in a mixed features diagnosis (as part of bipolar disorder or major depressive disorder) means that, often, antidepressants will not be the correct course of treatment. 

Antidepressants may not alleviate depressive symptoms, and instead may pose a potential hazard for exacerbating subthreshold mania symptoms that accompany the patient’s depression. Instead, researchers recommend these patients be prescribed atypical antipsychotics, recognizing that this marks a paradigm shift in the field and that most practitioners are not yet aware of the implications, no randomized controlled trials exist, and there are no FDA-approved medications. 

Mixed features have only recently been defined as a new category of diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5).

Other articles in the issue include “Treatment of Mixed Features in Bipolar Disorder,” “Treating Mixed Mania/Hypomania,” and “Pharmacological Treatment of Mixed States” (www.cambridge.org/core/journals/cns-spectrums/issue/2E373CD36DFEC3BCFD6AB7C25130C77B [8]).