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Bipolar Depression Specifiers CT1
Importance of Mixed Features and Anxious Distress Specifiers in the Care of Bipolar Depression

Released: June 07, 2024

Expiration: June 06, 2025

Roger S McIntyre
Roger S McIntyre, MD, FRCPC
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Key Takeaways
  • Mixed features and anxious distress, two specifiers modifying mood episodes in patients with bipolar disorder listed in the DSM-5-TR, are common but frequently not recognized or delayed in diagnosis.
  • Clinical implications for patients with these course specifiers include increased risk of comorbid psychiatric and medical conditions, increased risk of suicide, and more complex course of disease.
  • Prompt and accurate assessment of mixed features and anxious distress, including appropriate use of assessment tools specific to these symptom profiles, is a vital skill for clinicians to provide optimal management for their patients with bipolar depression.

Bipolar disorder is a common, severe, debilitating, and highly lethal psychiatric condition that can also be very costly in terms of healthcare and morbidity. A key unmet need in bipolar disorder is accurate and timely diagnosis of the condition. Numerous study replications have shown that patients often experience substantial delay in diagnosis and/or misdiagnosis. This experience prolongs suffering for the patient and decreases the probability of an optimal outcome for their lived experience. A second unmet need is personalization of treatment, including appropriate selection and sequencing of medications, which is often inadequate in community treatment of bipolar disorder. Both of these deficiencies are modifiable with the integration of currently available information into common psychiatric practice.

The underlying diagnosis of bipolar disorder may be obscured by the presence of mixed features or anxious distress, 2 specifiers recognized by the DSM-5-TR. Briefly, mixed features describes patients who experience both manic and depressive symptoms within a single episode or even at the same time, and anxious distress refers to symptoms of anxiety cooccurring within episodes of mania or depression. To enable complete diagnostic clarity, it is vital that clinicians evaluate patients for the presence or absence of mixed features or anxious distress by clinically probing for key characteristics of these conditions. The CUDOS-M tool developed by Dr Zimmerman supplements the standard Clinically Useful Depression Outcome Scale (CUDOS) with questions particular to the DSM-5 mixed features specifier. This tool has been shown to be a reliable and valid measure for this diagnosis and can be utilized in routine clinical practice.

The presence of mixed features and/or anxious distress can contribute to a more severe, unstable course of bipolar disorder with greater psychopathologic and functional impairment. Assessment of mixed features and anxious distress may also assist in adjudicating risk of suicide, as patients with these specifiers are more likely to report aspects of suicidality, suicidal ideation, suicidal behavior, and suicide plans. Moreover, as part of care planning, patients who present with mixed features or anxious distress should be carefully evaluated for comorbidities that differentially affect this presentation, including but not limited to anxiety disorders and attention-deficit/hyperactivity disorder.

Integration of psychosocial intervention with pharmacotherapy is key in managing patients with bipolar depression. When it comes to treatment selection and sequencing, data have shown that some treatments available for bipolar disorder are effective at alleviating mixed and/or anxious symptoms. These treatments should be considered and prioritized when managing patients with primary bipolar disorder that includes these symptom specifiers.

Register for an Expert-Led Workshop to Learn More
The upcoming live presentation series will focus narrowly on the topic of specifiers in adults living with bipolar disorder, but more broadly, will also cover the phenomenologic heterogeneity of bipolarity and the need for clinicians to engage in deep characterization of symptomatology to treat these patients most effectively. Please bring your questions regarding your clinical experiences for discussion with our expert faculty presenters. If you are unable to attend the live events, an on-demand webcast will be available.

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How confident are you in applying the DSM-5-TR specifiers of mixed features or anxious distress when diagnosing bipolar disorder?

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