The identification of mixed features during a major depressive episode is important due to the worse course and treatment issues associated with this condition. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition mixed features specifier criteria are controversial, because it includes typical manic symptoms, whereas it excludes overlapping excitatory symptoms that are frequently reported in mixed depression. Psychomotor agitation, mood lability, and aggressiveness are the new proposed criteria based on the results of the Bipolar Disorders: Improving Diagnosis, Guidance and Education-II-Mix study. Several clinical and course indicators of bipolarity were found to be associated with the presence of mixed characteristics, mainly overlapping excitatory symptoms, during a major depressive episode.
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