Mixed states are heterogeneous clinical entities difficult to define precisely. The stringent actual DSM IV criteria are unsatisfactory for current clinical use. Many frequently encountered mixed patients benefit without an accurate diagnosis from biological therapeutic interventions such as the introduction of mood stabilizers. We propose a brief review of the definition and characteristics of mixed states and propose a new approach to the typology of mixed states. Based on recent literature data, we add to the depressive and manic syndrome the concept of dysphoria as a third dimension. Integrating this three dimensional approach with recent factor analysis, we describe in addition to the DSM IV mixed state (type I) two new subtypes of mixed states (type IIM and IID). This new typology can give the clinician a more accurate understanding of the complex and polymorphous reality of mixed states and help him make more specific therapeutic interventions. These subtypes of mixed states will need validation through prospective clinical studies. Biological differences, differential outcome over time, and differential response to treatment will be important validation criteria.
Some authors advocate a broadening of the narrow concept of mixed episodes in the direction of mania leading to the concept of mixed mania, and in the direction of depression leading to the concept of mixed depression. The latter has been little investigated so far. In the present article, we retrospectively compare 49 patients with pure depression with 51 patients with mixed depression in terms of socio-demographic and clinical variables in order to contribute to the validation of the distinction between mixed and pure depression. Supporting this distinction, we observed that mixed depressive patients more frequently had past histories of bipolar disorder and alcohol abuse and had longer durations of hospital stay. These last two points remain significant even when we control for the effect of the association with bipolarity.
Thirteen major depressive patients not responding to a 4-week venlafaxine 300 mg treatment were eligible for a 4-week open trial of lithium addition. Two patients had to stop lithium for a possible moderate serotonin syndrome and five patients became responders, including one dramatic response and two semi-rapid responses.
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