title: Making sense of DSM-5 mania with depressive features.
abstract: OBJECTIVE
  The assessment of the depressive component during mania has become critical for the accurate diagnosis of mixed states, which were defined very narrowly in the past classification systems before Diagnostic and Statistical Manual of Mental Disorders (5th ed.). The aim of this study was to compare socio-demographic, clinical and therapeutic characteristics, as well as clinical and functional outcomes, between manic patients with and without mixed features to validate the relevance of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) mixed specifier.
  
  
  METHODS
  This is a subanalysis of a multicentre naturalistic study MANía Aguda y COnsumo de Recursos (acute mania and health resource consumption [MANACOR]) on the burden of mania in bipolar patients from four hospitals in Catalonia (Spain). The sample consisted of 169 adult patients presenting a manic episode and systematically assessed during a 6-month period.
  
  
  RESULTS
  A total of 27% (n = 46/169) of manic patients showed mixed features. Total number of episodes (p = 0.027), particularly depressive and mixed, was greater in manic patients with mixed features, as well as depressive onset (p = 0.018), suicide ideation (p = 0.036), rapid cycling (p = 0.035) and personality disorders (p = 0.071). In contrast, a higher percentage of pure manic subjects were inpatients (p = 0.035), started the illness with mania (p = 0.018) and showed family history of bipolar disorder (p = 0.037), congruent psychotic symptoms (p = 0.001) and cannabis use (p = 0.006). At baseline, pure manic patients received more risperidone (p = 0.028), while mixed patients received more valproate (p = 0.049) and antidepressants (p = 0.005). No differences were found in syndromic recovery at the end of the study. However, depressive change was higher in the mixed group (p = 0.010), while manic change was higher in the pure manic group (p = 0.029). At the end of follow-up, the group with mixed features showed a significant trend towards higher psychosocial dysfunction.
  
  
  CONCLUSIONS
  A total of 27% of manic patients showed mixed features. Groups differed regarding clinical characteristics, course of illness, psychosocial functioning, prescribed treatment and symptom progress. Depressive symptoms in mania should be routinely assessed and considered to guide treatment.
authors.affiliation: Bipolar Disorders Program, Institute of Neuroscience, Hospital Clínic de Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.
authors.forename: María
authors.initials: M
authors.lastname: Reinares
authors.affiliation: Bipolar Disorders Program, Institute of Neuroscience, Hospital Clínic de Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.
authors.forename: Caterina del Mar
authors.initials: Cdel M
authors.lastname: Bonnín
authors.affiliation: Bipolar Disorders Program, Institute of Neuroscience, Hospital Clínic de Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain.
authors.forename: Diego
authors.initials: D
authors.lastname: Hidalgo-Mazzei
authors.affiliation: Department of Psychiatry, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago de Chile, Chile.
authors.forename: Juan
authors.initials: J
authors.lastname: Undurraga
authors.affiliation: Psychiatric Service, Hospital Santa Maria, University of Lleida, IRBLleida (Biomedicine Research Institute), Lleida, Spain.
authors.forename: Maria
authors.initials: M
authors.lastname: Mur
authors.affiliation: Althaia, Xarxa Assistencial Universitària de Manresa, Manresa, Spain.
authors.forename: Evaristo
authors.initials: E
authors.lastname: Nieto
authors.affiliation: University Psychiatric Hospital, Institut Pere Mata, CIBERSAM, Reus, Spain.
authors.forename: Cristina
authors.initials: C
authors.lastname: Sáez
authors.affiliation: Bipolar Disorders Program, Institute of Neuroscience, Hospital Clínic de Barcelona, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain evieta@clinic.ub.es.
authors.forename: Eduard
authors.initials: E
authors.lastname: Vieta
mesh_terms: D000328:Adult; D001714:Bipolar Disorder / Q000175:diagnosis / Q000523:psychology*; D003863:Depression / Q000175:diagnosis / Q000523:psychology*; D039721:Diagnostic and Statistical Manual of Mental Disorders; D005260:Female; D006801:Humans; D008297:Male; D011569:Psychiatric Status Rating Scales; D012720:Severity of Illness Index
keywords: Bipolar disorder; depressive symptoms; mania; mixed features