title: Are manic symptoms that 'dip' into depression the essence of mixed features?
abstract: BACKGROUND
  Three symptoms of (hypo)mania that clinically represent mood disorders mixed states have been omitted from the DSM-5 mixed features specifier because 'they fail to discriminate between manic and depressive syndromes'. Therefore, the present study examined the role of distractibility, irritability and psychomotor agitation (DIP) in characterising mixed depressive states.
  
  
  METHODS
  Fifty in-patients at a specialist mood disorders unit underwent a detailed longitudinal clinical evaluation (3-6 weeks) and were assessed on a range of standardized measures to characterise their illness according to depression subtype, duration of illness and clinical features-including specifically depressive and manic symptoms and the context in which these occur.
  
  
  RESULTS
  49 patients met criteria for major depressive episode, and of these, 34 experienced at least one dip symptom. Patients who endorsed distractibility were more likely to be diagnosed with Bipolar Disorder than Major Depressive Disorder; patients who endorsed irritable mood were more likely to have non-melancholic depression (admixture of depressive and anxiety symptoms), and patients who reported psychomotor agitation experienced a significantly greater number of distinct periods of (hypo)manic symptoms compared with those who did not.
  
  
  CONCLUSIONS
  The present study used a modest sample size and did not control for medication or comorbid illness. Although this is inevitable when examining real-world patients in a naturalistic setting, future research needs to allow for comorbidity and its impact, specifically anxiety.
  
  
  CONCLUSIONS
  The present findings suggest that all 3 symptoms that have been excluded from DSM-5 may be cardinal features of mixed states, as they 'dip' into depressive symptoms to create a mixed state.
authors.affiliation: CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, NSW, Australia; Discipline of Psychiatry, Sydney Medical School, University of Sydney, NSW, Australia; Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia. Electronic address: Gin.malhi@sydney.edu.au.
authors.forename: Gin S
authors.initials: GS
authors.lastname: Malhi
authors.affiliation: CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, NSW, Australia; Discipline of Psychiatry, Sydney Medical School, University of Sydney, NSW, Australia.
authors.forename: Kristina
authors.initials: K
authors.lastname: Fritz
authors.affiliation: Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technische Universitaet Muenchen, Germany.
authors.forename: Christine
authors.initials: C
authors.lastname: Allwang
authors.affiliation: Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia.
authors.forename: Nicole
authors.initials: N
authors.lastname: Burston
authors.affiliation: Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia.
authors.forename: Chris
authors.initials: C
authors.lastname: Cocks
authors.affiliation: Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia.
authors.forename: Jill
authors.initials: J
authors.lastname: Devlin
authors.affiliation: Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia.
authors.forename: Margaret
authors.initials: M
authors.lastname: Harper
authors.affiliation: Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia.
authors.forename: Ben
authors.initials: B
authors.lastname: Hoadley
authors.affiliation: Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia.
authors.forename: Brian
authors.initials: B
authors.lastname: Kearney
authors.affiliation: Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Klug
authors.affiliation: Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia.
authors.forename: Linton
authors.initials: L
authors.lastname: Meagher
authors.affiliation: Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Rowe
authors.affiliation: Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia.
authors.forename: Hany
authors.initials: H
authors.lastname: Samir
authors.affiliation: Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia.
authors.forename: Raymond
authors.initials: R
authors.lastname: Way
authors.affiliation: Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia.
authors.forename: Craig
authors.initials: C
authors.lastname: Wilson
authors.affiliation: Mood Disorders Unit, Northside Clinic, Ramsay Mental Health, Greenwich, NSW, Australia.
authors.forename: William
authors.initials: W
authors.lastname: Lyndon
mesh_terms: D000328:Adult; D001007:Anxiety / Q000175:diagnosis; D015897:Comorbidity; D003527:Cyclothymic Disorder / Q000150:complications / Q000175:diagnosis*; D003863:Depression / Q000150:complications / Q000175:diagnosis*; D005260:Female; D006801:Humans; D007508:Irritable Mood; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D019964:Mood Disorders / Q000150:complications / Q000175:diagnosis*
keywords: Bipolar disorder; DSM-5; Distractibility; Irritability; Mixed states; Psychomotor agitation