Assessment of suicidal risk in adolescents is a solemn professional obligation that involves obtaining as much information as possible from family members or caregivers. Evaluation of mood disorders is an essential part of the assessment.
When DSM-V took a significant step beyond previous editions to include the mixed features specifier for unipolar major depression, the already contentious area of child and adolescent mood disorders became even more challenging. It is also an opportunity, however, to expand our understanding of mood disorders and to provide safer treatment for affected youths.
What’s past is prologue
Numerous authors have reviewed Kraepelin’s original conceptualization of mixed features. In recent decades, research on mixed features has re-established Kraepelin’s thinking and has provided insights that challenge established dogma about depression and mania and show how overlooking mixed symptoms can increase suicide attempts and completed suicides in adolescents and adults.
Another major contributor to our understanding of mixed features in depressive states is Athanasios Koukopoulos. Verdolini and colleagues1 place one of Koukopoulos’s core criteria, mood lability (or affective lability), which they define as “the predisposition to rapidly reversible and marked shifts in affective states that are extremely sensitive to environmental events with intense behavioral responses” (as distinguished from DSM-defined “mood reactivity” in response to positive stimuli), near the center region of their Revised Affective Spectrum that bridges the continuum from pure depression to pure mania. These researchers explain that affective lability was excluded from the DSM-5 “with mixed features” specifier, possibly leaving many cases of mixed depression undiagnosed and subsequently inadequately treated.
Studies clearly indicate that mixed presentations are the rule rather than the exception in adolescents:
• “This study showed that bipolar spectrum disorders in youth are episodic disorders most often characterized by subsyndromal episodes and, less frequently, by syndromal episodes, with mainly depressive and mixed symptoms and rapid mood changes.”2
• “The mixed state was the most common presentation for bipolar adolescents who were in the midst of an MDE at the time of presentation to a mental health clinic.”3
• “Mixed hypomania was a common phenomenon in pediatric bipolar II patients.”4
Dr Yost provides telemedicine psychiatric services in several states for both adults and adolescents in hospitals and clinics. He reports no conflicts of interest concerning the subject matter of this article.
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2. Birmaher B, Axelson D. Four-year longitudinal course of children and adolescents with bipolar spectrum disorder: the Course and Outcome of Bipolar Youth (COBY) Study. Am J Psychiatry. 2009;166:795-804.
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