Key Hospitalist Clinical Practice Guidelines in 2017

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO


January 16, 2018

In This Article

Mixed Depression

International panel of experts on mood disorders

Not all patients with depression (as part of bipolar disorder or major depressive disorder) should be prescribed an antidepressant.

All patients who receive antidepressants for a major depressive episode (MDE) should be monitored for signs of abnormal behavioral activation or psychomotor acceleration.

The use of antidepressants in MDE patients with mixed features may not alleviate depressive symptoms and may pose a potential hazard for exacerbating subthreshold mania symptoms that accompany depression.

For an individual presenting with a depressive episode with mixed features, in addition to antidepressant medication, alternative psychotropic agents (eg, lithium, anticonvulsant mood stabilizers, atypical antipsychotics) with demonstrated efficacy in treating depressive symptoms as part of MDE may be considered.

You will not know if a depressed patient has (hypo)manic symptoms or a positive family history of bipolar disorder unless you ask. Ask every patient. Every time.

Antidepressant monotherapy should probably NOT be utilized for patients with mixed depression of any type (unipolar, BP II, or BP I), given persisting doubts about the relative efficacy of standard antidepressants in treating bipolar disorders and their potential to destabilize mood.

The treatment of depressive mixed states (DMX) may require a combination of medications: Atypical antipsychotic + mood stabilizer; Atypical antipsychotic + antidepressant; Olanzapine/fluoxetine combination in particular (caution in overweight or obese patients and those with metabolic dysregulation); Mood stabilizer + antidepressant.

Suicide is the main serious safety concern in this population, and an individualized approach is necessary depending on clinical variables, social support, and preexisting suicide risk factors.

Children and adolescents presenting with major depression should be screened and monitored for any (hypo)manic symptoms, suicidality, and family history of mood disorders.

Antidepressant monotherapy should be avoided in children and adolescents until any presence of (hypo)mania or positive family history of bipolar spectrum disorder is ruled out.



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