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DSM-5 is the recent update of DSM IV-TR, and currently there is considerable controversy about the mixed-features specifier of major depressive disorder (MDD) for mixed depression in DSM-5. This mixed-features specifier consists of a major depressive episode and modified (hypo)manic criteria that were based on criteria B of bipolar disorder. The (hypo) manic criteria of this specifier and bipolar disorder are very similar to each other, although the former deleted distractibility and psychomotor agitation, and added elevated and expansive mood (in criteria A of bipolar disorder). These changes mean that the paradigm has shifted from a categorical concept into a dimensional or spectrum concept in mood disorder. However, some investigators are still criticizing the mixed-features specifier of MDD. They consider that these DSM-5 criteria have a weak scientific basis and do not identify a large proportion of the possible mixed depressive states.1 Some authors have referred to these DSM-5 criteria as ‘a farewell to mixed depression’ or ‘the miracle that never happens.’1,2 One of the reasons that authors have been criticizing DSM5 is that euphoria and grandiosity with MDD do not coexist commonly in clinical practice.3 Another reason is that DSM-5 excludes the core symptoms of mixed depression such as psychomotor agitation, irritability, and distractibility (so-called overlapping symptoms) because these symptoms may overlap with a major depressive episode. However, a recent study found that large proportions of patients presented with distractibility (59.2%), irritability (57.3%), and psychomotor agitation (36.5%) in mixed depression, whereas only 18% and 6.6% presented with euphoria and grandiosity, respectively.4 Another study also found that agitation, marked irritability, and mood reactivity were common symptoms in mixed depression.5 Thus, adding overlapping or nonspecific symptoms to the criteria Print ISSN 1738-3684 / On-line ISSN 1976-3026 OPEN ACCESS

The Mixed-Features Specifier of Major Depressive Disorder in DSM-5: Is It Practical?