​Assessing patients with depression for hypomanic symptoms and/or a family history of bipolar disorder is critical in diagnosing depressive mixed states (DMX); this can only happen if clinicians "ask every patient, every time." So state the authors of new guidelines for the recognition and management of mixed depression, published in CNS Spectrums in April 2013. In 2013, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced the "mixed features specifier" to classify two groups of individuals: those who meet diagnostic criteria for a major depressive episode (MDE) and have "subthreshold symptoms of (hypo)mania," and "individuals with syndromal mania and subthreshold depressive symptoms." Citing a dearth of decision support for the treatment of these individuals, the authors developed the new guidelines based on the modest amount of available literature in combination with their collective clinical experience. Among the guideline's key points are that not all patients who have depression associated with bipolar or major depressive disorder should take antidepressants and that patients with MDE who take antidepressants should be monitored for specific complications of antidepressant use (e.g., signs of abnormal behavior activation or psychomotor agitation). The authors stress that distinguishing DMX from pure unipolar depression as early as possible is critical in order to avoid treatments (e.g., antidepressant monotherapy) that could worsen symptoms of hypomania in individuals with MDE. The guidelines provide recommendations for acute pharmacologic treatment of mixed depression, dosing recommendations, and longitudinal monitoring. In related news, major depression is common in older adults and can be treated with a variety of modalities. However, according to the authors of a literature review published in JAMA in May, it is often treated inadequately, "with a majority of patients receiving no treatment at all." Accordingly, the authors issued guidance on the management of depression in older adults—with particular attention to those who are frail and taking several medications for concurrent medical disorders. Because older adults are at risk for adverse events owing to multiple medical comorbidities and drug-drug interactions, the authors recommend that physicians use the Screening Tool to Alert doctors to Right Treatment (STOPP/START) criteria to ensure appropriate prescriptions, avoid undertreatment, and avoid failure to treat. While acknowledging the "limited evidence" developed by studying older individuals who have serious medical comorbidities, the authors found that major depression in older adults can be treated effectively with both antidepressants and electroconvulsive therapy. Additionally, the authors stated, psychological therapies and exercise "may also be effective" for patients with mild to moderate depression as well as those who are too frail for or who prefer to avoid pharmacologic treatment.

HRC Recommends: Depression in its various forms is a serious disorder that can present many treatment challenges across a variety of patient populations. Timely diagnosis and appropriate treatment are critical; treatments come with both risks and benefits. Risk managers may wish to share these guidelines with appropriate clinical staff. Medical staff leaders should encourage physicians to use brief mental health screening measures with their patients to enable earlier identification of mental health disorders, which may translate into earlier care.