Comparing MDD With Mixed Features and Bipolar I Disorder

Dive into the complexities of mood disorders with Amber Hoberg, MSN, APRN, PMHNP-BC, Morningstar Family Medicine, and Brooke Kempf, MSN, PMHNP-BC, psychiatric mental health nurse practitioner and adjunct faculty member for Indiana and Purdue Universities, as they dissect the disparities between major depressive disorder (MDD) with mixed features and bipolar I disorder, providing valuable insights for precise diagnosis and tailored treatment strategies. Nurses Hoberg and Kempf discuss the differences in appearance between these two disorders and how mental health professionals can better differentiate and get to the right diagnosis the first time. 

Read the transcript:

Amber Hoberg, PMHNP-BC: Hi, my name is Amber Hoberg. I'm a psychiatric mental health nurse practitioner in the San Antonio, Texas, area. I have my own private practice, Morningstar Family Medicine, where I see patients in the office. I do group homes, nursing homes, assisted livings, and then I also work for the Baptist Health System.

Brooke Kempf, PMHNP-BC: Hello, I'm Brooke Kempf, a psychiatric mental health nurse practitioner located in Tarahoe, Indiana, where I work for a community mental health center called the Hamilton Center. In addition, in working clinical practice at the Hamilton Center, I teach for Indiana University and Purdue University of Indianapolis for their psychiatric mental health nurse practitioner program.

Nurse Hoberg: So the question is what is the difference between major depressive disorder and bipolar disorder? And the biggest thing is the mania. That's really what you want to focus on and talk to your patients to try to tease out: have they had any manic-type symptoms? Now there are 2 types of bipolar. You have bipolar 1 and you have bipolar 2. With bipolar 1, not only are you teasing out the manic symptoms but you have to look at the length of time. Has it been over that seven days? Versus bipolar 2 tends to be the same symptoms but just more on the lower end of the frequency so for bipolar patients that tends to be what we look for. Now the depressive symptoms are very similar but when it comes to the psychotic features, what I tend to see is that with major depression, those psychotic features tend to be more like negative statements or negative thoughts versus when you are looking at psychosis with mania and bipolar disorder, it tends to be a little more disorganized.

So Brooke, what do you think, how do you, you know, how do you tease this out in your practice?

Nurse Kempf: Diagnosing is really tough because you talked about the time and the length. It's really hard for our patients to be able to say "I have this many symptoms for this period of time." And when it came to differences between DSM-4 and DSM-5, looking at mixed states associated with mania and depression, it can be very confusing. It takes a very good assessment. I like to check for family history. I look at that family history, and previous medication responses. There are some red flags in there that make me start thinking more about bipolar versus major depressive disorder. But you mentioned it: If you have a clear history of mania or hypomania, that's not major depressive disorder.

You might have an overlapping of symptoms, but if your primary core diagnosis is major depressive disorder and some overlapping symptoms, those are just some mixed features. 

Nurse Hoberg: Absolutely, and when it comes to treatment also, that's important, looking at treatment response. And so that can be another big red flag or big telltale symptom if they've been on antidepressants and they have failed to respond, even at optimal doses, sometimes what we tend to find is that maybe it's more on the bipolar spectrum.

Amber Hoberg, MSN, APRN, PMHNP-BC, is a board-certified psychiatric mental health nurse practitioner from University of Texas Health Science Center San Antonio. She has been working for the past 12 years with the adult and geriatric populations, treating all types of psychiatric conditions. Her background, as a Psychiatric Advanced Practice Nurse, includes outpatient, inpatient, group home, and nursing home/ALF settings. She currently works for Baptist Health System and Morning Star Family Medicine PLLC treating the chronically mentally ill in both inpatient and outpatient settings.

Brooke Kempf, MSN, PMHNP-BC, has worked as a psychiatric nurse at Hamilton Center in Terre Haute, Indiana, since she graduated from Indiana State University with an associate degree in 1994. Her passion for mental health was sparked as she worked as a charge nurse on the Inpatient Unit and continued to grow as she served in their outpatient setting while obtaining her bachelor’s degree from ISU in 1996. She was awarded the 2008 Hamilton Award for Outstanding Staff Member. Kempf was then able to obtain her master’s degree from the State University at Stony Brook of New York and is board-certified by the ANCC as a psychiatric mental health nurse practitioner. She currently practices as the Hospitalist for the Inpatient Psychiatric Unit of Hamilton Center Community Mental Health Center in Terre Haute, Indiana and is an adjunct lecturer for IUPUI’s PMHNP program, teaching and was awarded the 2022 Daisy Award for Extraordinary Nursing Faculty.