Agitated depression isn’t a formal clinical term but may be used to describe symptoms of depression that manifest at the same time as elevated mood, increased energy, and grandiosity. It may happen in bipolar disorder and major depression.

Agitated depression is clinically described as “mixed features.” This description may accompany a bipolar disorder or major depressive disorder diagnosis. It means that you meet the criteria for either one of these conditions, but also present symptoms that may be atypical to depression.

For example, depressive episodes are commonly characterized by low energy, fatigue, and deflated self-esteem.

Someone with depression with mixed features may show overlapping depression and agitation symptoms like increased energy, an elevated sense of self, and restlessness.

Depression with mixed features may look and feel different for each person. In general, agitation may refer to a feeling of restlessness manifested as unusual talking or moving faster than typical, sleeping fewer hours, and bursts of energy to engage in different activities.

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR) is a reference handbook that most U.S. medical professionals use to diagnose mental health conditions. It establishes that a “mixed features” specifier (extension) must be added to a major depression or bipolar disorder diagnosis when the following criteria are met:

  • At least three of seven mania symptoms are present most days during a depressive episode:
    • uplifted mood, including feeling happy and sociable
    • elevated self-esteem, including bursts of grandiosity (a raised sense of self-importance)
    • unusual or unexpected talkative mood
    • racing thoughts
    • higher-than-usual energy or level of activity
    • tendency to engage in behavior that may lead to negative consequences
    • reduced need for sleep and decreased fatigue (feeling energized despite lack of rest)
  • Other people can observe these behaviors (as opposed to just “feeling” this way).
  • Symptoms are not a result of substance or medication use.

The specifier “mixed features” is added to these diagnoses only when the above criteria are observed at the same time as symptoms of depression.

Read more about the symptoms of depression.

Behavioral signs and symptoms of agitation during a depressive episode or clinical depression may include:

  • persistent pacing
  • atypical hand gesturing while talking
  • talking more than usual or faster and louder than typical
  • shifting from one topic to another
  • feeling and acting irritably and impatiently
  • walking faster than usual
  • having unusual angry outbursts
  • fidgeting
  • nail biting
  • being hyperactive or energetic even when not sleeping much
  • planning multiple activities at the same time

These and other agitation symptoms may be present for about 2 weeks at a time and may come and go.

The DSM-5-TR also notes that suicidal ideation and a higher chance of suicide attempts are possible in depression with mixed features.

Agitation in depression may mimic mild mania in bipolar disorder. However, the difference is that symptoms of hypomania or mania are typically not present during episodes of depression in bipolar disorder.

In other words, moods change from hypomania or mania to depression. In depression or bipolar disorder with mixed features, symptoms of depression and agitation occur at the same time.

According to the DSM-5-TR, mixed features in major depressive disorder may increase the chance of developing bipolar disorder.

The causes of bipolar disorder and clinical depression, with or without mixed features, have not been established yet.

Experts suspect a combination of different factors may be at play, including:

  • adverse childhood experiences, including abuse and bullying
  • substance use
  • genetics

Read more about the risk factors of depression.

Possible causes of agitated behavior in depression and bipolar disorder may also include:

In some cases, depression medications may cause agitation or excitability.

Read more about the causes of agitation.

Bipolar disorder and depression with mixed features require ongoing treatment that involves psychotherapy and medications, in addition to self-help coping strategies.

Psychotherapy

Psychotherapy is the first line of treatment for depression and an essential part of bipolar disorder management.

Cognitive behavioral therapy (CBT) is an effective option if you present mixed features. In CBT, a therapist focuses on how your thoughts affect your mood and behavior and helps you frame these thoughts in a different way to decrease their impact.

Because depression with mixed features may have a higher chance of developing into bipolar disorder, and lead to suicidal ideation, experts may recommend that medications are a part of the treatment plan.

Medications

A medical professional may prescribe specific medications for severe symptoms of depression. These are typically used for every case of bipolar disorder.

Depending on your specific diagnosis and needs, medications may include:

In many cases, finding the right medication, dosage, or combination of medications will take some time. Working with the prescribing doctor is essential in finding the medication that offers symptom relief for you.

The outlook for people with agitated depression may vary depending on individual factors.

In general, depression with mixed features has a high chance of developing into a bipolar disorder diagnosis. Bipolar depression with mixed features may also carry a higher chance of suicidal ideation and attempts.

If you have depression or bipolar disorder and also experience symptoms of agitation, it’s important to let a medical professional know. They can work with you in developing a treatment plan that offers symptom relief.

Help is out there

If you or someone you know is in crisis and considering suicide or self-harm, please seek support:

If you’re calling on behalf of someone else, stay with them until help arrives. You may remove weapons or substances that can cause harm if you can do so safely.

If you are not in the same household, stay on the phone with them until help arrives.

Agitated depression isn’t a formal medical term. Instead, the term is sometimes used to refer to “mixed features” observed in bipolar disorder or clinical depression.

“Mixed features” refers to experiencing symptoms of depression at the same time as symptoms of agitation, such as restlessness, grandiosity, and high levels of energy.

Treatment is available and effective for bipolar disorder and depression, with and without mixed features.

These resources may help you find a therapist: