Navigating Anxiety, Pain, and Mixed Features in Depressive Disorders

Diagnosing major depressive disorder (MDD) can be complex, particularly when symptoms overlap with anxious distress, pain, or mixed features. In this video, Psych Congress Steering Committee member Brooke Kempf, PMHNP-BC, offers clinicians a practical framework for differentiating these presentations to reach an accurate diagnosis. She highlights key signs to distinguish anxious distress from mixed states, emphasizes the power of the clinical interview as a primary diagnostic tool, and discusses how the presence of chronic pain may impact treatment in depression.

• In major depressive disorder (MDD), clinicians should distinguish anxious distress, characterized by worry-driven racing thoughts, from mixed features marked by excess energy and agitation, while ruling out bipolar disorder. 
• The clinical interview remains the primary diagnostic tool, using DSM criteria and detailed symptom and family history, with screening tools such as Mood Disorder Questionnaire, QIDS-SR, PHQ-9, and GAD-7 to prompt further assessment. 
• Chronic pain and mental health have a bidirectional relationship, as untreated pain can limit psychiatric treatment response and depression can amplify pain, requiring concurrent management of both conditions.

Brooke Kempf, PMHNP-BC: Hello, my name is Brooke Kempf. I'm a psychiatric mental health nurse practitioner out of Terre Haute, Indiana. I'm an adjunct faculty member at Indiana University Indianapolis in Indianapolis, Indiana.

Psych Congress Network: What key signs or symptom clusters should clinicians be looking for to distinguish subthreshold mixed features from anxious distress or unipolar depression alone?

Kempf: When I think of the job that we have as clinicians, to get a clear diagnosis, it can often be quite complicated. Nobody really fits into this little puzzle piece that you're trying to come up with. 

But whenever I'm speaking with a patient, and primarily when I've identified I'm dealing with unipolar major depressive disorder (MDD), there are some signals sometimes that we add as specifiers. When [the patient talks] about some subgroups of some specific symptoms—when I start hearing words like “anxiety,” “anger,” “agitation,” “I feel like I have ADHD because my mind's all over the place”—I start to do a further evaluation of symptoms to see if I can clarify if they might meet diagnostic criteria for an additional specifier. 

Which ones might those be? If I hear things about anxiety or mind racing, I try and clarify: Is that specifically worry? Is our mind racing because of worry? Then I often look at that anxious distress specifier. 

However, anytime I'm diagnosing major depressive disorder, I want to rule out bipolar disorder. Once I've ruled that out, I might notice some symptoms that indicate excessive energy. When that mind is racing, [the patient is] not sleeping, is agitated because of this energy, not because of worry, that's when I start evaluating more for mixed state.

PCN: In patients whose symptoms don’t fit neatly into one diagnostic category, what practical assessment tools or clinical frameworks can help clinicians refine diagnosis and improve prognosis?

Kempf: Our whole job as clinicians in identifying and taking these clusters of symptoms and calling them a formal diagnosis, the whole purpose of that is to have adequate treatment to obviously have better outcomes and prognosis. 

In order to get that diagnosis right, our best tool that we have as clinicians is our clinical interview. During that clinical interview, it's our job to get a clear, good history of symptoms, and also get a family history. Then it’s utilizing that tool to really pull out the symptoms that meet criteria on your DSM. 

Now, you are often not going to find somebody that checks all of the boxes and you want to ensure that you don't miss something.

Again, asking the right questions is important but you can also use screening tools. The most common ones we have in day-to-day practice are the Mood Disorder Questionnaire (MDQ), Quick Inventory of Depressive Symptomatology—Self-Report (QIDS-SR-16), we have Patient Health Questionnaire-9 (PHQ-9), and the Generalized Anxiety Disorder-7 (GAD-7). 

But remember, these are just tools that patients are filling out maybe ahead of time or during the appointment. They're screening tools, they're not diagnostic. What they can help you do is identify symptoms that you may not have asked about so that you know to ask and dive deeper. But once you get positive screens on any one of those tools it all goes back to your clinical assessment, diving in, and asking more questions so that you can meet your criteria and clarify your diagnosis. That then is going to guide your treatment and provide better prognosis. 

PCN: How should clinicians think about chronic pain as a psychiatric signal and how does its presence alter both diagnostic clarity and treatment planning?

Kempf: Chronic pain with mental health is somewhat bidirectional. What I mean by that is if an individual is dealing with chronic pain, that's obviously going to impact their mental health. As a mental health provider, that's going to impact my treatment. If their pain is not adequately controlled, I can throw all the treatments that I have at their depression, at their bipolar illness, at whatever I'm treating and we're not going to see improvement because that pain is very impactful on their day-to-day functioning. 

But also, it works in the opposite direction too. Pain can be depressing. Depression can have a pain signal. We share a lot of those same pathways. So, I want to do a good job during my evaluation. I want to ensure that I am fully treating their depression so that it is not impacting their pain further, or their bipolar disorder or whatever mental health treatment you're needing. 

In summary, it's important for both of those things to be addressed—their mental health and pain—they have to both be treated. They have to be looked at equally to ensure they both have adequate treatment. 

Thank you for taking the time out to listen and try to learn more about this topic. Please join me at Psych Congress Elevate to learn more.

Brooke Kempf, PMHNP-BC, is a nationally recognized psychiatric-mental health nurse practitioner and educator with nearly three decades of experience providing direct patient care and advancing evidence-based mental health services. Brooke began her career at Hamilton Center in Terre Haute, Indiana, where she worked as a psychiatric nurse across multiple areas of the community mental health center. She earned her Master of Science in Nursing from Stony Brook University and is board-certified as a Psychiatric-Mental Health Nurse Practitioner through the American Nurses Credentialing Center. Her advanced certification expanded her clinical role to include medication management and psychiatric care as an outpatient provider, inpatient hospitalist, and Chief Nursing Officer. 

In addition to her clinical and administrative leadership, Brooke serves as adjunct faculty in the PMHNP program at Indiana University Indianapolis, where she has taught neuro-psychopharmacology and serves as a clinical instructor. She has contributed to program development at George Washington University and received the DAISY Award for Extraordinary Nursing Faculty. Nationally, she serves on pharmaceutical advisory boards, the Psych Congress Steering Committee, and volunteers with the American Foundation for Suicide Prevention.

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