Criteria for mixed episodes of bipolar disorder

We tend to think that bipolar disorder is a disease characterized by alternating depression and mania. Although it is true that some people with this disease experience a unique emotional pendulum swing, with obvious highs and lows, the clinical manifestations are often not so obvious.


In many cases, depressive episodes may be the defining feature of the disease. At other times, a person may experience a less severe form of mania, called hypomania, in which the elevated mood may not be so obvious, especially for casual observers.

Even more confusing is a disease called bipolar disorder, with mixed characteristics, in which one person experiences depression and mania at the same time. Although this seems paradoxical-being in a state of mania and depression at the same time-it is more common than you think.


According to a 2015 study by the University of Siena School of Medicine, approximately 40% of patients with bipolar disorder will experience at least one mixed episode during the course of the disease.

Bipolar disorder with mixed characteristics is a term used to describe a manic state with depressive symptoms or a depressive state with manic symptoms. Although this distinction seems to be accidental, in fact, these two emotional states are clearly described in the Diagnostic and Statistical Manual of Mental Disorders (DSM) issued by the American Psychiatric Association.

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The characteristics of the emotional state are called “specifiers,” which add more detail to the diagnosis and help ensure that the most appropriate treatment plan is prescribed.

Although an emotional state usually predominates in mixed episodes, in general, the symptom bodies are contradictory. An example might be an overactive person who has a deep sense of guilt or remorse (the latter is characterized by symptoms of depression).

Or, a person may cry uncontrollably, but focus on performing tasks that must be done now (the latter is characterized by symptoms of mania).

People who experience mixed episodes usually have worse symptoms, more frequent recurrences of acute episodes, increased risk of psychosis, and it is more difficult to find effective treatments.

Diagnosis of mania

If you are in a manic or hypomanic state with mixed characteristics, you will meet the complete diagnostic criteria for a recent manic or hypomanic episode, but you will experience at least three depressive symptoms for most of the same time period:

  • Persistent sadness or feeling of emptiness
  • Loss of interest or fun in activities you usually enjoy
  • Speak or react slower than usual
  • Continuous fatigue and energy loss
  • Feelings of worthlessness or inappropriate guilt
  • Recurring thoughts of death or suicide
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The doctor needs to make sure that there are no other explanations for the symptoms of depression, such as alcohol or drugs or recreational drugs, such as opioids or benzodiazepines.

This is especially important given that more than half of people diagnosed with bipolar disorder abuse drugs and/or alcohol. Often, drug abuse is associated with more serious illnesses and worse control of bipolar symptoms.

Diagnosis of depression

If you are in a state of depression with mixed characteristics, you will meet the complete diagnostic criteria for a recent major depressive episode, but for most of the same time period, you will also experience at least three symptoms of mania or hypomania:

  • An emotional state that is excessively high and inflated
  • Inflated self-esteem or arrogance
  • Be overly talkative or feel pressured to keep talking
  • Racing idea or the flight of ideas
  • Focus on goal-oriented tasks and increase energy
  • Unfounded risks (financial, physical, sexual, etc.)
  • Reduced need for sleep
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In order to make a diagnosis, doctors need to make sure that there are no other causes of depressive symptoms, such as neurological diseases or medications or recreational stimulants, such as crystal methamphetamine, cocaine, or Ritalin.


The treatment of mixed episodes of bipolar disorder is complex and may involve a combination of mood stabilizers and atypical antipsychotics.Antidepressants are almost always avoided because they may worsen emotional symptoms.

Depakote (sodium valproate) is an anticonvulsant and also an effective mood stabilizer. It is usually the drug of choice for the treatment of bipolar disorder with mixed characteristics. Other mood-stabilizing anticonvulsants include Lamictal (Lamotrigine) and Tegretol (Carbamazepine).

Commonly used atypical antipsychotics include Abilify (aripiprazole), Risperdal (risperidone), Seroquel (quetiapine) and Zyprexa (olanzapine). In some cases, these drugs will be used alone, in other cases together with different types of mood stabilizers.

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If drugs cannot control the severity and/or frequency of acute attacks, electroconvulsive therapy (ECT) may be recommended. Despite its notoriety, ECT can provide relief at any stage of bipolar disorder, including episodes with mixed characteristics.