Mixed Episode Criteria for Bipolar Disorder

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We tend to think of bipolar disorder as a disease characterized by alternating bouts of depression and mania. While it is true that some people with the disorder will experience a distinctive pendulum swing in moods, with clear highs and lows, more often than not the clinical picture will not be so obvious.


In many cases, the depressive episodes may be the defining feature of bipolar disorder. At other times, a person may experience a less severe form of mania known as hypomania, in which the elevated mood may not be so apparent, especially to casual observers.

Another condition, known as bipolar disorder with mixed features, causes a person to simultaneously experience depression and mania. While this may seem contradictory—to have a manic and depressed state at the same time—it is more common than you may think.


According to a 2015 study from the University of Siena School of Medicine, around 40% of people with bipolar disorder will experience a mixed episode at least once during the course of their disease.

Bipolar disorder with mixed features is a term used to describe either a manic state with depressive symptoms or a depressive state with manic symptoms. While the distinction may seem incidental, the two mood states are, in fact, clearly delineated in the Diagnostic and Statistical Manual of Mental Disorders (DSM) issued by the American Psychiatric Association.

The characteristics of a mood state are known as specifiers, which add more detail to a diagnosis and help ensure that the most appropriate treatment is prescribed.

While one mood state will typically predominate during a mixed episode, in their totality, the body of symptoms will be contradictory. An example might be someone in a hyperactive state (a symptom of mania) who has feelings of deep guilt or remorse (a symptom of depression).

Alternately, a person may be crying uncontrollably (a symptom of depression) but be fixated on performing a task that has to be done now (a symptom of mania).

People who experience mixed episodes generally have worse symptoms, more frequent recurrence of acute episodes, an increased risk of psychosis, and greater difficulty in finding an effective treatment.

Diagnosis With Mania

If you are in a manic or hypomanic state with mixed features, you will have met the full diagnostic criteria for a recent manic or hypomanic episode but would also have experienced at least three symptoms of depression during the majority of the same time frame:

  • A persistent feeling of sadness or emptiness
  • A loss of interest or pleasure in activities you usually enjoy
  • Speaking or responding more slowly than is normal
  • Persistent fatigue and loss of energy
  • Having feelings of worthlessness or inappropriate guilt
  • Recurrent thoughts of death or suicide

If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 988 for support and assistance from a trained mental health professional. If you or a loved one are in immediate danger, call 911.

For more mental health resources, see our National Helpline Database.

A doctor would need to ensure that there are no other explanations for the depressive symptoms, such as alcohol misuse or pharmaceutical or recreational drugs like opioids or benzodiazepines.

This is especially important to note given that research has linked people who've been diagnosed with bipolar disorder with higher rates of misusing drugs and/or alcohol. As a rule, substance use is associated with greater disease severity and poorer control of bipolar symptoms.

Diagnosis With Depression

If you are in a depressed state with mixed features, you will meet the full diagnostic criteria for a recent major depressive episode but will also have experienced at least three symptoms of mania or hypomania during the majority of the same time frame:

  • An excessively elevated and expansive mood state
  • Inflated self-esteem or grandiosity
  • An excessively talkative state or feeling pressured to keep talking
  • Racing thoughts or flight of ideas
  • Increased energy with a focus on goal-oriented tasks
  • Unwarranted risk-taking (financial, physical, sexual, etc.)
  • A decreased need for sleep

To make the diagnosis, a doctor would need to ensure that there are no other causes of the depressive symptoms, such as a neurological disorder or pharmaceutical or recreational stimulants like crystal methamphetamine, cocaine, or Ritalin.


The treatment of a mixed episode of bipolar disorder is complex and may involve a combination of mood stabilizers and atypical antipsychotics. Antidepressants are almost always avoided as they can tend to worsen mood symptoms.

Depakote (sodium valproate) is an anticonvulsant drug that also functions as an effective mood stabilizer. It is often the first-line drug of choice in treating bipolar disorder with mixed features. Other mood-stabilizing anticonvulsants include Lamictal (lamotrigine) and Tegretol (carbamazepine).

The atypical antipsychotics commonly prescribed include Abilify (aripiprazole), Risperdal (risperidone), Seroquel (quetiapine), and Zyprexa (olanzapine). In some cases, these agents will be used alone, and in other circumstances along with a different type of mood stabilizer.

If medications are unable to control the severity and/or frequency of acute episodes, electroconvulsive therapy (ECT) may be recommended. Despite its scary reputation, ECT can provide relief at any phase of bipolar disorder, including episodes with mixed features. Be sure to consult with a doctor and treatment team to help you decide what treatment options are right for you.

4 Sources
Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5). 5th edition. 2013.

  3. McIntyre RS, Masand PS, Earley W, Patel M. Cariprazine for the treatment of bipolar mania with mixed features: A post hoc pooled analysis of 3 trials. J Affect Disord. 2019;257:600-606. doi:10.1016/j.jad.2019.07.020

  4. Swann AC. The strong relationship between bipolar and substance-use disorder. Ann N Y Acad Sci. 2010;1187:276-293. doi:10.1111/j.1749-6632.2009.05146.x

By Marcia Purse
Marcia Purse is a mental health writer and bipolar disorder advocate who brings strong research skills and personal experiences to her writing.