Mixed Features in Bipolar Disorder

When Manic and Depressive Symptoms Co-Occur

Woman clutching her head in mental anguish
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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 the disease with only brief moments of mood elevation. 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.

More confusing yet is a condition known as bipolar disorder with mixed features in which a person will simultaneously experience depression and mania. While this may seem contradictory—to have a manic and depressed state all at the same time—it is more common than you may think.

Understanding Bipolar Disorder With Mixed Features

According to a 2015 study from the University of Siena School of Medicine, around 40 percent 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. In this way, a person is not treated for a mania/hypomania if the underlying mood state is depression or vice versa. 

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 who has feelings of deep guilt or remorse (the latter feature being symptomatic of depression). Alternately, a person may be crying uncontrollably but be fixated on performing a task that has to be done now (the latter feature being symptomatic 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 effective treatment.

Diagnosing Bipolar Mania With Mixed Features

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

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

This is especially important to note given that more than half of the people diagnosed with bipolar disorder abuse drugs and/or alcohol. As a rule, substance abuse is associated with greater disease severity and poorer control of bipolar symptoms.

Diagnosing Bipolar Depression With Mixed Features

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, the 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.

Treatment

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 are more likely to trigger an acute manic episode.

Depakote (sodium valproate) is an anticonvulsant drug which 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 stabilizers include Lamictal (lamotrigine) and Tegretol (carbamazepine).

The atypical antipsychotics commonly prescribed include Abilify (aripiprazole), Risperdal (risperidone), Seroquel (quetiapine), and Zyprexa (olanzapine). In some cases, an atypical antipsychotic will be used on its own after which a mood stabilizer may be added when the acute symptoms are under control.

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.

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