Mixed Episode

What is Mixed Episodes?

In a bipolar patient, manic as well as depressive periods can be present at the same time in one episode. This is called a mixed episode and is very common.

It occurs just about every day for a whole week. It severely reduces judgment and holds the risk of suicide. The episode is acute and affects social, work and educational events. According to the Diagnostic and Statistical Manual of Mental Disorders Fourth edition or DSM-IV, what used to be called mixed episodes are now called mixed features or mixed moods.

The DSM-5 is currently under construction, so all we have to go on is the DSM-IV. It says that for a bipolar patient to meet the criteria of “mixed episode”, the patient must meet the full criteria of both a fully manic episode as well as a fully depressive episode. In the manner in which the book is written now, the patient is not having mixed features if not all the criteria of manic and depressive episodes are present. However, the writing of version five of the DSM takes into account that a patient can have a few of the symptoms of both manic and depressive and still have a mixed episode.

It has been recorded that some bipolar patients with mixed features suffer psychosis during the mixed episode. This break from reality manifests in hallucinations or delusions which might harm other people. The psychosis must be attached to either mania or depression; it can’t stand alone. The presence of psychosis in bipolar disorder with mixed features places the patient at the far end of the bipolar spectrum. It means that the patient shows more than the requisite number of symptoms needed for a diagnosis. It pretty much disrupts or at the worst case scenario negates any work, social, and relationship associations.

Mixed Episodes Symptoms

The specifier “with mixed features” as described by DSM-5 can be attached to a patient exhibiting the signs of bipolar or depression, by the patient or as described by those who work with the patient or are family members or friends. Obviously, psychosis makes the symptoms worse.

As such, the symptoms of each are much the same:


  • Feeling high, euphoric
  • Inflated self-esteem, or feeling like a god
  • Talking more than normal, or feeling as if under pressure to talk more
  • Energetic in any kind of circumstances
  • Loss of appetite or unintended weight loss
  • Involved in activities predictive of harm that one wouldn’t normally consider, such as spending sprees, unwise business decisionsCan’t think clearly or concentrate
  • Irritability
  • Crying too much
  • Reduced need for sleep
  • Unexplainable aches and pains
  • Racing thoughts
  • Easily distracted


  • Losing interest in anything one used to enjoy such as hobbies
  • Feeling low, sad or empty
  • Talking more slowly than is normal for that person
  • Tiredness or less energetic
  • Feeling worthless
  • Suicidal thoughts or actions
  • Psychotic hallucinations and delusions

In order to be diagnosed with either depression or bipolar with mixed features, the patient must have had at least five of the depressive symptoms and three of the manic symptoms for a period of two weeks before a diagnosis by a doctor.

Mixed Episodes Causes

The Mayo Clinic states that, although the specific causes of bipolar disorder are unknown, it is thought that two things could be at fault. The Mayo Clinic explains that the size of the brain has something to do with it as well as genetics (it is more common in those whose parents or siblings have the disorder). That having been said, the triggers of bipolar disorder with mixed features are far better documented. Such triggers include:

Sleep pattern changes

Changes in sleep patterns highlight a medical or psychiatric problem, such as the inability to sleep, oversleeping, getting by on less sleep than normal, circadian-rhythm disruption, sleep apnea and abnormal sleep schedules.

Seasonal changes

When one is euphorically high in spring and very low during fall and winter or even the reverse, then a mixed episode is on the cards.

Alcohol or drugs

Many bipolar patients tend to self-medicate, or use alcohol and drugs to numb the occurrences of a mixed state. Sleeplessness, anxiety arising from it, depression and pain are controllable with drugs and alcohol, but the very same things set off depressive or manic moods.

Starting a medication

Many mixed features in bipolar patients are stimulated through the use of antidepressants. The truth is that sugar pills or placebo are more effective and don’t set off a manic episode.

Discontinue a medication

Nearly all the research states that if one takes an antidepressant for depression, then discontinuing its use will generally cause a manic episode.

Those are the triggers that have more or less to do with a medical explanation.

Triggers concerned with life include:

  • The death of a loved one
  • The breakup of a relationship
  • Losing a job
  • Divorce
  • Problems inside a relationship
  • Problems inside a friendship
  • Beginning a new job
  • Beginning college

Mixed Episodes Treatments

When people around a patient spot the signs of either depression or bipolar with mixed features, they should not wait. Moving immediately to help the person will prevent the symptoms from getting worse, especially when psychosis is present. There are many things to be done to make the situation better.


The first thing a doctor will do is prescribe mood stabilizers and antidepressants. There is a difference between the two. Mood stabilizers control the mood swings to which a bipolar patient is subject too. They also have the extra benefit of keeping occurrences and symptoms from returning. It’s done by the chemicals decreasing or increasing brain activity levels, so that the neurotransmitters can become normalized. Lithium is the first choice for the manic phase, resulting in 60 to 80 per cent remission.


Are usually used in epilepsy. However, it was discovered that these medications were beneficial in reducing the neuron activity necessary for brain function, thereby aiding in the manic phase of mixed features.

Valproic acid is an anti-convulsant

Used to control seizures, but it has been found to have mood stabilizing effects. It also helps during manic episodes. How it works is still somewhat fuzzy, except that it has to do with neurotransmission and ionic channel sensitivity in the manic phase.


Also helps control the manic phase in bipolar. It, too, has to do with neurotransmitters and ion channels, but has just as good effect as lithium with fewer side effects.

Antidepressants, alternatively, treat the depressive state of bipolar. Antidepressants are prescribed in conjunction with mood stabilizers, because by itself it makes manic symptoms worse. Should bipolar be present with other psychiatric disorders like ADHD, OCD or others, then antidepressants help control those symptoms.

Trycyclic antidepressants

Are made of three benzene rings. They block the absorption of the neurotransmitters serotonin and norepinephrine, which are mood and brain activity boosters.

Heterocyclic Antidepressants

These have a different effect on dopamine, serotonin and norepinephrine than first generation antidepressants. They treat different symptoms of depression like fatigue, sadness and anxiety.


Is a neurotransmitter that affects social interaction. It boosts the mood. In a depressed patient or the depressive phase of bipolar, serotonin needs to be released into the body. Serotonin reuptake inhibitors make sure it is, by blocking the reabsorption of serotonin. It’s safer to take than other antidepressants.

Selective inhibitors

Block only certain neurotransmitters, and are safer with fewer side effects. In the case of depression, the enzyme monoamine oxidase metabolizes dopamine, serotonin and norepinephrine. It balances the neurotransmitters.


Help decrease psychotic symptoms during the mania phase of bipolar. Some help the depressive phase of bipolar. They could be prescribed by themselves or in combination with antidepressants.

Note: Not all medications are going to work the first time out of the bottle. The patient and his doctor should keep a record of all medications, whether they worked or not, the side effects, whether the triggers were controllable and the strength of the episodes. Doctor and patient will then know how and when to adjust medications.

Transcranial magnetic stimulation or TMS

Might help when a patient has no luck with antidepressants. The patient sits in a reclining chair with a coil on his head. The coil sends magnetic impulses to the cells in the brain governing mood and depression.

Electroconvulsive therapy or ECT

Generally used on patients whose symptoms remain the same using antidepressants or who are medication-resistant. Electrical currents get into the brain and affect the levels of neurotransmitters there.


Psychotherapy helps bipolar patients. People tend to forget that bipolar symptoms don’t just stay in the patient’s head. Other people see the mania, the depression symptoms and wonder if the person is mad. This makes the patient feel isolated, because he wonders if anyone will be his friend or love interest, or even if he can keep his job or ever get another one. These feelings make the mania and the depression even worse.

Talking it out helps. Psychotherapy offers the patient ways to cope with the disorder, ways to recognize the triggers, recognize and control stress triggers, and it can even help family and friends understand the disorder better and help cope with it along with the patient. That’s personal and family-focus therapy. There’s also cognitive therapy for the bipolar with a mixed features patient.

Cognitive behavioral therapy or CBT

Cognitive behavioral therapy or CBT, on the other hand, deals mainly with negativity and how to turn it into positivity. No one would argue that depression and even some parts of mania is negative. CBT seeks to take a negative thought or feeling, examine it, and then turn it into a positive thought or feeling, thereby making the depression and some parts of the mania more manageable.

Mixed Episodes Prevention

While there is no cure for or way to prevent bipolar disorder with mixed features, there are ways to recognize the triggers of mania and depression and beat them to the punch. People at risk for bipolar such as those with family members who have it and those whose friends or acquaintances have it should know the triggers so as to be prepared to deal with them. Sensitivity to these triggers is the first step towards prevention.

Mood swings can be felt before they become full-blown. Just ask any woman in the throes of the “change of life”. It might be difficult to talk about this with a family member who has bipolar with mixed features. However, it will prepare you for an episode when you recognize the triggers. Some signs an episode is coming could be changes in sleep patterns, energy levels, changes in dress and hygiene as well as changes in sexual interest or motivation. You will be able to ask a doctor for help before the episode gets full-blown.

Last Reviewed:
September 17, 2017
Last Updated:
September 17, 2017