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Mixed States
When symptoms of mania and depression are present at the same time it is referred to as a mixed state. The symptom picture frequently includes agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. Depressed mood accompanies manic activation.
Mixed states are believed to be under-recognized by mental health professionals, with approximately 40% of manic episodes having prominent depressive elements. Studies have shown that suicidal thoughts are greatly increased in people in the midst of a mixed state, and the presence of manic activation means a greater risk that these people will have the energy and motivation to carry out their suicidal plans.
Symptoms during a mixed state can vary, but most individuals experience a full range of both depression and irritable mania symptoms. The deep despair and hopelessness of depression often occurs simultaneously with the increased energy, and impulsivity seen in mania. Thoughts often race as in a manic episode, but the content is often dark and full of pessimism, worry, guilt, and self-hatred. Anxiety is also often a prominent feature of mixed mood states, evidenced by an increase in panic attacks and compulsions. Many persons with bipolar disorder describe mixed episodes as feeling much worse than either mania or depression alone.
Treatment of mixed states can be tricky, as use of antidepressants can increase manic symptoms or induce rapid cycling. Many prefer treatment with some of the newer antipsychotic medications in combination with mood stabilizers. Care must be taken to ensure the safety of the patient, as the risk of substance abuse, suicide attempts, and other complications increases greatly during a mixed episode. Self-Injury and rage is also not uncommon.
Here are some descriptions of mixed states written by members of the BPhoenix support groups:
"It is impossible to explain the pain, anger, and exhaustion a mixed episode causes. It is to be filled with rage, at yourself and others and at the world. It is to have so much angry energy inside that you are sure you will explode. The mind can focus on nothing but death and hate. There is no reason. And there is no escape.
"For me mixed states have always been moods of perpetual euphoria veiled with clouds of dread. Not enjoyable."
"Mixed states are my most frequent. They vary - some more manic and some more depressive. Prefer the latter, seemingly have more control of these. In the last few years I seem to be having
more mood states than not."
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This Site Updated 04/09/11
The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.