Mixed state (psychiatry)

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This article is an expansion of a section titled Mixed state from the main article: Bipolar disorder
Mixed state (psychiatry)
Classification and external resources
Specialty psychiatry
ICD-10 F38.0
ICD-9-CM 296.6

In the context of mental disorder, a mixed (affective) state, also known as a "mixed" or "mixed-manic" episode, is a condition during which features of mania and depression—such as agitation, anxiety, fatigue, guilt, impulsiveness, irritability, morbid or suicidal ideation, panic, paranoia, pressured speech and rage—occur simultaneously or in very short succession.

In current psychiatric nomenclature, they are a defining feature of bipolar I disorder, a type of bipolar disorder wherein mania or, less commonly, mixed-mania alternate with euthymia and, in the vast majority of cases, depression.

As mentioned below, the diagnostic criteria specifies that at least the minimum number of symptoms required for an independent diagnosis of both mania and depression be consistently present for at least one week (or less should psychiatric hospitalization be required); in reality, however, this criteria is rarely met, with "dysphoric mania" (up to three concurrent depressive symptoms) being much more common. Mixed affective states with a heavy preponderance of depressive symptoms may also be seen, although these may be more difficult to diagnose, as, for example, flight of ideas and "racing thoughts" may be confused for depressive rumination, and a certain tense excitation for agitation.

Diagnostic criteria[edit]

As affirmed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a mixed state must meet the criteria for both a major depressive episode and a manic episode nearly every day for at least one week.[1] However, mixed episodes rarely conform to these qualifications; they may be described more practically as any combination of depressive and manic symptoms.[2][3][4]

The Merck Manual of Diagnosis and Therapy (MMDT) splits the DSM-IV diagnosis into two distinct states: dysphoric mania, which consists of a manic episode with depressive symptoms; and agitated depression, which is a "major depressive [episode] with superimposed hypomanic symptoms".[5][dubious ] Despite the term “agitated depression” being used to refer to mixed-manic episodes, however, it is important to note that psychomotor agitation is a cardinal feature of major depression, with bipolar depressed patients actually tending more towards psychomotor retardation; thus, the mere presence of agitation does not necessarily imply a mixed affective state, and it is important that such symptoms as flight of ideas and a certain tense inner excitement are not confused for agitation. The term “excited depression,” therefore, may be better.

According to the MMDT, increased energy and some form of anger, from irritability to full blown rage, are the most common symptoms of dysphoric mania. Symptoms may also include auditory hallucinations, confusion, insomnia, persecutory delusions, racing thoughts, restlessness, and suicidal ideation. Alcohol, drug abuse, and some antidepressant drugs may trigger dysphoric mania in susceptible individuals. A study by Goodwin and Ghaemi (2003) reported manic symptoms in two-thirds of patients with agitated depression, which they suggest calling "mixed-state agitated depression".[6]


Treatment of mixed states is typically based upon administration of mood stabilizing medication, which may include anticonvulsants such as valproic acid; atypical antipsychotics such as olanzapine, aripiprazole, and ziprasidone; or first-generation antipsychotics such as haloperidol. There is question of lithium's efficacy for treatment of mixed states due to conflicting conclusions drawn from various trials and research.[7][8] Mood stabilizers work to reduce the manic symptoms associated with the mixed state, but they are not considered particularly effective for improving concurrent depressive symptoms.[9] Divalproex is considered superior to lithium in the acute and continuation treatment of mixed affective states.


  1. ^ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press, Inc., 1994.
  2. ^ Akiskal, H.S. Pinto, O. (1999). The evolving bipolar spectrum. Prototypes I, II, III, and IV. Psychiatr Clin North Am. 22(3):517–34.
  3. ^ Goldman, E. (1999). Severe Anxiety, Agitation are Warning Signals of Suicide in Bipolar Patients. Clin Psychiatr News. pg 25.
  4. ^ Perugi, G. Toni, C. Akiskal, H.S. (1999). Anxious-bipolar comorbidity. Diagnostic and treatment therefore challenges. Psychiatr Clin North Am. 22(3):565–83.
  5. ^ Benazzi, F. (2000). Depressive mixed states: unipolar and bipolar II [Abstract]. Eur Arch Psychiatry Clin Neurosci. 250(5):249–53.
  6. ^ Goodwin FK, Ghaemi SN (December 2003). "The course of bipolar disorder and the nature of agitated depression". Am J Psychiatry 160 (12): 2077–9. doi:10.1176/appi.ajp.160.12.2077. PMID 14638572. 
  7. ^ Pharmacotherapy of manic-depressive mixed States
  8. ^ Muzina, D. J. (2009), Pharmacologic treatment of rapid cycling and mixed states in bipolar disorder: an argument for the use of lithium. Bipolar Disorders, 11: 84–91. doi:10.1111/j.1399-5618.2009.00713.x
  9. ^ Thase ME, Sachs GS. Bipolar depression: pharmacotherapy and related therapeutic strategies. Biol Psychiatry. 2000 Sep 15;48(6):558-572.