Mixed State Bipolar Treatment

Bipolar disorder is defined by recurring mood swings between mania and depression. When a person with bipolar disorder is in a mixed state, it means that they are experiencing the symptoms of both mania and depression at the same time. This is a potentially volatile mix of negative mood plus extreme energy that requires immediate treatment.

Bipolar Symptoms

• Bipolar mania is defined by feelings of elevated self-esteem, talkativeness, racing thoughts, distractability, high energy, increased goal-directed activity, agitation and excessive pleasure-seeking activities that are potentially harmful or illegal. On the other hand, symptoms of depression include low energy, fatigue, lack of interest in activities, feelings of worthlessness and hopelessness, sadness, inability to concentrate or make decisions, and recurrent thoughts of death or suicide.

Mixed Episode

• In a mixed episode, mania and depression may switch back and forth rapidly, but, according to the Merck Manual, in at least one-third of all mixed episodes, both moods occur at the same time. When mania exists with depression, a crisis can quickly arise. Consider a person who feels worthless and suicidal while also feeling highly energized and impulsive. Thoughts of suicide combined with the energy to put a plan into action can result in death. The flip side of that is a person whose mania makes them feel highly creative and grandiose, yet they lack the energy to accomplish any task. This mixed state is likely to be expressed as constant agitation and frustration.

Diagnosis

• Diagnosis of a mixed state can be difficult because the primary symptoms may appear to be anxiety or a state of panic. The unstable moods may appear as hyperactivity or hypersensitivity. Sometimes the person is verbally or physically aggressive. This mixture of symptoms without an established history of bipolar mood swings may result in a diagnosis of anxiety, panic disorder or possibly agitated depression.

Medications

• Mood stabilizing medication will be prescribed. Typically, lithium is prescribed, but anticonvulsants that act as mood stabilizers (valproate, carbamazepine and oxcarbazepine) are often used for mixed states. If the mixed state is severe, then more than one mood stabilizer may be needed. If the mixed episodes recur, then adding an antidepressant medication may be necessary, but this is done with caution because antidepressants can trigger a swing back to mania or induce rapid cycling. Atypical antipsychotic medications may also be considered to treat symptoms of anger and aggression. If mixed episodes or rapid cycling recur, it is important to gradually remove all antidepressants, stimulants, caffeine, benzodiazepines and alcohol.

Risk Factors

• Adults with rapid cycling bipolar disorder experience at least four episodes in a year. Children with bipolar disorder are more likely to have what you might think of as a truly rapid cycle because they swing between several episodes in one day. In this type of rapid cycling, there is a higher risk of having a mixed state.