Mixed episodes in bipolar disorder are a form of mental illness. In most forms of bipolar disorder, moods alternate between elevated and depressed over time. A person with mixed episodes experiences both mood “poles” — mania anddepression — simultaneously or in rapid sequence. Technically, mixed episodes are described only in people with bipolar I disorder (not bipolar II disorder), although this distinction is expected to change as the psychiatric diagnostic classification system is currently being revised.
Who Gets Mixed Bipolar Disorder?
Virtually anyone can develop bipolar disorder. About 2.5% of the U.S. population suffers from some form of bipolar disorder – nearly 6 million people.
Mixed episodes are common in people with bipolar I disorder. Estimates vary widely, but between 20% and 70% of people with bipolar disorder experience mixed episodes.
Those who develop bipolar disorder at a younger age, particularly in adolescence, may be more likely to have mixed episodes. People who develop mixed episodes may also develop “pure” depressed or “pure” manic or hypomanic phases of bipolar illness.
Most people are in their teens or early 20s when symptoms from bipolar disorder first start. Nearly everyone with mixed episodes develop bipolar disorder before age 50. People who have an immediate family member with bipolar are at higher risk.
What Are the Symptoms of a Mixed Episode?
Mixed episodes of bipolar disorder are defined by symptoms of mania and depression that occur at the same time, or in rapid sequence.
- Mania in mixed episodes usually involves irritability, racing thoughts and speech, and overactivity or agitation.
- Depression in mixed bipolar disorder is similar to “regular” depression, with feelings of sadness, loss of interest in activities, low energy, feelings of guilt and worthlessness, and thoughts of suicide.
This may seem impossible — how can someone be manic and depressed at the same time? Because mixed manic episodes are a form of mental illness, they defy any predictable pattern of feelings or behavior.
For example, a person in a mixed manic episode could be crying uncontrollably while announcing they have never felt better in their life. Or they could be exuberantly happy, only to suddenly collapse in misery. A short while later they might suddenly return to an ecstatic state.
Mixed manic episodes can last from days to weeks or sometimes months, if untreated. Mixed episodes may recur and recovery can be slower than during episodes of “pure” bipolar depression or “pure” mania or hypomania.
What Are the Risks of Mixed Episodes in Bipolar Disorder?
The most serious risk of mixed bipolar disorder is suicide. People with bipolar disorder are 10 to 20 times more likely to commit suicide than people without bipolar disorder. Tragically, 8% to 20% of people with bipolar disorder eventually lose their lives to suicide.
Evidence shows that during mixed episodes, people may be at even higher risk for suicide than people in episodes of bipolar depression.
Treatment reduces the likelihood of serious depression and suicide. Lithium in particular, taken long term, reduces the risk.
People with bipolar disorder are also at higher risk for substance abuse. Nearly 60% of people with bipolar disorder abuse drugs or alcohol. Substance abuse is associated with more severe or poorly controlled bipolar disorder.
What Are the Treatments for Mixed Episodes of Bipolar Disorder?
Mixed manic episodes generally require treatment with medication. Unfortunately, mixed episodes are more difficult to control than other episode types of bipolar disorder. The main drugs used to treat mixed manic episodes are mood stabilizers and antipsychotics.
Depakote is an antiseizure medication that also levels out moods. It has a more rapid onset of action, and in some studies has been shown to be more effective than lithium for the treatment of mixed episodes. Depakote is also sometimes used “off-label” for prevention of mixed manic episodes.
Some other antiseizure drugs, such as Tegretol, are also effective mood stabilizers.
Many atypical antipsychotic drugs are effective, FDA-approved treatments for mixed episodes. These include Zyprexa, Abilify, risperidone, Seroquel, Geodon, and Saphris. Antipsychotic drugs are also sometimes used alone or in combination with mood stabilizers for preventive treatment.
Electroconvulsive Therapy (ECT)
Despite its frightening reputation, electroconvulsive therapy (ECT) is an effective treatment for mixed manic episodes. ECT can be helpful if medication fails or can’t be used.
Treatment for Depression in Mixed Bipolar Disorder
Common antidepressants such as Prozac, Zoloft, and Paxil have been shown to worsen mania symptoms during mixed episodes without necessarily improving depressive symptoms. Most experts therefore advise against using antidepressants during mixed episodes. Mood stabilizers (particularly Depakote), as well as atypical antipsychotic drugs, are considered the first-line treatments for mixed episodes.
Mixed episodes of bipolar disorder often involve recurrences of mixed, manic, or depressed phases of illness. Therefore, it is usually recommended that medications be continued in an ongoing fashion to prevent relapses.