Mixed mood states

In spite of the fact that these mixed states have been recognized for more than a century, they are still difficult to explain to bipolar patients. Mixed state refers to the presence of manic and depressive symptoms together rather than as polar opposites as they are usually conceived. After explaining depression and then mania and how they are different to a newly diagnosed patient and their family, it then seems almost contradictory to explain that these symptoms can in fact occur together. Not only can they occur together but they very frequently do.

A recent large study done under the auspices of the National Institutes of Mental Health in the USA found that of 1380 patients diagnosed with bipolar depression more than half had concomitant manic symptoms. Depressive symptoms without co-occurring manic symptoms were observed in less than one-third of the patients at study entry. Patients with both depressive and manic symptoms were more likely to be male, have bipolar type II disorder, earlier age of onset, recent rapid cycling, and greater likelihood of past suicide attempts.

The presence of even minimal manic symptoms in someone with bipolar depression increases the risk of full blown mania when they are given antidepressants. This is one of the reasons why modern practice is to avoid antidepressants when treating bipolar depression if at all possible. Antidepressants in this situation also increase the likelihood of suicidal ideation and mood cycling. Manic symptoms to look for in depressed patients are racing thoughts, distractibility, agitation, irritability, and pressured speech. When these symptoms are present along with depression, we try instead to use so-called mood stabilizers such as lamotrigine and divalproex sodium. Lithium is thought to be less effective in mixed states.

Likewise more that 60% of patients who are predominantly manic have significant co-occurring depressive symptoms.

Considering that many bipolar patients have co-existing conditions such as drug and alcohol abuse or dependence, ADD/ADHD, generalized anxiety disorder and borderline personality disorder, these distinctions are not easy to make. People with all of these diagnoses often have racing thoughts, restlessness, distractibility, irritability and pressured speech. Even with careful evaluation it is often necessary to do a certain amount of trial and error in selecting medication. The responses to these trials may gradually help to refine the diagnosis.

These complexities indicate why ongoing clinical research is so critical to the advancement of our knowledge and treatment methods. Our current diagnostic classification, evaluation methods and treatment options are far from satisfactory. A research culture that encompasses both patients and doctors is essential to move beyond our present knowledge base. Unfortunately, at present there are too few of both patients and doctors who are actually engaged in the enterprise other than agreeing with the oft repeated motherhood statement that 'more research is necessary'.


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