A mixed affective state, formerly known as a mixed-manic or mixed episode, has been defined as a state wherein features and symptoms unique to both depression and (hypo)mania, including episodes of anguish, despair, self doubt, rage, excessive impulsivity and suicidal ideation, sensory overload, racing thoughts, heightened irritability, decreased "need" for sleep and other symptoms of depressive and manic states occur either simultaneously or in very short succession.
Previously, the
depressive), meaning that they are now officially recognized in patients with, in addition to bipolar I disorder, bipolar II disorder and, by convention, major depressive disorder. A depressive mixed state in a patient, however, even in the absence of discrete periods of mania or hypomania
or major depressive disorder, with at least three concurrent features of the opposite polarity being present. As a result, the presence of "mixed features" are now recognized in patients with bipolar II disorder and major depression; as earlier noted, however, although it is customary to withhold a diagnosis of a bipolar disorder until a manic or hypomanic episode appears, the presence of such features in a depressed patient even with no history of discrete mania or hypomania is strongly suggestive of the disorder.
Nevertheless, the DSM-5's narrower definition of mixed episodes may result in fewer patients meeting mixed criteria compared to
DSM-IV.[2] A call was made by Tohen in 2017 for introducing changes from a currently phenomenological to a target oriented approach to DSM-5 mixed mood criteria in order to achieve more personalized medical attention.[3]
Two features of both mania or hypomania and depression may superficially overlap and even resemble each other, namely "an increase in goal-directed activity" (psychomotor acceleration) vs.
anger issues or an anxiety disorder; they may seem to overreact in many or most situations; they may go from depressed to rapidly being "cured" or manic in just a few hours. Episodes of sudden mood change must be in a situation that promotes the feelings of anger, anxiety, and happiness or excitement. There also may be inappropriate and impulsive decision making, which can cause severe, life changing, or even deadly problems (like binge eating, excessive arguments, and an increased chance for suicides). Irritability can also be present among mixed affective states. While irritability is present in all affective disorders, in depression it is often more subtle. In mixed episodes the irritability is intense and easily noticed. Even when such experiences are accounted for on the basis of depression, the possibility does still exist, however, that the depressive episode may be complicated by other manic or hypomanic symptoms, in which case it is often prudent to attend to the patient's personal and family history (e.g., family history of bipolar disorder, early age of onset) to determine whether or not the patient has bipolar disorder.[4]
Treatment
Treatment of mixed states is typically based upon administration of
lithium's efficacy for treatment of mixed states due to conflicting conclusions drawn from various trials and research.[5][6] 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.[7]
