Principles of managing mixed features bipolar disorder in adults and young people

A manic or hypomanic episode with mixed features occurs when a patient having a manic episode simultaneously has some depressive symptoms. A depressive episode with mixed features occurs when a patient having a depressive episode simultaneously has some manic or hypomanic symptoms. If a patient meets the full diagnostic criteria for both a manic and depressive episode simultaneously, they are diagnosed with a manic episode with mixed features. For the symptoms of mood episodes, see Features of bipolar disorder.

Mixed features bipolar disorder is difficult to treat; a psychiatrist should supervise management. There is limited evidence to guide treatment; the major mood disturbance determines the treatment approach, but the presence of mixed features can affect drug choice.

For patients who have a manic episode with mixed features, treatment follows the principles of treating acute mania. The following should inform drug choice:

• There is limited evidence to support the use of sodium valproate, carbamazepine and antipsychotics for manic episodes with mixed features.
• There is an absence of evidence to support the use of lithium for manic episodes with mixed features because the diagnosis has only recently been described and there are no recent controlled trials of lithium. Despite this, lithium is still used for mixed features.

For patients who have a depressive episode with mixed features, determine whether the patient is taking any substance that may contribute to an elevated mood or induce cycling to another mood state (eg antidepressant monotherapy); if they are, gradually withdraw and stop the substance. Treatment should follow the principles of managing bipolar depression and consider the factors influencing drug choice. Limited evidence demonstrates that the most effective treatments (used as monotherapy) for depressive episode with mixed features are cariprazineMalhi 2021, lamotrigine, lurasidoneMalhi 2021, olanzapine, quetiapine or sodium valproate. If there is no response or an inadequate response after a suitable trial period of monotherapy, subsequent pharmacotherapy will be determined by the psychiatrist.

Although there are no controlled trials evaluating electroconvulsive therapy (ECT) for mixed features bipolar disorder, psychiatrists may consider ECT for patients with severe symptoms.