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Bipolar With Mixed Features (Mixed Episodes)

Reviewed by: HU Medical Review Board | Last reviewed: August 2023

Some people with bipolar disorder (BPD) have symptoms of mania and depression at the same time. This may be called mixed features, mixed episodes, or mixed states. About 1 in every 5 people with bipolar mania have mixed features.1

It may seem contradictory for someone to have symptoms of mania and depression at the same time. But it is entirely possible. Someone with mixed features may spend money impulsively, stop sleeping, and be full of energy. At the same time, they may feel hopeless and have thoughts of self-harm.2,3

What is mixed features?

Mixed features is a more serious form of BPD. This is because when compared to classic bipolar types, people with mixed features:2

  • Tend to be younger when their bipolar symptoms began
  • Have more delusions, hallucinations, and other other signs of being unable to tell what is real
  • Are more likely to be hospitalized and have longer hospital stays
  • Are at higher risk of suicide
  • Respond less well to mood stabilizers

People with mixed episodes feel higher highs and lower lows, and they feel them more often, than other people with BPD. They also have shorter periods in between episodes.2

What bipolar with mixed features looks like

To be diagnosed with mixed features, people with mania or hypomania must have 3 or more symptoms of depression. If their primary mood is depression, they must also have 3 or more symptoms of mania.1

Symptoms of depression

People who have bipolar depression with mixed features will experience some combination of:1

  • Low mood and very low energy (fatigue)
  • Lack of interest or enjoyment in favorite activities
  • Feeling sad, hopeless, empty, or tearful
  • Weight loss or weight gain due to loss of or increase in appetite
  • Sleep problems, such as sleeping too much (hypersomnia) or not enough (insomnia)
  • Feeling worthless or inappropriate guilt
  • Trouble concentrating and making decisions
  • Catatonia (lack of movement or communication, failure to respond to surroundings)
  • Thoughts of death or planning to die

At the same time, they also will have at least 3 symptoms of mania or hypomania. Hypomania is a less extreme version of mania.1

Symptoms of mania

People who have mania with mixed features will experience some combination of:1

  • High energy and nonstop physical activity such as pacing or fidgeting
  • Extreme irritability
  • Rapid, nonstop conversation or a feeling of pressure to keep talking
  • Racing, overwhelming thoughts
  • Over-the-top self-esteem
  • Needing little to no sleep
  • Obsession with goal-oriented projects
  • Risky, uncontrolled behaviors like spending money recklessly
  • Psychosis (being unable to tell what is real, such as having hallucinations and delusions)

Treating mixed features

Mood stabilizer drugs and antipsychotic drugs are the primary treatments for people with bipolar mania or depression with mixed features.2

Doctors do not recommend antidepressants for people who have mixed episodes. That is because antidepressants increase a person’s risk of having a manic episode and more mixed episodes.3

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