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Bipolar disorder is often thought of as a condition with alternating periods of depression and mania. While some people do experience distinct periods of each, many people with bipolar disorder may experience symptoms of both depression and mania at the same time.

This is now called bipolar disorder with mixed features, but it was previously known as mixed state bipolar disorder.

Bipolar disorder with mixed features is thought to affect one-third to half of people with bipolar disorder. Knowing more about this condition can help you make informed decisions about your treatment plan.

“Mixed state bipolar” or “bipolar with mixed states” are outdated terms previously used as a specifier for bipolar disorder. A specifier is a term used to describe characteristics of mental health conditions like mood disorders.

When the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) was released in 2013, the specifier became “mixed features” rather than “mixed state.”

If you have bipolar disorder with mixed features, you experience symptoms of both manic and depressive episodes.

This means you can have a depressive episode with mixed features, where the main symptoms are depressive but subclinical manic symptoms are also present. For example, you may feel depressed and also experience racing thoughts or rapid speech.

Or you can have a manic episode with mixed features, where the main symptoms are those of a manic episode but depressive symptoms are also present. For example, you may be doing several high-energy activities, but you also feel depressed.

Symptoms of bipolar disorder with mixed features may vary, depending on the mood episode in question. They can include:

  • feeling a mixture of elevated and low moods
  • doing pleasurable activities but still having depressive symptoms
  • experiencing low mood with rapid speech
  • experiencing elevated mood with suicidal ideation
  • experiencing severely disturbed sleep
  • having a severe disruption of appetite

It’s important to note that how well an individual functions in their everyday life can vary, depending on their exact diagnosis and symptoms.

For bipolar disorder with mixed features, the diagnostic criteria in the DSM-5 include the following, according to a 2017 review:

  • three or more manic or hypomanic symptoms during a major depressive episode
  • three or more depressive symptoms during a manic or hypomanic episode

Once bipolar disorder is diagnosed, a clinician may add a specifier like “with mixed features,” depending on the reported mood episodes and symptoms.

There’s no specific known cause of bipolar with mixed features, but experts have some insights about potential causes.

Researchers suspect one factor is a change in the functioning of a part of the brain called the hypothalamus. These changes may contribute to sleep problems many people with bipolar disorder report. Sleep problems, difficulty falling asleep or staying asleep, may also affect the ability to regulate moods. Both sleep disturbances and variable moods seem to follow seasonal patterns and may be associated with changes in the intensity of available natural light.

In addition, people with bipolar disorder may also experience changing hormone levels which have been found to be related to functions of the hypothalamus as well.

Every person with bipolar disorder shows manic and depressive symptoms to some extent. But different factors trigger mood changes differently for each person. Some people switch or cycle between often extreme mood states rapidly, others more slowly.

More research needs to be done on potential triggers in order to find out the exact causes of these mood changes.

Sometimes people with bipolar depression may switch into manic or hypomanic states if they’re taking certain antidepressants called tricyclic antidepressants.

Mixed episodes are more likely to happen in these cases. In fact, long-term treatment with tricyclic antidepressants has been associated with mood changes in up to 70 percent of people taking them.

The antidepressant bupropion has also been associated with mood changes, even when a person is taking mood stabilizers at the same time.

So, looking at what medications a person is taking may give some insight into mood changes. There may also be genetic changes, but more research is needed.

Certain risk factors do exist for bipolar disorder, but specific risk factors for bipolar disorder with mixed episodes are not known.

According to a 2008 review, children may have greater chances of developing later bipolar disorder if they have a first-degree relative who has bipolar disorder and:

  • a subsyndromal form of bipolar disorder
  • a major depressive episode with manic symptoms
  • possibly, ADHD with mood fluctuation

No single neurobiological risk factor has been found for bipolar disorder, but others may include:

  • a stressful event or major life change
  • drug misuse
  • certain elements of brain structure and development, such as the prefrontal cortex, hippocampus, and hypothalamus

There’s no known way to prevent bipolar disorder. However, if you experience a mixed episode during treatment, your care team can work on figuring out what might have caused it, then adjust any necessary medication or work with you on lifestyle behaviors.

Managing episodes with mixed features is part of the treatment for bipolar disorder.

Episodes with mixed features typically indicate a more serious condition, as well as poor response to treatment, according to the 2017 review mentioned earlier.

No single medication is indicated for use in treating mixed features. Usually, a mental health professional will prescribe a combination of two or more medications, depending on your individual circumstances. Using one antidepressant for therapy isn’t recommended, according to a 2014 review.

Combination therapy for bipolar disorder with mixed states may include:

  • atypical antipsychotics (one or more)
  • mood stabilizers, including newer anticonvulsants
  • electroconvulsive therapy (ECT)

In severe cases where medication is not effective, ECT may be effective very quickly and resolve symptoms.

Atypical antipsychotics can include:

  • risperidone
  • olanzapine
  • quetiapine
  • ziprasidone
  • asenapine
  • lurasidone
  • aripiprazole

Mood stabilizers can include:

  • lithium
  • divalproex sodium
  • carbamazepine/oxcarbazepine/eslicarbazepine
  • lamotrigine
  • topiramate
  • gabapentin/pregabalin

While there’s no cure for bipolar disorder with mixed features, there is treatment to help you manage it.

Mixed episodes can be especially serious because of the risk of suicide — the depression is there, as well as the energy to carry it out. That’s why symptom management and supportive treatment are extremely important.

A mental health professional can help you better manage symptoms and can alter your treatment plan to help stabilize moods and reduce subsequent mood shifts.

If there’s an underlying cause to the mixed features, like medications, your care team can recommend other medication options to help stabilize your moods.

While more research is necessary to determine the underlying causes of mixed states and triggers, there are ways to manage the mixed episodes. If you’re experiencing symptoms of bipolar disorder with mixed features, reach out to a mental health professional.