Bipolar Mixed States: An International Society for Bipolar Disorders Task Force Report of Symptom Structure, Course of Illness, and Diagnosis

Abstract

The definitions and properties of mixed states have generated controversy, but the stability of their characteristics over a range of clinical definitions and diagnostic methods shows that the concept of mixed states is robust. Distinct characteristics related to the course of illness emerge at relatively modest opposite polarity symptom levels in depressive or manic episodes.

Treatment of mixed features in bipolar disorder

“…Reference lists from included articles were also manually searched for additional pertinent references. Of note, primary studies assessing treatments of DSM-IV-TR-defined mixed episodes were not systematically retrieved or reviewed in the current article, as this has been done by numerous other authors previously 3,9,[24][25][26][27] and the focus of the current article is on studies specifically evaluating the treatment of DSM-5-defined "mixed features" rather than DSM-IV-TR-defined "mixed episodes. "…”

“…1 Empirical evidence has revealed that the rare occurrence of fully meeting criteria for both mood states (ie, a DSM-IV-TR-defined mixed episode) lacked sufficient clinical utility to remain included in the diagnostic manual. [3][4][5] Rather, mood states in which a patient met criteria for either a MDE, manic episode, or hypomanic episode with some symptoms, but not necessarily meeting full criteria, of the opposite mood state had greater clinical and scientific relevance. [3][4][5] As such, the DSM-5 introduced the "with mixed features" specifier, which is defined by the presence of a mood episode wherein criteria for either a MDE or manic/hypomanic episode is met while simultaneously having 3 or more criteria from the opposite mood state.…”

“…[3][4][5] Rather, mood states in which a patient met criteria for either a MDE, manic episode, or hypomanic episode with some symptoms, but not necessarily meeting full criteria, of the opposite mood state had greater clinical and scientific relevance. [3][4][5] As such, the DSM-5 introduced the "with mixed features" specifier, which is defined by the presence of a mood episode wherein criteria for either a MDE or manic/hypomanic episode is met while simultaneously having 3 or more criteria from the opposite mood state. The mixed features specifier may have significant clinical relevance given that approximately 30-40% of patients with BD experience mood episodes with mixed features during the course of illness.…”

“…23 At the current time, inadequate evidence exists to adequately inform evidencebased treatment guidelines for mixed features in BD, as randomized controlled trials (RCTs) assessing the efficacy of various treatments specifically for BD mood episodes with mixed features have yet to be conducted. Numerous RCTs have assessed the efficacy of treatments of DSM-IV-defined mixed episodes 3,9,[24][25][26][27] ; however, the translational application of these results to the treatment of DSM-5-defined mixed features is speculative, as the DSM-IV overlaps but is distinctly different.…”

Lurasidone in the Treatment of Bipolar Depression With Mixed (Subsyndromal Hypomanic) Features

“…Multiple lines of evidence indicate that the presence of mixed features during a depressive episode identifies a bipolar disorder population characterized by more severe and/ or chronic depressive episodes, with shorter interepisode remissions, a higher recurrence rate, an increased risk of switch to mania during antidepressant therapy, higher rates of comorbidity (most notably anxiety disorders and/or substance use disorders), and a higher risk of suicide attempts. [1][2][3][4][5][6][7][8][9] Prevalence estimates for mixed features vary widely depending on the criteria used and on the setting and population studied. 1,2 In a community sample, 41.4% of individuals who met DSM-IV criteria for major depression also met criteria for subthreshold hypomania (≥ 4 symptoms, but not meeting DSM-IV criteria for hypomania, based on the Munich Composite International Diagnostic Interview).…”