Mixed Mania - The Lethal Combination For Bipolar Disorder

Mixed mania is a manic episode that also has a depressive component. In such a state, mania is present to a significant degree, but depression is present most of the day and nearly every day. Such mixed symptoms occur for at least a week. The pioneering German psychiatrist Emil Kraepelin divided mania into four classes, including hypomania, acute mania, delusional or psychotic mania, and depressive or anxious mania, now known as mixed mania or a mixed state. Though mixed mania was not formalized by Kraepelin, he acknowledged that "the doctrine of mixed states is ... too incomplete for a more thorough characterization..."

Mixed mania is a particularly unpleasant form of bipolar disorder. Those who suffer from mixed episodes simultaneously experiences symptoms of both mania and depression during the same period of time. During a mixed state, the depressed mood occurs with manic agitation. This is frequently accompanied by insomnia and psychosis. Mixed mania is thought to b more common in bipolar children and women. Mixed mania can be common in younger males, but can occur in anyone at any stage in their illness.

The next edition of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association is likely to include more variants of bipolar disorder including a more clear description of mixed mania. The DSM alludes to mixed states where full-blown mania and major depression collide in a raging sound and fury, but nowhere does it account for more subtle manifestations. These subtle mixed states are often what many bipolar patients may experience for a significant proportion of their lives. The treatment implications can be enormous.

Clinicians commonly refer to these under-the-DSM radar mixed states as dysphoric hypomania or agitated depression, often using the terms interchangeably. A 2002 study described mixed bipolar states characterized by major depression as the primary emotional state with atypical manic features (e.g., irritability, distractibility, and racing thoughts). Such patients may receive an inaccurate diagnosis of major depression.

A phenomenon known as rapid cycling is difficult to distinguish from mixed mania. Rapid cycling occurs in up to 20% of bipolar patients. In rapid cycling, manic and depressive episodes alternate frequently; at least 4 times in 12 months. In some cases, the episodes may alternate between depression and mania as frequently as several times a day. This ultra-rapid cycling can be easily mistaken for mixed mania.

Patients with mixed mania, especially when it is marked by irritability and paranoia, are at higher risk for suicide. Studies show that bipolar patients who suffer from mixed episodes rather than pure manic episodes are more likely to develop substance abuse problems.

Lithium is not used to treat bipolar patients who experience mixed episodes. Because the older typical anti-psychotic medications run the risk of causing permanent movement disorder, and have been associated with depression when used over the long term, the new atypical anti-psychotics are now preferred for this purpose. All the new atypicals are effective in the treatment of acute and mixed mania. Olanzapine (Zyprexa) and risperidone (Risperdal) are FDA-approved for this purpose.

The next DSM is likely to expand on mania. The DSM alludes to mixed states where full-blown mania and major depression collide in a raging sound and fury, but nowhere does it account for more subtle manifestations, often the type of states many bipolar patients may spend a good deal of their lives in. The treatment implications can be enormous. Clinicians commonly refer to these under-the-DSM radar mixed states as dysphoric hypomania or agitated depression, often using the terms interchangeably.