Clinical picture and etiologic models of mixed states

Although conceptualized as polar opposites, manic and depressive symptoms often co-occur in bipolar disorder. This article explores the clinical characteristics, prevalence, biologic features, and response to treatments of mixed states. Issues of diagnosis and cause are considered. The course is often protracted beyond acute episodes, psychotic symptoms are common, and suicide is a major risk. Bipolar mixed states are over represented in women. Mixed states respond poorly to lithium salts; mood stabilizers, particularly divalproex, are the mainstay of modern treatment. Electroconvulsive therapy is also effective, and can be used in severe cases.