Mixed affective states: a study within a community mental health team with treatment recommendations

Agitated Depression and Bipolar mixed states combine depressive and manic symptoms, reflecting severe forms of affective disorders with an increased suicide risk. These states have not been defined with adequate consensus and hence present a diagnostic and therapeutic challenge. In this study, we argue that both states are part of the bipolar spectrum rather than a distinct affective syndrome or a mixed anxiety-depression state.

The current literature has been reviewed and suggestions are made for a unified definition of this entity, which would be valuable in recognising this dangerous state. We have then studied 17 cases of mixed states identified from a database held by a UK community mental health team. We have studied the treatments offered and estimated the time these treatments have taken to end the mixed state and so reduce the risk of suicide.

Not surprisingly, there are no clear recommendations for treatment of these mixed states. We found that The best results were achieved with a three pronged regimen including increasing/adding mood stabilisers; and/or increasing/adding antipsychotics; as well as decreasing antidepressants. Resolution was achieved in two and a half weeks.

From this work we have deduced several general principles, which are here reviewed and hence we have been able to suggest possible treatment strategies.

Because of the close link between affective mixed states and suicidality, it is of great importance that patients be brought out of the mixed affective state as soon as possible, hence we believe that our findings are of importance in managing these patients. However we recommend further study on a larger sample in order to confirm our findings.