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Mixed Bipolar Disorder


What Are the Risks of Mixed Episodes in Bipolar Disorder?

The most serious risk of mixed bipolar disorder is suicide. People with bipolar disorder are 10 to 20 times more likely to commit suicide than people without bipolar disorder. Tragically, 8% to 20% of people with bipolar disorder eventually lose their lives to suicide.

Evidence shows that during mixed episodes, people may be at even higher risk for suicide than people in episodes of bipolar depression.

Treatment reduces the likelihood of serious depression and suicide. Lithium in particular, taken long term, reduces the risk.

People with bipolar disorder are also at higher risk for substance abuse. Nearly 60% of people with bipolar disorder abuse drugs or alcohol. Substance abuse is associated with more severe or poorly controlled bipolar disorder.

What Are the Treatments for Mixed Episodes of Bipolar Disorder?

Mixed manic episodes generally require treatment with medication. Unfortunately, mixed episodes are more difficult to control than other episode types of bipolar disorder. The main drugs used to treat mixed manic episodes are mood stabilizers and antipsychotics.

Mood Stabilizers

While lithium is often considered a gold standard treatment for mania, it is thought to be less effective when mania and depression occur simultaneously, as in a mixed episode. Lithium has been used for more than 60 years to treat bipolar disorder. It can take weeks to work fully, making it better for maintenance treatment than for acute manic episodes. Blood levels of lithium must be monitored to avoid side effects.

Depakote is an antiseizure medication that also levels out moods. It has a more rapid onset of action, and in some studies has been shown to be more effective than lithium for the treatment of mixed episodes.  Depakote is also sometimes used "off-label" for prevention of mixed manic episodes.

Some other antiseizure drugs, such as Tegretol, are also effective mood stabilizers.


Many atypical antipsychotic drugs are effective, FDA-approved treatments for mixed episodes.  These include Zyprexa, Abilify, risperidone, Seroquel, Geodon, and Saphris.  Antipsychotic drugs are also sometimes used alone or in combination with mood stabilizers for preventive treatment.

Electroconvulsive Therapy (ECT)

Despite its frightening reputation, electroconvulsive therapy (ECT) is an effective treatment for mixed manic episodes. ECT can be helpful if medication fails or can't be used.

Treatment for Depression in Mixed Bipolar Disorder

Common antidepressants such as Prozac, Zoloft, and Paxil have been shown to worsen mania symptoms during mixed episodes without necessarily improving depressive symptoms. Most experts therefore advise against using antidepressants during mixed episodes. Mood stabilizers (particularly Depakote), as well as atypical antipsychotic drugs, are considered the first-line treatments for mixed episodes. 

Mixed episodes of bipolar disorder often involve recurrences of mixed, manic, or depressed phases of illness. Therefore, it is usually recommended that medications be continued in an ongoing fashion to prevent relapses.


WebMD Medical Reference

Reviewed by Joseph Goldberg, MD on May 14, 2012
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