Everything about Mixed State Psychiatry totally explained
» This article is an expansion of a section entitled Mixed state from the main article: Bipolar disorderIn the context of
mental illness, a
mixed state (also known as
dysphoric mania,
agitated depression, or a
mixed episode) is a condition during which symptoms of
mania and
depression occur simultaneously (for example,
agitation,
anxiety,
fatigue, guilt, impulsiveness, irritability, morbid or
suicidal ideation,
panic,
paranoia,
pressured speech and rage). Typical examples include tearfulness during a manic episode or racing thoughts during a depressive episode. One may also feel incredibly
frustrated in this state, since one may feel like a failure and at the same time have a flight of ideas. Mixed states can be the most dangerous period of mood disorders, during which
substance abuse,
panic disorder,
suicide attempts, and other complications increase greatly.
Diagnostic criteria
As affirmed by the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a mixed state must meet the criteria for a major depressive episode and a manic episode nearly every day for at least one week. However, mixed episodes rarely conform to these qualifications; they may be described more practically as any combination of depressive and manic symptoms (Akiskal & Pinto, 1999; Goldman, 1999; Perugi et al., 1999). The
Merck Manual of Diagnosis and Therapy (MMDT) splits the DSM-IV diagnosis into dysphoric mania and an agitated depression state.
A
dysphoric mania consists of a manic episode with depressive symptoms. Increased energy and some form of anger, from irritability to full blown rage, are the most common symptoms (MMDT). Symptoms may also include auditory hallucinations, confusion, insomnia, persecutory delusions, racing thoughts, restlessness, and suicidal ideation. Alcohol, drug abuse, and some
antidepressant drugs may trigger dysphoric mania in susceptible individuals.
An
agitated depression is a "major depressive [episode] with superimposed hypomanic symptoms" (Benazzi, 2000). Mixed episodes in which major depression is the primary state, concurrent with atypical manic features were described in two studies (Benazzi & Akiskal, 2001; Perugi et al., 2001). A study by Goodwin and Ghaemi (2003) reported manic symptoms in two-thirds of patients with agitated depression, which they suggest calling "mixed-state agitated depression".
Treatment
Mood stabilizers (
lithium and some
anticonvulsants) and
antidepressants are the traditional medications used in the treatment of
bipolar disorder and
major depression, respectively. Antidepressants, however, may induce mixed states and rapid cycling; hence, coadministration with an anticonvulsant and/or lithium reduces (but doesn't eliminate) this risk. Among the anticonvulsants, only
lamotrigine (Lamictal) has strong antidepressant effects. Lamotrigine and
lithium (not an anticonvulsant) are the only drugs FDA-approved for the maintenance treatment of bipolar disorder. These are the only "true" mood stabilizers in that they possess antidepressant as well as antimanic properties. Of the two, lamotrigine is the more effective treatment for bipolar depression and lithium is more effective for mania (Calabrese, Vieta & Shelton, 2003).
Mixed states require medication (
psychotherapy is best reserved for a more stable period). There are doubts as to
lithium's efficacy in mixed states. The anticonvulsant
divalproex (Depakote) is used frequently, particularly when
psychotic features are present (MMDT). The
atypical antipsychotics (such as
clozapine (Clozaril),
quetiapine (Seroquel) and
olanzapine (Zyprexa)) are also effective, but
clozapine,
quetiapine and
lithium are not US
FDA-approved for bipolar mixed states.
Electroconvulsive therapy may benefit the most severe cases.
Further Information
Get more info on 'Mixed State Psychiatry'.
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