In the context of mental disorder, 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 (e.g., 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 or be prone to fits of rage in this state, since one may feel like a failure and at the same time have a flight of ideas. Mixed states are often the most dangerous period of mood disorders, during which susceptibility to substance abuse, panic disorder, commission of violence, 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. 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”. Mixed episodes in which major depression is the primary state, concurrent with atypical manic features have been described. 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
Successful treatment of mixed states require administration of mood stabilizing medication, which may include anticonvulsants such as lamotrigine and valproic acid; atypical antipsychotics such as olanzapine, aripiprazole, and ziprasidone; or first-generation antipsychotics such as haloperidol. There is question of lithium’s efficacy for treatment of mixed states due to conflicting conclusions drawn from various trials and research. Mood stabilizers work to reduce the manic symptoms associated with the mixed state, but they are not considered particularly effective for improving concurrent depressive symptoms.