What You Should Know About Bipolar Disorder Mixed Episodes

Bipolar disorder is a mental health condition that involves significant changes in your mood and energy levels. These changes in mood and energy are called “episodes.” Mixed episodes are one type of episode that people with bipolar disorder may experience.

Read on to learn more about the signs and symptoms of a mixed episode, causes, risks, and treatment options.

What is a bipolar disorder mixed episode?

During a bipolar mixed episode, you have symptoms of a manic or hypomanic episode along with those of a depressive episode.

Mixed episodes are one of four types of episodes that a person with bipolar disorder may experience:

• Manic: Periods of abnormally elevated or irritable mood that last at least 7 days

• Hypomanic: Periods of elevated or irritable mood that are less extreme than a manic episode and last for at least 4 days

• Depressive: Periods of low energy and loss of pleasure that last at least 2 weeks

• Mixed: Periods involving a combination of manic/hypomanic and depressive symptoms

Mixed episodes are common among people with bipolar disorder. In fact, professionals believe that people rarely show symptoms of just mania, hypomania, or depression.

Knowing what type of episode you or a loved one is experiencing can help you find the best treatment approach.

Signs and symptoms of a bipolar mixed episode

To be considered a mixed episode, you must experience one of the following conditions: 

1. At least three manic or hypomanic symptoms during a depressive episode

2. Three or more depressive symptoms during a manic/hypomanic episode

Symptoms of a manic or hypomanic episode include:

• Inflated sense of confidence

• Feeling rested even with little sleep

• Excessive talking

• Racing thoughts

• Inability to stay focused

• Taking on several activities or tasks at one time

• Engaging in pleasurable activities that could have negative consequences, such as gambling or unprotected sex

Symptoms of a depressive episode include:

• Sadness or depressed mood that occurs most days, nearly all day for at least 2 weeks

• Loss of interest in things that were once enjoyable

• Poor concentration

• Feelings of guilt or worthlessness

• Changes in appetite or weight

• Sleeping more or less than usual

• Changes in movement, such as sluggishness or agitation

• Lack of energy

• Thoughts of suicide

What causes a bipolar mixed episode?

Like bipolar disorder in general, researchers do not fully understand what causes or triggers mixed episodes. Specific causes can vary from person to person.

Based on what we do know, possible triggers for a mixed episode in people with bipolar disorder may include:

• Experiencing a stressful or traumatic event

• Taking antidepressant medications

• Disturbances in your circadian rhythms, such as lack of sleep

• Changes in seasonal patterns

Who gets mixed bipolar episodes?

A large number of people with bipolar disorder experience mixed episodes. Certain groups of people are at greater risk:

• Those with previous mixed episodes: People with bipolar disorder tend to experience the same types of episodes over time. A person who has a mixed bipolar episode one time is at higher risk of mixed episodes again in the future.

• People who are younger in age: Younger people are more likely to experience mixed episodes compared to middle-aged and older adults. Bipolar disorder typically first begins around 25 years old.

• Women: Mixed episodes are more common among females with bipolar disorder compared to males with the disorder. But, women typically present with depression at first. This can lead to them getting misdiagnosed.

What are the risks involved with mixed bipolar episodes?

One of the most serious risks of bipolar disorder is suicide. The rate of suicide is 10 to 30 times greater among people with bipolar disorder. And the risk of suicide is highest for people who experience depressive and mixed episodes.

People who experience bipolar mixed episodes may also engage in impulsive and dangerous behaviors associated with mood episodes like:

• Substance use

• Criminal activity

• Risky sexual activity

These actions can have serious short and long-term consequences, such as:

• Job loss

• Incarceration

• Contracting STDs

Because of the dangers associated with bipolar mixed episodes, getting the proper treatment is important.

Treatment options for mixed bipolar episodes

The recommended treatment for mixed episodes is similar to treating bipolar disorder itself. It typically involves a combination of therapy and medication. In cases where other treatment approaches haven’t worked, electroconvulsive therapy (ECT) may be recommended.

Medication

There are several different types of medications used to treat bipolar disorder, including mixed episodes. The right medication will depend on your specific symptoms and history of previous bipolar episodes.

Medications for bipolar disorder include:

• Antipsychotics, such as risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel)

• Mood stabilizers, such as lithium and lamotrigine (Lamictal)

Antidepressants are sometimes prescribed alongside antipsychotic medications or mood stabilizers. But, antidepressants can sometimes trigger manic symptoms. So, providers are cautious when it comes to prescribing antidepressants for bipolar disorder.

People who experience mixed bipolar episodes are also likely to have other mental health conditions, including anxiety and substance use disorders. It is important that treatment targets all mental health concerns. Not addressing all of a person’s symptoms can lead to poorer outcomes and unnecessary suffering.

Therapy

Therapy for bipolar disorder focuses on:

• Offering support

• Educating the person and family on the condition

• Encouraging healthy habits

• Teaching coping skills

• Preventing relapse

Individual, group, and family therapy can all be helpful. Therapy approaches that are effective for treating bipolar disorder include:

• Cognitive behavioral therapy (CBT): Works to spot and change negative thought patterns.

• Family-focused therapy (FFT): Teaches people with bipolar disorder and their families about the condition and how to communicate effectively with one another.

• Interpersonal and social rhythm therapy (IPSRT): Helps people with bipolar disorder create daily routines and habits that promote mood stability.

ECT

Electroconvulsive therapy may also be a treatment option for people who have severe symptoms and have not responded well to medication. During ECT, the brain is stimulated with an electrical current while a person is under anesthesia. It is considered a safe treatment.

A typical course of ECT involves 2 to 3 treatments a week for a total of 6 to 12 treatments. ECT is considered an effective treatment for conditions like bipolar disorder. But it does not necessarily “cure” the condition. After ECT, you likely still need to take medication and attend therapy. And you may need extra maintenance ECT sessions from time to time.

Mental health resources and support for bipolar disorder

If you or someone you know is experiencing bipolar disorder, it is important to get the proper help. To locate a mental health provider or program, contact SAMHSA’s National Helpline at 1-800-662-HELP (4357) or search the online treatment locator tool.

Along with treatment, people with bipolar disorder and their loved ones can benefit from the following resources:

• National Alliance on Mental Illness (NAMI): NAMI provides information and support for a range of mental health conditions. NAMI also hosts virtual and in-person support groups for people with mental illness and their loved ones.

• Depression and Bipolar Support Alliance (DBSA): DBSA offers information on mood disorders like bipolar disorder, wellness tools, and hosts local and online support groups.

• International Bipolar Foundation (IBF): IBF has educational articles and videos, as well as resources on bipolar disorder. They also offer an online screening tool to help you figure out if you might have bipolar disorder.

If you or someone you know is experiencing suicidal thoughts or a mental health crisis, call or text the 988 Suicide & Crisis Lifeline. The lifeline offers free and confidential support 24/7.

Why trust our experts?

Written by:

Emily Guarnotta, PsyD

Emily Guarnotta, PsyD, is a licensed clinical psychologist and certified perinatal mental health professional with over 10 years of clinical experience.

Edited by:

Renée Fabian, MA

Renée Fabian is the senior pet health editor at GoodRx. She’s worked for nearly 10 years as a journalist and editor across a wide range of health and well-being topics.

Reviewed by:

Mona Bapat, PhD, HSPP

Mona Bapat, PhD, HSPP, has 15 years of clinical experience providing therapy. She is a licensed clinical psychologist in Indiana and Illinois with treatment experience in individual, couples, family, and group therapy modalities.

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