Mixed Bipolar Disorder – How to Treat Mixed Mood Episodes

In the final installation of my mixed moods series, I talk about how to treat mixed moods in bipolar disorder. If you need a refresher on mixed moods in bipolar 1 or bipolar 2, see the first three articles in this series:

Treating Mixed Moods in Bipolar 1 – Mixed Mania

We know most about treating mixed moods in bipolar type 1 as that’s what has been classically defined as a mixed mood in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Because mixed moods in bipolar disorder type 1 are considered a type of mania, one could think of treating them in the same way bipolar mania is treated. Typical mania treatments include:

  • Lithium
  • Some anticonvulsants
  • Antipsychotics (normally atypical)
  • Benzodiazepines (for acute anxiety, commonly seen in mania and mixed moods)

Often a combination of an anticonvulsant and an antipsychotic is used.

FDA-Approved Drugs for Treating Mixed Moods in Bipolar 1

Since mixed moods are defined in the DSM, there are specific medications approved by the Food and Drug Administration (FDA) to treat mixed mania. FDA-approved drugs for treating mixed moods in bipolar disorder type 1:

  • Carbamazepine extended release (Equetro)
  • Aripiprazole (Abilify)
  • Ziprasidone (Geodon)
  • Risperidone (Risperdal)
  • Asenapine (Saphris)
  • Olanzapine (Zyprexa)

Bipolar Type 1 and Mixed Mood TreatmentWhy lithium didn’t make the list I’m not entirely sure;* because, as I’ve mentioned, mixed moods and acute anxiety carry a significant risk of suicide and lithium seems to have a particularly strong anti-suicide effect.

Electroconvulsive therapy (ECT) is also indicated for the treatment of bipolar disorder mixed moods.

Treating Mixed Moods in Bipolar 2

As I mentioned in the article on mixed moods in bipolar disorder type 2, mixed moods can either have hypomania or depression as the primary mood. This primary mood then, dictates the type of treatment chosen.

Treating Mixed Hypomania

According to this two-part Psychiatric Times article by Steven C. Dilsaver, MD, mixed hypomania in bipolar type 2 can be treated similarly to treating a mixed mood in bipolar type 1.

Specifically noted is the concern of acute anxiety during mixed hypomania and the fact not all patients readily admit to psychological and physical symptoms of anxiety. However, this is critical information to your doctor and should always be offered, even if not specifically asked.

Other mixed hypomania treatment tips include:

  • Comorbid (co-occurring) anxiety may decrease the effectiveness of mood-stabilizing agents, so benzodiazepines may be a better choice.
  • Not treating anxiety aggressively can reduce overall long-term treatment outcomes.

Treating Mixed Depression

Mixed depression is particularly hard to treat as mixed moods often predict a lack of response to antidepressants, not to mention the fact that antidepressants can make hypomanic or manic symptoms worse.

A suggested treatment strategy for mixed moods in bipolar 2 with the primary mood of depression is the following:

  • Begin by suppressing hypomanic symptoms by using an mood stabilizer or antipsychotic (antipsychotics may work in 1-2 weeks)
  • Start medication at low doses and titrate (raise the dose) quickly – this is generally necessary due to the severity of mood symptoms
  • If depressive symptoms persist after response to the above medication, add a selective serotonin reuptake inhibitor (SSRI) antidepressant very slowly while watching for signs of hypomania – this requires very close monitoring and likely weekly doctor visits (impossible for some, obviously)

This is very similar to what many doctors are now recommending for bipolar disorder type 2 in general. First, stop the cycling (or hypomania) and see if that also corrects the depression. Avoid the use of antidepressants whenever possible.

Preventing Mixed Depression in Bipolar Type 2

How To Prevent Bipolar Disorder Mixed Moods

Obviously, no one can guarantee prevention of any mood, but there are some recommendations given in the article, as people with mixed depression are known to be at high risk for reoccurrence.

Tips on preventing mixed depression in bipolar 2 include:

  • Lamotrigine is the favorite prophylactic medication as it seems to prevent depression without being an antidepressant
  • Ongoing scheduled benzodiazepine doses can help prevent panic attacks^
  • A combination of an antipsychotic, plus lamotrigine, plus a benzodiazepine is often “highly effective” (words Dr. Dilsaver’s)
  • Lithium is known to be a highly preventative agent; however, in many cases divalproex (Depakote) is superior and has fewer side effects

Series on Mixed Moods in Bipolar Disorder

Whew. OK, there turned out to be a lot to know about mixed moods in bipolar disorder. I hope you learned something reading it as I certainly did writing it.

For your convenience, here are the links to the other three parts in the series:

——————————————————————————————————————————-

Notes

* I suspect there wasn’t enough money to be made on a generic drug to fund the studies, especially when doctors are going to use it anyways.
^ Yes, I know, long-term (sometimes any term) benzodiazepine use is controversial. Personally, I’m not against them and neither are many doctors – when used responsibly.

Reference

Psychiatric Times, Mixed States in Their Manifold Forms. Part one and part two.

——————————————————————————————————————————————

About Natasha Tracy

Natasha Tracy is an award-winning writer, speaker and consultant from the Pacific Northwest. She has been living with bipolar disorder for 18 years and has written more than 1000 articles on the subject.

Natasha’s New Book

Find more of Natasha’s work in her new book: Lost Marbles: Insights into My Life with Depression & Bipolar. Media inquiries can be emailed here.

  1. In addition to having ultradian bipolar there’s mixed with depression being the main event. Practically always I have agitation and restlessness. Exercise and work and watching movies takes up a nice amount of space in my brain, pushing out a portion of the agitation and restlessness. It’s like I’m getting a lovely break from being myself.

  2. Oh and my meds now are seroquel dep (quetapine) valproas propvane low doses of seroquel to use with theralen if I cant get to sleep in the evening, plus wellbutrin that has made my will to live better.

  3. Ridingthewave your story is like a copy of mine. Always on top except for when I was 20 and got depressed. I worked too hard and took so much responsibility that when I crashed 6 years ago I was full of anxiety. My doctor gave me benzo’s and antidepp…. Two years later I almost killed myself twice, lost all friends except for my husband and one more friend, everything ruined since I
    Mixed antidep with benzo plus alcohol and lost myself so completely I got treated in the hospital for three weeks.

    After those three weeks I was told I might be Bipolar. Might. It has taken 4 years to find medicin that takes my killing anxiety away and it is a mix of heavy doses of medicines.

    My biggest problem now is that I need too much sleep. I can easily sleep 12-15 hours if I get the chance. A full time job makes that impossible.

  4. Thanks for this blog – I really need the distraction. I’m in a mixed state now and have just crawled into work after 2 days sick. I have to squirm in my office for another 6 hours. Thanks to a great pdoc and a ton of meds I function a lot of the time but these relapses are just so miserable. It’s like looking through the window of a toyshop, seeing what you can’t have and then being hit round the head just for looking. Now listening to death metal – the noise outside my head seems to deaden the noise inside…

  5. I’m in a mixed state now. Loved this page and comments. I was on Limictal, loxalate and seroquel wen I had a servere depression 18 mths, then after the correct antidepressant Pristiq came gud several months. Went off seroquel in that time Bcoz of weight gain. Then randomly the past week noticed hypomanic symptoms.. moved into mixed states.. finally at its worst today. Taking seroquel again until I see the doc in 2 days. I’m 33 yrs and diagnosed wen I was 18 yrs old. The above all sounds much too familiar so all I want to say is my heart goes out to all suffering this at times extremely torturous and painful illness. But pls don’t give up. On medicine, lifestyle, support systems, on yourself. Don’t give up on God. I no u can have moments of peace and happiness. Always, Leah

  6. As far as I am concerned Ativan is a miracle drug.I have remained on the same dosage for many years.I know dosage creep is a concern.

    The biggest problem I face is the comments that I get from other medical professionals.They know nothing about me or my history and yet they seem to feel they should warn me off taking it.I hate going to the doctor because of it.If I stand up for myself and remind them that a- they met me 5 min. ago and b- they are not a pdoc they always tell me to ‘calm down’ in that particularly annoying nursery school teacher sing songy voice.Augh!

  7. Hi, I just had a serious attempt on the 4th of July. I have bipolar II and was in mixed states. I cycle several times a day. They have me on Lamictal, Welbutrin, Depakote, Risperdal and Ativan now. I was on Lamictal, Lexapro and Ativan before this hospitalization. The hospital pdoc said the Lexapro was shooting me into hypomania and then I would crash because of anxiety, over and over again all day. The Depakote. Is hurting my stomach to the point I can’t do anything. Hopefully my own pdoc will change to something else.

  8. I am finally coming to terms after 20 years of my diagnosis with Bipolar 1. I have self medicated most of this time but managed a Master’s Degree and high career success only to crash in spectacular fashion. I entered a mixed state when I was given anti-depressants for what I thought was “seasonal depression” even knowing that 20 years prior I had been hospitalized and on Depakote for a few years. I just could not bear to be labeled and told I was not capable of living a successful life. So for years, I self medicated with alcohol, pain killers, adderall for when the winter came and I was totally without ability to move. It worked for a long time although I would suffer job losses often in the winter and school grades dropping while I begged instructors for time due to many made up reasons. This last mixed episode lead to a suicide attempt that almost worked. I was in a coma for two days. I am still struggling although on 1200 lithium, 200 lamictal, 1mg of clozapine three times per day, 30 mg of abilify and 15 mg of Ritalin twice per day as I have gone into the depression side. The goal is to raise the lamictal to 300. I had two days of clarity but the last two days have slept 14-16 hours per day and have lost 8 lbs in two weeks. I feel so down. I have so much to do and can’t seem to get up. I just watch Andy griffin when I am awake to try and feel better and I feel like I am letting everyone around me down. It is just so hard. I guess I got a lot sicker over the years but finally just cracked up. I had manias over the years where I would work 2-3 jobs, gamble, spend, sexually indulge and drive like a maniac. I would get so angry at people’s slowness I would have rages that included throwing a shopping cart and cussing people out at the store or wherever. I passed people on the highway in the emergency lane without a thought. I worked like a machine but started making less and less sense leading to a lot of conflicts and emails that would be 2-4 pages long with rants to coworkers. I didn’t realize in my denial state just how bad I really was. I took on four states when most reps had 1 or two. I took the jobs of two other reps in my mania, sure I could outperform everyone else. I created an unsustainable work life. I have 4 children who would basically watch me work 80 hours a week and in the winter, I would hole up in my bedroom and cry all the time. It feels scary and freeing at the same time to admit this. I feel I needed to accomplish a lot before I could. I just could not admit this. Now I finally can. I still feel so unstable and scared. I am afraid I will lose the man I love because he won’t be able to handle this. I can barely hang on to it. I feel very tired and alone. I feel like I have let my whole family down. My kids have been at my Mom and Dad’s over the last few months while I have been in the hospital several times. They are supposed to come home this week and I miss them so bad but I am still not right. How long is this going to take? I am taking the meds and now I am down in a hole again. They say i am a rapid cycler so why won’t this depression hurry up and leave? I had two good days. I want those days every day. I felt calm, clear, happy and hopeful. I felt organized in my mind and solved problems quickly with math. I felt normal. God I want that back. I want that so bad. I wish I could just lay this down. I feel so overwhelmed.

  9. Hi… I’m bipolar type 1 and I belive I’m a rapid cycling type. I also have to dx of generalized anxiety disorder. Anyway I’ve been real irritable and productive with more anxiety. My Dr increased my lamictal. Anyway no I just feel slow and tired and kinda hopeless. Real emotional and not really enjoying anything. But my anxiety has became more prominent. Any thoughts on what’s going on? I have a hard time conveying this to my Dr? Any thought on improving my mood?

  10. Just came through a mixed episode. Mostly depressed with hypo manic, obsessional thoughts of suicide. Not one bit of sleep last night. I’m on Celexa and Lamictal (low doses). I’d been stressed out all week, slept a good chunk of the day yesterday, went for a long walk while going to pay my landlord (the cause of the stress) and came home to clean. Maybe I’d gotten a bit too much sun and exercise, and was already hypomanic? I don’t know. The medication is working enough that I’m still alive, and distracted myself with video games and reading your blog so I wouldn’t do something stupid. Slept most of today and now I feel human against. I wish this pain would permanently stop. The screaming inside my head, the irritation at inane conversations around me, the pain of missing my boyfriend… It’s too much sometimes. If I take too high a dosage of meds I flip out and become full blown manic, which is when the ranting and paranoia take over, and the delusions burst through. As it is, my whole body hurts like I was used as a punching bag, but I’m glad to be alive enough to feel physical pain.

    Thank you for your blog. You helped to save me from a trip to the hospital or worse last night.

  11. Ahhhhh, those mixed states are the most dangerous ones for me. Typically when I am so so so depressed I think about suicide…but don’t have the energy. However, that doesn’t always last though…

    The mixed rapid cycling of the moods I experience, is where I am rather dangerous to myself. I have enough energy to carry the thoughts out…..I am agitated, and it doesn’t help matters that is when I am mostly sleep deprived too.

    Waking up at 3:00 am is no fun. Especially when one wakes up and IMMEDIATELY goes into a mood swing that lasts for several hours…..having to deal with all the frustration, irritability, agitation that early in the morning makes for a long long day!!!

    I don’t like me when I am in a mixed state. For me, this occurs when I have already experienced the depression/hypomania (or mania) parts of the cycle. It’s not good. I would rather not experience those moments……

    I just have to keep stressors to a minimum and limit my sun intake when I’m mixed. Too much sun causes serotonin to be excessive which in return cranks my moods up…..Talk about having a naturally occurring high—I don’t have to do illegal drugs to have it…….

  12. Thank you for this info and Tracy you are so right. Thanks to oxcarbarbazepine, clonazepam and aripiprazole, i have fought my way through a mixed episode. Tracy, my real name is NOT Amelia_mims and you do NOT owe anyone your real name. Thank you much for your honesty and for sharing so much valuable information. With advocates like you, we’ll see the end of stigma against mental illness in our lifetimes and that’s a whole lot of hope to hold onto.

    • Hi Amelia_mims,

      I’m glad to hear you fought through a mixed episode. Thanks for reminded us all that it is possible.

      Thanks for your support and kind words. I certainly appreciate it.

      (It’s Natasha, by the way.)

      – Natasha Tracy

  13. Further thoughts ….

    I’m never 100% if the dysphoric hypo’s are actually mixed episodes. By and large, I think ther are different but the line between is as ever grey! To illustrate, I can be full of the usual hypo energy and productivity and depressed, but there has also been times when I am not depressed by I have been very confused, highly agitated, a great deal of energy and wanting to get out of my skin – it is an extremely distressing feeling, it “hurts” too much; I combat it, as best I can, by trying to sleep it off, if I can sleep! I’d say that last state is the absolute worst of all and probaby the most dangerous because the thoughts racing through the head are not of depressed despair but “this really hurts and I need it to stop now”.

    • Hi Graham,

      I know that, “it hurts too much” feeling. I don’t know a word for it but it happens to be quite a bit. And i do agree it is very dangerous because you really do just want to do anything to make the pain stop which is probably the worst headspace in which to be. It hard to talk yourself out of just wanting the pain to stop.

      – Natasha Tracy

  14. I see Saphris listed as an anti-psychotic approved for mixed episodes. It surprised me by making me feel very happy and non-anxious — and I’ve been through a lot of meds. I don’t like the taste (it’s sublingual) but one can’t have everything. We’re all different but maybe it’ll work for someone else out there too.

    • HI Sheila,

      Yes, Asenapine (Saphris) is a newer drug that most people haven’t heard of. I’ve heard a couple report about it but yours is the first positive one – lucky you :)

      – Natasha Tracy

  15. I can feel that over the last few months that I’ve been phasing through a mixed episode. For quite awhile, I quit the gym and doing self-care. My PDoc has been reticent about applying ANY anti-depressive relief, because I had a devastating manic (type 1) episode nearly a year ago. My antipsychotic dose was triple as a result, leading to even more weight gain. I feel like I’ve lost the “battle with the bulge” as my weight has climbed, I’ve become very limited in my ability to walk or stand for any length of time. I have a ruptured L4-5 lumbar disc and am quite sure I’ll have another positive MRI tomorrow. The combination of chronic pain upon weight-bearing and increase in isolation and depression has made life nearly intolerable; I feel useless.
    Your treatment profile for MIXED_STATE depression gives me hope now, however, as it affirms that an SSRI can be applied in a low dose, with close monitoring. I know my PDOC will see me every two weeks. The problem is that each course of antidepressant seems to have resulted in hospitalization for manic psychosis, at least that’s the med-heads have read it. SSRIs are the first to be withdrawn. But I’m going to ask for 30mg Cymbalta which also may help with chronic back pain. Also, I’m confident that a microsurgical dissection will give me pain relief, and get me back to the gym.

    • Hi Thomas,

      I feel your doctor is right to be wary of any antidepressants during a mixed episode. I would think that antidepressants would be expressly contraindicated at that time. Above, it’s referring to a treatment technique where the person positively reacts to the mood stabilizer first and gets stable _before_ adding an antidepressant if needed.

      However, what about mood stabilizers? I know you are an an antipsychotic, but what about lithium, lamotrigine, etc. Lamotrigine, in particular has antidepressant properties without the risks of flipped you into mania. They can likely be added to what you’re already taking and perhaps if you find them useful, you could take the antipsychotic dose down somewhat.

      Just a thought. See what your doctor says.

      – Natasha Tracy

  16. My brother was only diagnosed about a year before he found his final solution. I highly encourage anyone reading this to encourage their loved one to explore all types of therapies as well as chemical, to help them bring their body and lives in to balance before they come to the final solution that my brother did.

    • Hi Terri,

      I’m extremely sorry to hear about your brother. When we’re first diagnosed it can be a dangerous time because we don’t yet understand our disease and usually we don’t have effective treatments yet.

      “I highly encourage anyone reading this to encourage their loved one to explore all types of therapies as well as chemical, to help them bring their body and lives in to balance before they come to the final solution that my brother did.”

      Absolutely. Thanks for your comment.

      – Natasha Tracy

  17. Great article, will be sure to read the others, plus pass it on to the bipolar group I help run {see link}. Due to numerous insurance problems, I was diagnosed with Bipolar 1 about 6times, only as I had that mixed episode. It was bad, the only time I ever actually tried to kill myself, but luckily I was too hasty.

    With what the bipolar did to my life, I can see now that I was Bipolar 2 because of all the serious depression I had. I had some type of symptom at some level of depth, for roughly 80% of my life. Never had anything of a psychotic nature happen.

    Okay, a Gemini so once I get going.. God Bless You and Agape Love

    • Hi, @God_Loves_You2,

      Just to let you know, psychosis is not a requirement for bipolar 1. I hope you’re getting some help now. Thanks for the comment.

      – Natasha Tracy