Bipolar disorders are a group of disorders characterised by episodes of mania or hypomania and depression. Concurrent ‘mixed’ episodes of both mania and depression can also be present. For a mixed episode, the latest Diagnostic and Statistical Manual of Mental Disorders (DSM-5) states a requirement of at least three manic/hypomanic symptoms (e.g. elevated mood, inflated self-esteem, decreased sleep, increased energy) occurring nearly every day during a major depressive episode. Alternatively, the presence of at least three symptoms of depression (e.g. depressed mood, diminished interest or pleasure, slowed physical and emotional reaction, fatigue or loss of energy, and recurrent thoughts of death) need to occur nearly every day throughout a manic or hypomanic episode.

What is the evidence for pharmaceutical treatments for mixed states?

High quality evidence suggests a medium-sized effect of improved manic symptoms and a smaller effect of improved depression symptoms with second-generation antipsychotics (with or without adjunctive mood stabilisers) compared to placebo.

November 2021

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