mixed features

Mixed features, sometimes referred to as mixed states or mixed episodes, can be a feature of both Bipolar I or II disorder.  Mixed features are defined when symptoms of the other type of mood episode occur within the context of another primary mood episode.  This can happen during either a manic or hypomanic episode (where symptoms of depression are experienced at the same time), or during a depression episode (where symptoms of hypomania or mania are experienced at the same time).

An abbreviated list of the manic or hypomanic episode, with mixed features criteria according to the DSM-5-TR is below:

A.  Full criteria of a manic or hypomanic episode are met along with at least 3 of the following symptoms (most days).

1. Prominent depressed mood

2. Diminished interest or pleasure in activities

3. Psychomotor retardation (walking or moving more slowly than usual)

4. Fatigue or loss of energy

5. Feeling worthless or guilty

6. Recurrent thoughts of death, suicidal ideation, planning or attempts.

B.  The mixed symptoms are observable to others and represent a change from usual.

C.  If criteria for a full episode of both mania and a depression episode are met, the diagnosis is ‘manic episode,    with mixed features’

D.  The episode is not caused by drugs or another medical condition.

An abbreviated list of a Depressive episode, with mixed features criteria according to the DSM-5-TR is below:

A.   Full criteria of a depression episode are met along with at least 3 of the following symptoms (most days).

1. Elevated or expansive mood

2. Inflated self-esteem

3. More talkative than usual

4. Flight of ideas or racing thoughts

5. Increase in energy or goal-directed activity

6. Increased involvement in activities that have negative consequences (eg buying sprees)

7. Decreased need for sleep (feeling rested after only a few hours of sleep)

B.  The mixed symptoms are observable to others and represent a change from usual.

C.  If criteria for a full episode of both mania and a depression episode are met, the diagnosis is ‘manic episode, with mixed features’

D.  The episode is not caused by drugs or another medical condition.

Mixed symptoms

Mixed symptoms are common for people living with bipolar disorder with around 33% reporting these, regardless of bipolar subtype.  They are found more often in bipolar disorder compared to unipolar depression, however, mixed symptoms for those with unipolar depression may lead to a later diagnosis of bipolar disorder. 

Mixed symptoms and features are often experienced differently to single mood episode types and can be associated with greater suicidal behaviour and instability.  Some report that these can have a greater impact on quality of life and that these symptoms last longer compared to other types of episodes.

Although the criteria list a broad range of symptoms, many people report the presence of certain types of symptoms when describing mixed features more often than others. For example, within a depression episode people report mania symptoms such as racing thoughts or an increase in energy which can be expressed as agitation.  Within a manic episode, people report depression symptoms such as feeling worthless or guilty, persistent negative thoughts and recurrent thoughts of death or suicide.

Treatment

Treatment of mixed features is complex as symptoms may worsen with certain types of treatment.  Guidelines for the treatment of bipolar disorder are published by the Royal Australians and New Zealand College of Psychiatrists (https://www.ranzcp.org/clinical-guidelines-publications/clinical-guidelines-publications-library/mood-disorders-cpg).

These guidelines cover a range of areas and treatment types, but updated advice is required from your medical practitioner.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Grasso, V., Hernandorena, C., Dines, M., Tondo, L., Baldessarini, R. J., & Vázquez, G. (2025). Mixed features in depressive and bipolar disorders: An updated systematic review. Journal of Affective Disorders, 120929.

Tondo, L., Vazquez, G. H., & Baldessarini, R. J. (2020). Suicidal behavior associated with mixed features in major mood disorders. Psychiatric Clinics, 43(1), 83-93.