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Bipolar mixed states: still mixed up?

Castle, David J.

Current Opinion in Psychiatry: January 2014 - Volume 27 - Issue 1 - p 38–42
doi: 10.1097/YCO.0000000000000029
MOOD AND ANXIETY DISORDERS: Edited by Cornelius Katona and Gordon Parker

Purpose of review To provide an update regarding the nosological status of, and treatments for, bipolar mixed states.

Recent findings Mixed states are increasingly recognized as relatively common. The nosological approach in DSM-5 reflects a more liberal application of a mixed states specifier to either the depressed or manic pole of bipolar disorder. The presence of mixed features is associated with a worse clinical course and higher rates of comorbidities including substance abuse. There is ongoing debate about the role of antidepressants in the evolution of such states, but there is increasing consensus that the presence of mixed features should preclude the use of antidepressants.

Summary Clinical vigilance and careful evaluation are required to ensure mixed states are not missed in the clinical context. Atypical antipsychotics are emerging as the medications of choice in the pharmacological management of mixed states. Furthermore, research is required into the aetiogenesis and effective treatment of mixed states.

Correspondence to Professor David J. Castle, Chair of Psychiatry, St Vincent's Hospital and The University of Melbourne, PO Box 2900, Fitzroy, 3065, Australia. Tel: +61 3 92884751; fax: +61 3 92884802; e-mail:

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins