What Is A Bipolar Mixed Episode?

Updated May 12, 2023by BetterHelp Editorial Team

Many of us are familiar with the fact that people with bipolar disorder may experience states of mania, hypomania, or depression. One piece of bipolar disorder that often goes overlooked, though, is the possibility for mixed features and episodes that overlap with each other in terms of symptoms. A “mixed episode” may present signs of mania, hypomania, and depression at the same time, which can make determining the best course of action for treatment a challenge. Fortunately, there are steps you can take to prepare for and manage mixed feature episodes effectively.

Do You Experience Signs Of Mixed Feature Bipolar Disorder?

Previously, mental health professionals recognized certain symptoms that can come with bipolar disorder as “mixed episodes.” This terminology has recently been transitioned to the specifier “mixed features,” which can be applied to manic, hypomanic, and depressive episodes. In general, then, a “mixed episode” is typically an affective state where symptoms of mania, depression, or hypomania overlap at the same time.

Mixed Episodes and Mixed Features in the DSM

The Diagnostic and Statistical Manual (DSM-5) is used by mental health professionals as a standard tool for diagnosis of mental health disorders. In its most recent edition, the terminology used to describe mixed features became broader; instead of being classified as its own separate phenomenon, a mixed feature state is now seen as a variation of the intense highs and lows that typically accompany bipolar disorder. A mixed feature episode is detailed as being either of the following:

  • Three or more depressive symptoms during a manic or hypomanic episode

  • Three or more hypomanic or manic symptoms during a major depressive episode

How Prevalent Is Bipolar Disorder With Mixed Features?

Since the DSM-5 has broadened the definition of bipolar disorder episode with mixed features, old statistics have become outdated. However, some studies have explored how many people do have mixed features along with bipolar disorder. 

For example, one study found that 40% of major depressive episodes also included at least one symptom of hypomania. What's more, those in the study who had that experience were more likely to be diagnosed with bipolar disorder later on. While more research needs to be done to get a full picture, doctors and scientists already know that bipolar disorder episodes with mixed features are not necessarily uncommon.

Mixed Affective Episode Symptoms

Bipolar disorder with mixed features typically creates symptoms that fall into the categories of manic, hypomanic, and depressed. However, it's the fact that the opposite symptoms occur together that can indicate mixed features. Here is a list of common symptoms of each type of mood disturbance, followed by a look into how they can show up together.

Manic Symptoms

The following are symptoms commonly associated with bipolar disorder manic episodes.

  • Euphoric or elated mood
  • Grandiosity or overinflated self-esteem
  • Irritability
  • Rapid, excessive, or pressured speech
  • Personality changes
  • Racing thoughts
  • Excessive energy
  • Decreased need for sleep
  • Distractibility
  • Working feverishly towards goals, even if the goals don't make much sense
  • Engaging in risky behaviors and activities

These symptoms must last for at least one week and be present most of each day. Severe symptoms may also lead to hospitalization due to injury, a lack of sleep, and similar concerns.

Hypomanic Symptoms

Hypomanic symptoms often look like a milder version of manic symptoms. In fact, the DSM-5 notes the same symptoms of hypomania as for mania, with a few key differences. Hypomanic symptoms need only be present for 4 consecutive days for diagnosis. Likewise, hypomania typically isn’t severe enough to cause impairment in work or school. It also does not generally lead to hospitalization.

Depressive Symptoms

These symptoms are common in bipolar disorder depressive episodes:

Do You Experience Signs Of Mixed Feature Bipolar Disorder?

  • Intense sadness or numbness
  • Finding little or no pleasure in once-enjoyed activities
  • Weight loss/weight gain
  • Sleeping too much or too little
  • Feeling guilty, even if there is no clear reason
  • Waking up too early
  • Trouble thinking or concentrating

Symptoms must be present during the same two-week period to fit the diagnostic criteria for a depressive episode.

Mixed Features

Any of the above symptoms can be a part of a mixed state caused by bipolar disorder. If you or a loved one experiences characteristic signs of depression, for instance, but also things like impulsivity, a reduced need for sleep, or feelings of sadness, it may be worth noting. Discussing your concerns with a trusted healthcare professional may be the best way to determine what your symptoms may mean and how to best address them.

How Long Do Bipolar Episodes Last?

Bipolar episodes can last for a week, several weeks, or longer. To qualify as a manic episode, the symptoms must be present for at least seven days or be so severe as to require hospitalization. Depressive episodes usually last at least two weeks but can last much longer.

In mixed episode bipolar disorder, emotional states can last a long time. Sometimes, though, they resolve quite quickly or switch to another distinct state (mania, depression, etc.) instead. 

Treatments For Bipolar Disorder With Mixed Features

Mixed bipolar disorder episodes can require specialized treatment. Typically, treatment includes a combination of medications and therapy. When you're being treated for this type of mental health disorder, it's often critical that you work together with your doctor and therapist to get the most from your treatment. That may mean reporting symptoms as soon as possible and discussing the concerns you notice as openly as you can. 

Medications For Bipolar Disorder With Mixed Features

The medications used are often the same medications used for depression or mania. However, your doctor may need to keep a close eye on how things are going and make adjustments as needed. Some medications may work well for those with certain symptoms, but others might be more likely to cause unwanted side effects or exacerbate symptoms.

Examples of medications that can be used for mixed state bipolar disorder are mood stabilizers, which helps diminish mood swings, antidepressants, and antipsychotics. Finding the right combination of medications that can successfully manage symptoms without causing any negative side effects can take time, but for many, this step can be an important part of finding a sense of stability that can make healing possible.

Therapy For Mixed State Bipolar Disorder

Therapy can also help with mixed episodes in bipolar disorder. Talking to a counselor can be a great way to navigate confusing moods, thoughts, and behaviors. It can also help you during times of remission when the symptoms are mild or not present. At those times, you can gain perspective on the course of your disorder and learn better ways to respond when symptoms do arise.

You may find that resources like online therapy can make it especially easy to get the support you deserve. Because you only need an internet connection to attend sessions, online therapy can help you save time and money that might otherwise go to things like gas costs, childcare, and other expenses. 

Research suggests that online therapy can be effective for treating mental health symptoms of all sorts. One 2017 study found that online and smartphone-based treatment options for bipolar disorder could help patients monitor their symptoms, learn more about their diagnosis, and get the support needed to maintain a positive attitude. No matter what sort of mixed symptoms you may have, it’s likely that online therapy can give you the tools you might need to find solutions that can work for you.


Bipolar disorder episodes with mixed features aren’t as uncommon as they may seem, but they can be a bit tricky to identify if you’re not familiar with them. However, with the right treatment, even mixed feature episodes can be managed successfully and efficiently. 

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