Bipolar Mixed Episode: Common Questions And Answers

Reviewed by Aaron Horn, LMFT

Published 06/24/2022

When many people think, discuss, or read about Bipolar Disorder, they associate it most often with the ups and the downs, the highs and the lows, the activity juxtaposed with the inactivity. Many people who live with the disorder or are close to those that do, do not even know that mixed episodes exist. 

Yet for many people with Bipolar Disorder, the mixed episodes are a substantial part of their struggle. Mixed episodes are sometimes ignored by people, so in this article, information regarding mixed episodes will be broken down into common questions and answers. 

What is a Mixed Episode?

First, we answer the most basic and simple question: What is a Mixed Episode? This definition is much simpler than you might think. 

Mixed episodes are Bipolar episodes in which the symptoms and criteria of both manic and depressive episodes are present every day for at least a week.

The fifth and most current edition of the Diagnostic and Statistical Manual of Mental Disorders (which is used to diagnose mental health issues) uses the term “mixed features” to be applied to depression, hypomania, and mania.

This helped to open up the diagnosing of mixed episodes, by removing the restrictive criteria used in previous editions of the manual.

A mixed episode is not a separate disorder. It describes how Bipolar Disorder can manifest. Similar to the manifestations of mania and depression, mixed episodes have to be severe enough to cause distress or impairment in areas such as the home, friends, education, work, or some other important area of life such as the church. In addition, the disorder is not attributable to other physical conditions, general medical conditions, or substance use such as alcohol, medication, or drugs. 

Simply put, mixed episodes are difficult time periods when a person with Bipolar Disorder’s mood changes rapidly. They show a variety of symptoms and they are struggling with mania and depression at the same time. It can be a daunting emotional roller coaster for those involved because the symptoms are so wide and varied, and they can be damaging as well. 

The best, and really the only way, to describe mixed episodes are to list the symptoms of mania and depression. In order to be diagnosed with mania or depression, a person needs several symptoms lasting over several days. For a mixed episode, many symptoms of both must be present. 

Mania symptoms include: 

  • Elevated, expansive, or irritable mood.
  • Increased energy, agitation.
  • Lessened need for sleep. Energy levels stay similar or are raised despite the lack of sleep in mania. 
  • Forced speech. (Not being able to stop talking.) 
  • Uncontrollable, racing thoughts.
  • Unable to focus.
  • Impulsivity

Depression symptoms include:

  • Depressed mood. This can be defined as a general sadness or emptiness.
  • This is a loss of interest and/or pleasure from activities that were previously enjoyable.
  • Weight loss. This does not include deliberate weight loss. 
  • Sleep problems. This can include insomnia and hypersomnia. 
  • Loss of energy.
  • Loss of concentration.
  • Suicidal thoughts. 

When these symptoms overlap enough, someone with Bipolar can be having a mixed episode. Mixed episodes come with their own set of issues, such as being tiring, emotionally confusing, and difficulty stabilizing their mood. 

Furthermore, if these symptoms feel familiar, you can always take a diagnostic test at Mind Diagnostics. If both sets of symptoms connect with you, a mixed episode is a possibility. Here’s a link to visit:

How Long Do Bipolar Episodes Last?

There is no good answer to this question because it depends on each situation. It could last anywhere from days to weeks to months. It depends on a number of factors such as the severity, the medical treatment undergone, and the actions of the person with Bipolar Disorder.

To officially diagnose mania, a certain set of symptoms must be established for one week (or the patient is severely manic and/or hospitalized within a few days). To officially diagnose depression under the DSM-5, severe symptoms must be present for two weeks. In order to officially diagnose a mixed episode, major symptoms of both mania and depression must be present for a week. 

There is no telling how long a mixed episode could last. With exacerbating conditions and without pursuing treatment, a mixed episode could go on for a long time. The most important thing is to reach out for help from a medical professional, you will be better off and on your way to a sound recovery. Even when the episode is treatment-resistant, there is still reason to hope. 

How Difficult are Mixed Episodes?

There is no good answer to this question.Suffice it to say, mixed episodes can be extremely difficult. However, there is no way of telling whether a mixed episode will be worse than a depressive or manic episode. 

Bipolar Disorder is an incredibly difficult condition to live with. Mixed, manic, or depressed episodes can be extremely hard to handle and even dangerous over a long period of time. This is why it is crucial to seek help.

Who Gets Mixed Episodes?

It is estimated that around 2.6% of people have Bipolar Disorder. Any one of those millions of people can have a mixed episode because mixed episodes are common manifestations of Bipolar Disorder. Bipolar Disorder typically starts in the late teens or mid-20s. It is uncommon to first manifest itself after the age of 50. 

What are the Risks of Mixed Episodes?

The risks of mixed episodes are substantially high. They are similar to the risks of depressive and manic episodes, and mixed episodes combine the risk factors of both. With mixed episodes, someone may miss work by sleeping through their alarm, which would be a depressive episode, and later in the day, they may go on an online spending spree, which would be a symptom of mania/hypomania. 

There is a controversial discussion regarding suicide and mixed episodes. Some research suggests that the confusing emotional roller coaster of mixed episodes can make a person more likely to self-harm. An article published by the National Institute of Health found that there was no evidence of increased risk for mixed episodes over depressive or manic episodes, yet a competing paper found the risk doubled in adolescents for mixed episodes over depressive episodes. Suicide was 5.67 times higher than manic/hypomanic episodes in mixed episodes in adolescents. 

There is no consensus as to the link between suicide and mixed episodes, but there is enough controversy over the danger that people with Bipolar Disorder and their loved ones should be aware ofits risk factors. If you have been experiencing any thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255. The Lifeline is available 24 hours a day, 7 days a week.

How Do I Get Out of a Mixed Episode?

A mixed state is dangerous, as was previously mentioned. It must be a top priority to stabilize a person with mixed Bipolar Disorder right away.

A doctor needs to be involved in stabilizing a full-blown mixed state patient. Some of the most common medications include atypical antipsychotics and different mood stabilizers. With medication compliance, a less stressful environment, and self-care, a person with Bipolar in a mixed state can more quickly stabilize. 

How Do I Avoid Mixed Episodes in the Future?

People who deal with mixed episodes need to know how to prevent them. People with Bipolar Disorder need to work with a doctor, watch out for stress and other triggers, and practice self-care, which can come in the form of therapists, friends, entertainment, exercise, diet, and other healthy habits. 


Mixed episodes are one of the least understood aspects of Bipolar Disorder. Since they are extremely risky, patients, doctors, and loved ones need to be aware of this combination of up and down. On the whole, they are very comparable to hypo/manic and depressive episodes relative to treatment and lifestyle. With the right tools and commitment to treatment, it is possible to enjoy a healthy, fulfilling lifestyle while on the bipolar spectrum.