Worlds in Collision - Mixed Depression, Mixed Mania

John McManamy Health Guide
  • Two recent shareposts, “The Depression-Mania Two Step” (Part I and Part II ), zeroed in on a crucial fact that tends to be overlooked by clinicians, namely: Despite the fact that depression and mania present as polar opposites, the two can hardly be viewed as unrelated. For our own health and safety, they need to be seen together as part of the same cycling phenomenon.

    Today’s depression is tomorrow’s mania, but there is another twist: Too often, depression fails to clear the room. Too often, mania doesn’t wait to be invited in. The two show up at once. The dance is over. A free-for-all breaks out.

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    The experts refer to the condition as a “mixed” episode or state. Sweet mania turns sour. Vegetative depression becomes animated. Those who have been through either describe the experience as akin to wanting to crawl out of your skin, of feeling the urge to grab the world by the throat and wring it.

    I used to joke: “I get road rage a lot - and I don’t even drive.”

    Amazingly, for a condition so pronounced, that causes so much distress, the DSM-IV is inexcusably vague, and so will its successor, the DSM-5 (due out in 2013), based on draft proposals issued last month. The good news is that the DSM-5’s criteria for a mixed state will be far less restrictive. In light of the fact that in all other respects DSM-IV bipolar and DSM-5 bipolar are virtually identical, this is a very significant development.

    The current DSM recognizes mixed states only when full-blown depression is accompanied by full-blown mania. Thus: at least five (of nine) depression symptoms accompanied by at least four (of seven) mania symptoms. Technically, then, only those with bipolar I qualify.

    But in the real world, individuals may experience depression accompanied by only two or three mania/hypomania symptoms. Or mania with just two or three depression symptoms. Don’t these symptoms somehow count?

    Yes, says Ellen Frank PhD of the University of Pittsburgh. In an interview several years ago, Dr Frank explained to me that “even isolated symptoms that don’t cluster together to create episodes may be important." A 2004 study she collaborated on with Giovanni Cassano MD of the University of Pisa found that just one symptom of mania (the symptom list in the study was much longer and more refined than the DSM list) in unipolar depression increased risk for suicidal ideation 4.2 percent. More symptoms kept upping the risk.

    So what do we do with these so-called unipolars? Treat them as if they had pure depression? According to Hagop Akiskal MD of UCSD, in a journal article, “the nonrecognition of depressive mixed state is nothing short of a clinical tragedy because these are the very ‘unipolar’ depressive patients who are likely to do poorly on antidepressants …”

    These would be your agitated depressions, an unbearable energized psychic pain.

    Looking at it from the mania/hypomania side of the divide: In a 2003 grand rounds lecture at UCLA, Trisha Suppes MD, PhD of Stanford described having an epiphany while reading the DSM criteria for hypomania. "I said, wait, where are all those patients of mine who are hypomanic and say they don’t feel good?"

  • In a study analyzing outpatients experiencing hypomania, she found that 60 percent met her criteria for “dysphoric hypomania.” Think road rage, even if you don’t drive. One reader to my mcmanweb site posted that in a Wal-Mart she just wants to grab her cart and run down other shoppers.

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    Dr Suppes was on the DSM-5 workgroup tasked with updating the bipolar diagnosis, so it’s no surprise that the draft served up a greatly expanded view of mixed states. What we would see, in addition to the current limited view of mixed episode (mania plus depression), is recognition of mania inside depression (a mixed depressive episode) and depression inside mania/hypomania (a mixed manic episode).

    What is not provided for in the DSM-5 is a little bit of mania with a little bit of depression. Often 1/2 plus 1/2 equates to a lot more than one. To act as if nothing is going on is a gross oversight.

    Similarly, it is unclear from the draft whether mixed depression will apply to unipolar depression. The impression is that the DSM-5 is backing away from the suggestion that unipolar depression overlaps with bipolar depression. Hopefully, the DSM-5 will clear the ambiguity (in favor of an overlap) in its next version.

    Now to a major problem: We know what depression is - the DSM provides us with a symptom list. Feeling sad and irrational guilt, for instance. Same with mania. Grandiosity, racing thoughts, and so on. But what does a mixed state look like? Agitation? Energized psychic pain? The DSM-5 needs to spell it out.

    The DSM-5 also needs to find a better way of distinguishing mixed depression from mixed mania than by simply counting symptoms. Does one truly present differently than the other? The DSM-5 isn’t telling us.

    Hopefully, the DSM-5 will encourage clinicians to investigate our mood states more closely, to look for signs of mania inside our depressions, and for signs of depression inside our manias. But we can’t afford to wait till it becomes official in 2013.


    Mixed states are very common. We owe much to the experts, but the best insights (as always) come from you, patients and loved ones. Please let us know what your various mixed states are like or (if a loved one) what it’s like to be on the receiving end of a mixed state. Comments below ...

Published On: March 06, 2010