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Treatment of Mixed Features in Bipolar Disorder: an Updated View


Purpose of Review

Mixed presentations in bipolar disorder have long posed clinical and nosological challenges. The DSM-5 mixed features specifier was developed to provide a more flexible and clinically relevant definition of mixed presentations compared with narrowly defined DSM-IV mixed episodes. However, there is little guidance on treating such presentations. Here, we summarize the evidence for biological treatments of DSM-5 and similarly defined mixed features (MFs).

Recent Findings

The literature on treating MFs is almost exclusively based on post hoc analyses. Within this limited evidence base is preliminary positive data for aripiprazole, asenapine, cariprazine, olanzapine, risperidone, and ziprasidone in treating acute mania with MFs, and cariprazine, lurasidone, olanzapine, and ziprasidone for depressive symptoms in depression with MFs. Divalproex may also be efficacious for acute mania with MFs. The few extant maintenance studies suggest that divalproex and olanzapine may have long-term efficacy in those with index MFs or for the prevention of MFs, respectively.


The existing evidence suggests that clinicians consider atypical antipsychotics and divalproex for treating acute mixed presentations. However, adequately powered treatment trials—and studies of maintenance and neurostimulation therapies—are needed. Additionally, data-driven techniques to identify relevant symptom clusters may help improve our conceptualization of mixed presentations.

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Correspondence to Lakshmi N. Yatham.

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Trisha Chakrabarty and Kamyar Keramatian each declare no potential conflicts of interest.

Lakshmi N. Yatham has received research support from or served as a consultant or speaker for Alkermes, Allergan, CANMAT, CIHR, Dainippon Sumitomo, Janssen, Lundbeck, Otsuka, Sanofi, Sunovion, Teva, and Valeant.

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Chakrabarty, T., Keramatian, K. & Yatham, L.N. Treatment of Mixed Features in Bipolar Disorder: an Updated View. Curr Psychiatry Rep 22, 15 (2020).

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  • Mixed features
  • Mixed episodes
  • Bipolar disorder
  • DSM-5
  • Mood stabilizer
  • Antipsychotic