Mixed states were almost forgotten during the last century and in modern diagnostic criteria of DSMIV and ICD 10 they were characterized as episodes with manic and depressive syndromes simultaneously, described as mixed mania, dysphoric mania or depression during mania. Validation studies investigated various cutoff points, depending on the number of depressive symptoms during manic episodes. There are also growing evidences on the existence of depressive mixed states, already described by Kraepelin; they are characterized by depressive episodes with at least 3 manic symptoms. Data on therapeutics are limited and were derived from clinical studies in manic episodes, which included patients with mixed states. Rapid cycling is defined as the presence of at least 4 distinct affective episodes in a one year period, i.e. manic, hypomanic, depressive or mixed, in the course of the bipolar disorder. Treatment is difficult and includes identification of risk factors, such as hypothyroidism and substance related disorders. In mixed states and rapid cycling antidepressants should be avoided, if possible. In this study we present different clinical forms of mixed states, as well as guidelines for the sequential treatment of mixed states and rapid cycling affective disorders, according to existing evidences in the literature.
Bipolar disorder; mixed states; rapid cycling; clinical presentation; treatment; guidelines
