Mixed or dysphoric manic states: psychopathology and treatment.

Although the diagnostic criteria for the phenomenon of mixed states are not well defined, it is clear that this variant of bipolar disorder is prevalent, severe, and difficult to treat. The presence of complicating factors, such as substance abuse, neurologic insults or disorders, or developmental disorders, appears to increase the risk for developing mixed states. Several investigators have reported that patients with mixed episodes are less responsive to lithium therapy than are patients with pure mania. This review, however, reports that only limited data are available to support the efficacy of other antimanic agents. Divalproex appears to be more efficacious than lithium for patients in mixed states, but studies with larger patient populations are needed for confirmation. More than one agent may be required to bring about effective treatment, a factor that complicates simple comparator studies. When conventional pharmacotherapy fails, electroshock therapy often proves useful.