Mixed states in bipolar disorder: modelling, measuring and managing.

OBJECTIVE:: To consider whether consensus exists in recommendations for managing bipolar mixed states published in recent reviews and treatment guidelines, and to summarise what might be their best management.

CONCLUSION:: Limitations to and changes in the definition of mixed states compromise diagnosis and management. The striking comparison between DSM-IV and DSM-5 criteria sets risks under-diagnosis and over-diagnosis. Current reviews and guidelines offer limited evidence to guide treatment; however, management should involve addressing the contribution of any antidepressant medication, and the introduction of a second-generation antipsychotic medication to stabilise the condition.