Mixed features refers to the presence of high and low symptoms occurring at the same time, or as part of a single episode, in people experiencing an episode of mania or depression. In most forms of bipolar disorder, moods alternate between elevated and depressed over time. A person with mixed features experiences symptoms of both mood “poles” – mania and depression – simultaneously or in rapid sequence.

To review the nosological status of bipolar mixed states and its treatment.

Online search/review of the literature has been carried out, using Medline/Pubmed, concerning “mixed states”, “affective disorder”, “bipolar disorder”.

The presence of depressive symptomatology during acute mania has been termed mixed mania, dysphoric mania, depressive mania or mixed bipolar disorder. Highly prevalent, mixed mania occurs in at least 30% of bipolar patients. Correct diagnosis is a major challenge. The presence of mixed features is associated with a worse clinical course and higher rates of comorbidities. There is ongoing debate about the role of antidepressants in the evolution of such states.

Clinical vigilance and careful evaluation are required to ensure mixed states are not missed in the clinical context. Atypical antipsychotics are emerging as the medications of choice in the pharmacological management of mixed states.

The authors have not supplied their declaration of competing interest.