Diagnosis and treatment strategies for mixed episodes in bipolar disorder

Dr. McIntyre reiterated that the management of acute states begins with clarifying the diagnosis, screening for comorbidity, and establishing therapeutic targets. Patients should be educated as to the likelihood and duration of recovery, and it should be understood that for many patients, combination treatment will be required. Multiple drugs are approved for the treatment of mixed states. The largest body of evidence supports the efficacy of atypical antipsychotics and divalproex. Lithium is suboptimally effective in mixed states, and antidepressants should be avoided due to their unproven efficacy and their association with treatment-emergent mania. Finally, clinicians should consider the use of an algorithm or treatment guideline in order to organize and optimize the care of patients with mixed-state bipolar disorder.