Antimanic treatments in bipolar mixed states

Introduction: Mixed states present nosologic and diagnostic challenges with a relative paucity of evidence to guide treatment. Mixed bipolar states are difficult to treat and are associated with a high neuropsychiatric morbidity, a high risk of suicide and a poor outcome. In DSM-5, the definition of mixed episode has been removed (in DSM-IV TR: "juxtaposed full manic and depressive episodes"). Mixed symptoms are captured under a broader concept called "mixed features" that is applied to mania and depression. The classification of mixed states as defined in DSM-5 is less restrictive than in DSM-IV TR and challenges us at methodological and therapeutic levels. Objective: The aim of this paper was to conduct an overview of the literature to ascertain the efficacy of pharmacotherapy of mixed states. Method: A systematic review of the literature was conducted using PubMed. Results: Manic symptoms of mixed episodes seem to show a good response to second generation antipsychotics and to divalproate. There is no evidence of differential efficacy for second generation of antipsychotics (SGAs). Lithium and carbamazepine may be effective in mixed states in monotherapy and perhaps benefit in combination with SGAs as second line. Combination pharmacological treatment of SGAs and mood-stabilizers are common in mixed states. This pattern has the best literature evidence. Conclusions: There is a few evidence to help us to choose the right treatment for patients with mixed state. In light with the DSM 5, more drugs specifically designed to treat mixed state are needed. (C) L'Encephale, Paris, 2013. All rights reserved.