A clinical study comparing manic and mixed
episodes in patients with bipolar disorder
Estudo clínico comparativo entre episódios de mania
e mistos em pacientes com transtorno bipolar
Ângela Maria Schwartzmann,1 José Antonio Amaral,1 Cilly Issler,1
Sheila C Caetano,1,2 Renata S Tamada,1 Karla Mathias de Almeida,1
Marcia Brito de Macedo Soares,1 Rodrigo da Silva Dias,1,3
Objective: Mixed episodes have been described as more severe than manic episodes, especially due to their longer duration and
their association with higher rates of suicide attempts, hospitalization and psychotic symptoms. The purpose of this study was to
compare the severity between mixed and pure manic episodes according to DSM-IV criteria, through the evaluation of
sociodemographic data and clinical characteristics. Method: Twenty-nine bipolar I patients presenting acute mixed episodes
were compared to 20 bipolar I patients with acute manic episodes according to DSM-IV criteria. We analyzed (cross-sectionally)
episode length, presence of psychotic symptoms, frequency of suicide attempts and hospitalization, Young Mania Rating Scale
scores, Hamilton Depression Rating Scale scores and the Clinical Global Assessment Scale scores. Results: Young Mania Rating
Scale scores were higher in manic episodes than in mixed episodes. There were no differences in gender frequency, CGI scores
and rates of hospitalization, suicide attempts and psychotic symptoms, when mixed and manic episodes where compared.
Patients with mixed episodes were younger. Conclusion: In our sample, mixed states occurred at an earlier age than manic
episodes. Contrary to previous reports, we did not find significant differences between manic and mixed episodes regarding
severity of symptomatology, except for manic symptoms ratings, which were higher in acute manic patients. In part, this may be
explained by the different criteria adopted on previous studies.
Descriptors: Comparative study; Psychotic disorders; Bipolar disorder; Suicide, attempt; Hospitalization
Objetivo: Estados mistos têm sido descritos como mais graves que episódios de mania, especialmente pela maior duração dos
episódios, maiores taxas de suicídio, hospitalização e sintomas psicóticos. O objetivo deste estudo foi comparar a severidade entre
episódios mistos e mania pura definidos segundo critérios do DSM-IV, avaliando-se características clínicas e sociodemográficas
dos pacientes. Método: Vinte e nove pacientes bipolares do tipo I em estado misto foram comparados a 20 pacientes bipolares
do tipo I em episódio de mania aguda de acordo com os critérios do DSM-IV. Analisou-se transversalmente a duração dos
episódios, presença de sintomas psicóticos, tentativa de suicídio, hospitalização, escores da Escala de Sintomas de Mania de
Young, escores da Escala de Depressão de Hamilton e Escala de Avaliação Clínica Global. Resultados: As pontuações na escala
de avaliação de mania de Young foram maiores nos episódios de mania quando comparadas às de episódios mistos. Não houve
diferença estatisticamente significativa na freqüência de gêneros, nas pontuações da CGI, nas taxas de hospitalização, tentativa
de suicídio e sintomas psicóticos entre episódios mistos e de mania. Pacientes com episódio agudo misto tinham idade menor
que pacientes em episódio agudo de mania. Conclusão: Em nossa amostra, episódios mistos ocorreram em idade menor que em
episódios de mania. Ao contrário da literatura, não houve diferenças significativas entre episódios de mania e mistos no que se
refere à severidade da sintomatologia, exceto para a pontuação de sintomas de mania, que foi maior em pacientes em mania
aguda. Isto pode ser explicado, em parte, pela diferença nos critérios adotados por estudos anteriores.
Descritores: Estudo comparativo; Transtornos psicóticos; Transtorno bipolar; Tentativa de suicídio; Hospitalização
1Bipolar Disorder Research Program (PROMAN), Institute of Psychiatry, Department of Psychiatry, Universidade de São Paulo Medical
School, São Paulo (SP), Brazil
2Department of Psychiatry, University of Texas, Health Science Center, San Antonio (TX), USA
3Massachusetts General Hospital, Harvard Medical School, Boston (MA), USA
4Department of Psychiatry, Universidade de São Paulo Medical School, São Paulo (SP), Brazil
Rev Bras Psiquiatr. 2007;29(2):130-3
Cristiana C Rocca,1 Beny Lafer1,4
Conflict of interest: None
Submitted: April 10, 2006
Accepted: October 6, 2006
Ângela Maria Schwartzmann
Projeto de Assistência e Pesquisa em Transtorno Bipolar
(PROMAN) do Instituto de Psiquiatria do Hospital das Clínicas da
Faculdade de Medicina da Universidade de São Paulo
Rua Ovídio Pires de Campos, 785
05003-010, São Paulo, SP , Brazil
Rev Bras Psiquiatr. 2007;29(2):130-3
Manic and mixed episodes in bipolar disorder’s patients 131
In bipolar patients, mixed states have been reported to be
more severe than manic episodes.1-2 Mixed states have been
reported to be associated with longer episode length,3 higher
frequency of hospitalization2 and psychotic symptoms2,4 when
compared to pure manic episodes. More specifically, the
occurrence of suicide attempts have been found to be higher
among patients during mixed episodes in most studies that
compared them to patients during manic states.5-8
The few comparative studies regarding manic and mixed
states have used different diagnostic criteria. DSM-III-R mixed
episode criteria9 are as strict as DSM-IV criteria10 regarding
the number of depressive symptoms necessary for defining a
mixed episode (at least five depressive symptoms). However,
DSM-II-R and DSM-IV are more restrict than Cincinnati
criteria,11 which accept at least two depressive symptoms.
When mixed episodes are defined by broad criteria, differences
between the two types of episodes tend to diminish.8,12
Using broad criteria for mixed states, Akiskal et al.13 reported
that suicidal ideation and depressive mood are more frequent
in mixed episodes when compared to manic episodes. Irritability
has been found to be more frequent than depressive mood in
mixed episodes.4,12 Dell’Osso et al.14 observed lower latency
for hospitalization, more incongruent psychotic symptoms, and
tendency to longer episodes in patients with history of mixed
episodes compared to the ones without these episodes, they
found no differences in CGI scores between the two groups.
Regarding manic symptoms, data are not uniform and
different scales have been used: Swann et al. showed higher
global rates of mania in non-treated inpatient adults with mixed
episodes compared with patients with pure mania.15 However,
they applied a scale rarely used by other authors (Affective
Disorders Scale [ADRS], Murphy et al.). Baker et al. described
higher Young Mania Rating Scale (YMRS) scores in a large
sample of patients with mixed episodes.16 On the other hand,
McElroy et al. found similar YMRS scores in manic and mixed
episodes, using the Cincinnati or the DSM-III-R definition in
patients who aged above 12 years.8
Mixed episodes are more frequent in adolescents than in
adults.17-18 Nonetheless, patients in mixed episodes were not
found to be younger than patients in mania.3,8,12
We compared sociodemographic and clinical data of DSM-
IV bipolar patients with manic and mixed episodes. We
hypothesized that patients with mixed episodes defined by
DSM-IV criteria would have episodes with greater severity
than patients with manic episodes. Younger age at index
episodes, higher occurrence of psychotic symptoms, suicide
attempts and hospitalizations were considered indicators of
We studied outpatients who have been followed up in average
for five years at the Bipolar Research Program at the Institute
of Psychiatry, Universidade de São Paulo Medical School. The
study was approved by the ethical review committee of the
University Hospital. Written consent was obtained from all
patients when in euthymia. Patients were diagnosed with bipolar
disorder type I using the SCID-I/P (Structured Clinical Interview
for DSM-IV)19 and were assessed using the Young Mania Rating
Scale (YMRS),20 Hamilton Depression Rating Scale-31 items
(HAM-D),21 and the Clinical Global Assessment Scale (CGI).22
These scales have been used in the literature as severity
parameters by McElroy et al. and Baker et al., among others.8,16
We selected bipolar patients that met DSM-IV criteria for acute
mania, presented YMRS scores equal or higher than twelve
during follow-up, and did not present mixed episodes in their
past clinical history. The DSM-IV criteria for mixed episode
were used. For each patient, the first mixed or manic episode
during follow-up that met these criteria was considered the
index episode. Only one episode was analyzed per patient.
We also collected sociodemographic and clinical data such
as age at index episodes, gender, and presence of psychotic
symptoms, suicide attempts and hospitalization, the last three
used in the literature as severity parameters.8,14 This was a
transversal study, based on data stored at each patient visit.
1. Statistic analysis
We applied the Kolmogorov-Smirnov test to ascertain if the
distribution of the collected data was normal. Mean scores
were compared using Student’s t-test or the Mann-Whitney U
test. We used the Chi-square or the Fisher’s Exact test for
Sociodemographic data are presented in Table 1. Mean age
at the index episode was significantly lower in patients in mixed
episode compared to manic patients. Mixed state and manic
groups did not differ in gender frequency.
2. Clinical data
Clinical data are displayed in Table 2. Manic patients had
significantly higher YMRS scores than patients in mixed episode
(p < 0.001). Manic and mixed episodes had no statistically
significant differences regarding episode length, presence of
psychotic symptoms, suicide attempts and hospitalizations.
The following manic symptoms were significantly more frequent
in manic episodes in comparison to mixed episodes: distractibility
and racing thoughts, decreased need of sleep, lack of care with
appearance, and lack of insight. There was no difference in the
presence of irritability between mixed and manic episodes.
As expected, HAM-D scores were higher in patients in mixed
episode compared to the ones in mania (Mean = 20.0,
132 Schwartzmann AM et al.
Rev Bras Psiquiatr. 2007;29(2):130-3
SD = 1.4, versus Mean = 2.7, SD = 0.7; p = 0.001). The
main depressive symptoms in mixed episodes were insomnia,
depressive mood, decrease in general activities including
entertaining activities, somatic symptoms of anxiety, suicide
ideation and guilt feelings.
Age at index episodes was significantly lower in patients in
mixed episode compared to manic patients. Our results are in
disagreement with other studies that have included
inpatients.3,8,14 However, Dilsaver et al.4 studied mixed states
according to DSM-III-R in out and inpatients and reported
findings similar to ours. Himmelhoch and Garfinkel17 have
also noticed that mixed episodes occur at an earlier age. A
younger age at the index episode can be considered as a severity
marker, as the probability of a new episode is higher.12
We found similar gender frequencies in mixed and manic
episodes, which is in agreement with the report from Perugi
et al. who used DSM-III-R or Cincinnati criteria, the last
requiring a smaller number of depressive symptoms for mixed
episodes.3 These findings were different from McElroy et al.’s,
who have described a higher prevalence of women according
to DSM-III-R criteria but not when Cincinnati Criteria were
used, suggesting that women present more depressive
symptoms during mixed episodes.8 These conflicting results
can be attributed to different methodologies used in the
discrimination of the episodes. Our sample had a greater
percentage of women and we did not detect a higher
predominance of women with mixed episodes as described in
Length of mixed and manic episodes was similar to McElroy
et al., but different from Dell’Osso et al. and Perugi et al.,
probably because our patients presented good adherence to
treatment and were using mood stabilizers previously to the
index episodes, avoiding a recrudescence of both episodes.3,8,14
The rate of psychotic symptoms was similar between groups,
which has also been observed by Swann et al., but not by
Dilsaver et al.4,12 Rate of hospitalizations was similar to those
found by McElroy et al. but different from Post et al.2,8 Rate of
suicide attempts during episodes was similar to Swann et al.
and in disagreement with the results of Dilsaver et al.5,12 The
absence of differences between groups in these variables can
be due to medication use and prompt access to treatment in
Scores on YMRS found in this study were higher in manic
episodes than in mixed episodes, similarly to Swann et al.’s
findings. However, YMRS scores found in this study were
smaller than in Baker et al.’s study, in which patients were
free of medications before evaluation. Our results differed from
McElroy et al.’s whose scores were similar between groups of
patients with manic and mixed episodes.8,15-16 As stated before,
some studies show that manic patients have higher manic
scores than patients with mixed episodes. A possible explanation
for this is that patients in mixed episode may seek for treatment
earlier than manic patients due to the presence of more severe
depressive symptoms. The YMRS scores were relatively low in
manic patients, including patients with psychotic symptoms.
In a separate analysis, manic patients with psychotic symptoms
scored significantly higher than manic patients without
psychotic symptoms. CGI scores were similar between manic
and patients in mixed episode.14 These results are in
disagreement with previous reports that mixed episodes are
more severe than manic episodes.2
Depressive mood and insomnia were the two most common
depressive symptoms in mixed episodes, differently from the
report from Akiskal et al.,13 who observed a higher occurrence
of depressive mood and suicide ideation. Irritability was equally
present in both groups, differing from some authors’ findings
who reported irritability to be more frequent in mixed episodes.24
In this study, there were no significant differences between
manic and mixed episodes regarding severity of the episodes,
except for manic symptoms severity scores. A possible
explanation is that manic patients present less suffering than
patients with depressive symptoms, and probably look for
treatment later on than patients in mixed episode.25 This delay
would imply in higher manic scores in the patients with pure
mania. Despite the relatively smaller YMRS scores in mixed
episodes, we found that patients with mixed episodes and
psychotic symptoms had higher manic symptoms scores
compared to patients with mixed episodes and no psychotic
symptoms (M = 19.56, SD = 5.46, versus M = 14.02,
SD = 2.3, p = 0.003, Mann-Whitney). We found large
confidence intervals, what signalizes a possible type I error.
To reduce this effect we would have had to significantly
increase our sample, and this was not possible because we
began the study with a defined number of patients. Our criteria
were stricter than the ones used in other studies (Cincinatti
criteria which require less depressive symptoms,11 or Perugi’s
criteria3 which require less symptoms and a shorter period of
presentation). We observed a low frequency of suicide attempts
and hospitalizations, probably because the majority of patients
were under treatment. These low frequencies can lead to a
higher probability of a type II error than previously estimated.
The results of this study do not support our initial hypothesis
that mixed episodes are more severe than manic. This can be
due to: the small sample size (which in part can be attributed
to the methodology used); and to the use of medications that
diminished the severity of the episodes. An analysis of the
efficacy of therapeutic regimes was not included among our
objectives due to our dependence on the patients’ ability to
recall previous treatments and their difficulty to distinguish
antidepressants from other specific medications.
To our knowledge, this is the first controlled study analyzing
Brazilian bipolar patients during mixed states. Despite the caveats
described above, our results do not indicate that mixed episodes are
more severe than manic ones. Future studies should evaluate whether
the DSM-IV criteria for mixed states are the most appropriate one
when comparisons with pure mania are conducted.
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