[ultramar]

There have been some questions lately about mixed episodes, so I thought I'd cut and paste the description from the National Institute of Health (NIH):

Mixed states

In a full-blown mixed episode, criteria are met for a depressive episode and a manic episode nearly every day for at least 1 week (American Psychiatric Association, 1994). However, a mixture of manic and depressed symptoms may occur without reaching full diagnostic criteria. For example, a patient may have racing thoughts, agitation, overactivity and flight of ideas, but feel worthless, guilty and suicidal. The patients with bipolar I disorder who took part in the 12-year longitudinal study mentioned previously spent an average 6% of weeks in a mixed or cycling state (where polarity of episode was changing and symptoms of both were present) (Judd et al., 2002). For patients with bipolar II disorder the proportion was just over 2% (Judd et al., 2003). It is estimated that approximately two thirds of patients will suffer a mixed episode at some point in their illness (Mackin & Young, 2005). A study of 441 patients with bipolar disorder reported that subclinical mixed episodes are common – with 70% of those in a depressed episode showing clinically significant signs of hypomania and 94% of those with mania or hypomania showing significant depressive symptoms (Bauer et al., 2005). Sub-threshold mixed episodes were more than twice as prevalent as threshold mixed episodes. The combination of morbid, depressed affect with overactivity and racing thoughts makes mixed states a particularly dangerous time for people with bipolar disorder.

[Travelinglady]

Thanks for sharing!

[Cocosurviving]

Originally Posted by ultramar

There have been some questions lately about mixed episodes, so I thought I'd cut and paste the description from the National Institute of Health (NIH):

Mixed states

In a full-blown mixed episode, criteria are met for a depressive episode and a manic episode nearly every day for at least 1 week (American Psychiatric Association, 1994). However, a mixture of manic and depressed symptoms may occur without reaching full diagnostic criteria. For example, a patient may have racing thoughts, agitation, overactivity and flight of ideas, but feel worthless, guilty and suicidal. The patients with bipolar I disorder who took part in the 12-year longitudinal study mentioned previously spent an average 6% of weeks in a mixed or cycling state (where polarity of episode was changing and symptoms of both were present) (Judd et al., 2002). For patients with bipolar II disorder the proportion was just over 2% (Judd et al., 2003). It is estimated that approximately two thirds of patients will suffer a mixed episode at some point in their illness (Mackin & Young, 2005). A study of 441 patients with bipolar disorder reported that subclinical mixed episodes are common – with 70% of those in a depressed episode showing clinically significant signs of hypomania and 94% of those with mania or hypomania showing significant depressive symptoms (Bauer et al., 2005). Sub-threshold mixed episodes were more than twice as prevalent as threshold mixed episodes. The combination of morbid, depressed affect with overactivity and racing thoughts makes mixed states a particularly dangerous time for people with bipolar disorder.

Hi Ultramar,
I read the above criteria and have a few questions. I started going through a depressive episode last Oct and it seemed to get better in February (after a med increase Lithium). I was getting out the house more and crying stopped.
In March I started getting depressed again, by April my pdoc started me on Lamictal. I have days were I have energy and motivation. I even put thought into my close and put on make up. I joined s gym. I started back cooking and stopped buying junk food. However a week or two later I started back not practicing good hygiene and don't leave my apt for days at a time. I've canceled appts w/ my T and haven't been to church in 7 weeks. I'm in the process of moving, I was doing really good packing. Now I can't find the motivation to finish the last little bit. I also quick going to the gym. I look forward to laying in the bed and watching tv. I'm more agitated and lose
my cool very easily. I don't know what's going on w/ me. I called my pdoc abt it, I just started 200 MG of Lamictal. She wants to give it a little time. Could this not be depression?

[~Christina]

Thanks Ultra,
I don't think anyone really fits any of that in real life. Because Bipolar is so unique to each person I don't even believe anyones statistics. My Mixed episode are unlike anything my Pdoc or I could even read in a book, Or maybe I am just really really out there . LOL

Coco This is just my opinion , based on reading your threads here, Recently I feel your more in a depressed zone, It's been a while since I have seen a consistant "up" feeling from you. I have seen your struggle. I hope Lamictal pulls you out of it, and If not them maybe a med change will be needed.

I hope you get to feeling better soon

I agree with Christina on this, Coco. Lamictal is a very good mood stabilizer for those who can take it. I couldn't after about 1 year. Even 15 mg would send me into an almost hypomanic state.

The best I've taken in years has been Prozac and diet changes.

If you're experiencing a lot of depression, it could possibly be that the acidic ash of your meds has given you too much acidity in tissues and fluids. You need to talk to your psychiatrist about changes in meds, and in the meantime, you might try a little extra potassium, magnesium, and choline added to your diet. Calcium is also soothing for the nerves.

Some people knowledgeable about foods that cause depression are recommending that fhe following foods will cause depression for some:

1. Wheat
2. Sugar
3. Milk products
4. Too much protein in the diet.

I recommend that you go to some sites such as http://www.Foodswhichcancausedepression.com

That has some really helpful ideas for correcting a diet that lends itself to depression.

In the immediate interim, I would try the "lemon thing" to get the acid residue down to a tolerable level; that and the butter and raisin thing may be able to get you to sleep tonight. (Take the "lemon thing" about 6:00 P.M. and the butter and raisins after you get up once around 2:00 A.M. or so.)

I got your private message and thanks. This is in response to that, in part. If there's anything else, just send me another message. I'll try to respond quickly.

Talk to you later.

Got your second message and tried to respond. Hope you find what
you're looking for, Coco.

Take care.

[ultramar]

Originally Posted by Cocosurviving

Hi Ultramar,
I read the above criteria and have a few questions. I started going through a depressive episode last Oct and it seemed to get better in February (after a med increase Lithium). I was getting out the house more and crying stopped.
In March I started getting depressed again, by April my pdoc started me on Lamictal. I have days were I have energy and motivation. I even put thought into my close and put on make up. I joined s gym. I started back cooking and stopped buying junk food. However a week or two later I started back not practicing good hygiene and don't leave my apt for days at a time. I've canceled appts w/ my T and haven't been to church in 7 weeks. I'm in the process of moving, I was doing really good packing. Now I can't find the motivation to finish the last little bit. I also quick going to the gym. I look forward to laying in the bed and watching tv. I'm more agitated and lose
my cool very easily. I don't know what's going on w/ me. I called my pdoc abt it, I just started 200 MG of Lamictal. She wants to give it a little time. Could this not be depression?

To tell you the truth, even after reading what I posted, I still don't understand mixed episodes really well. But it does say that along with depression you have to also meet criteria for full-blown mania (it was interesting to me, actually, that it seems to say that it has to be mania, not hypomania, which makes it sounds like -technically, anyway- you can't have a mixed episode if you're bipolar II).

So it sounds like you have to be depressed but seriously manic at the same time. You mention agitation, which sounds manic-y, but it sounds like it has to be more than that to 'qualify' as a mixed episode?

I don't know -I think maybe there are symptoms of depression (like agitation, distractibility, etc.) that may seem like a mixed episode thing, when in fact it's all part of depression. Or I could see how depression mixed with anxiety could be mistaken for a mixed episode.

I guess the key is the full blown mania part along with the depression... Depression is complicated, I think there can be many flavors, just maybe not as many meeting criteria as 'mixed' as one might think.

[ultramar]

Originally Posted by Cocosurviving

Hi Ultramar,
I read the above criteria and have a few questions. I started going through a depressive episode last Oct and it seemed to get better in February (after a med increase Lithium). I was getting out the house more and crying stopped.
In March I started getting depressed again, by April my pdoc started me on Lamictal. I have days were I have energy and motivation. I even put thought into my close and put on make up. I joined s gym. I started back cooking and stopped buying junk food. However a week or two later I started back not practicing good hygiene and don't leave my apt for days at a time. I've canceled appts w/ my T and haven't been to church in 7 weeks. I'm in the process of moving, I was doing really good packing. Now I can't find the motivation to finish the last little bit. I also quick going to the gym. I look forward to laying in the bed and watching tv. I'm more agitated and lose
my cool very easily. I don't know what's going on w/ me. I called my pdoc abt it, I just started 200 MG of Lamictal. She wants to give it a little time. Could this not be depression?

Actually, I just re-read it and there's this 'sub-clinical' version where it looks like you wouldn't have to meet full criteria for mania. But doesn't 'sub-clinical' mean not meeting criteria? I'm confused, honestly. Maybe both of us need to ask our pdocs, I'm seriously considering it now.

[Cocosurviving]

Wow---I'm learning a lot. So is mixed only experienced by those with BP 2?
I now understand mixed is mania and depression at the same time. I'm defiantly not experiencing any mania. I had a full blown mania episode before. This is nothing like it at all.

[ultramar]

Originally Posted by Cocosurviving

Hi Ultramar,
I read the above criteria and have a few questions. I started going through a depressive episode last Oct and it seemed to get better in February (after a med increase Lithium). I was getting out the house more and crying stopped.
In March I started getting depressed again, by April my pdoc started me on Lamictal. I have days were I have energy and motivation. I even put thought into my close and put on make up. I joined s gym. I started back cooking and stopped buying junk food. However a week or two later I started back not practicing good hygiene and don't leave my apt for days at a time. I've canceled appts w/ my T and haven't been to church in 7 weeks. I'm in the process of moving, I was doing really good packing. Now I can't find the motivation to finish the last little bit. I also quick going to the gym. I look forward to laying in the bed and watching tv. I'm more agitated and lose
my cool very easily. I don't know what's going on w/ me. I called my pdoc abt it, I just started 200 MG of Lamictal. She wants to give it a little time. Could this not be depression?

Coco, I so hope the higher dose of Lamictal will help, I hate to see you like this Give it a little more time, hold out hope, and if it doesn't work out, surely your pdoc can help you with other options.

I really admire you for doing all of the research you do, trying to find out all you can to fight this -you're very brave, you seem resilient and strong to me, you'll get through it!

[Cocosurviving]

Thank you. I spoke with my pdoc Monday and she asked me to give the new dose 1-1/2 weeks. I'm going to be strong and make it through next week. Thank you for all your help, replying to my inquisitive threads.

[~Christina]

One thing that everyone needs to be mindful of is .... Say....

You can have a irritated angry mood(Manic) and depression and that is considered Mixed.

There are so many variations of mood combos that any Pdoc or T worth a damn can see it and go """" Mixed""""

Coco, Christina hits it pretty succinctly with her observation that it would be easy to
identify "mixed" episodes based on how a person responds at any one time to questions about symptoms he/she experiences.

The best source I've seen on this is Manic-Depressive Illness by Dr. Frederick K. Goodwin and Dr. Kay Redfield Jamison, on pages 44-49. I can't quote their material because their book has copyright laws applicable to the work, so you'll need to read it yourself to get the clearest, most accurate understanding of mixed episodes in
bipolar illness.

What they do suggest is that the mixed episodes are part of the dynamic of bipolar illness and not a distinct and separate form of bipolar illness. They also suggest
that all manic-depressive reactions are mixed types because the symptomatology is never static in the illness. Both phases of hypomania and depression may manifest at the same time and it is in these conditions that mixed episodes are most readily identified as part of the larger spectrum of bipolar illness.

So-oo-o, are you trying to determine if you have "mixed" bipolar illness? My answer would be that you may have episodes of "mixed" hypomanic and depressive states simultaneously that could be identified as "mixed", but it is still part of the larger spectrum of Bipolar Illness, according to these writers.

Just for your information, Bipolar I is distinguised from Bipolar II based on the facts that mania is not full-blown in Bipolar II, but the depression of Bipolar II is deeper and longer-lasting than in Bipolar I. There may not be psychotic breaks in Bipolar II as there are in Bipolar I, but I can imagine after reading Manic-Depressive Illness that "mixed" states occur in both, even in cyclothymic (or prepsychotic) bipolar illness.

It's a very thorough explanation in Dr. Goodwin's and Dr. Jamison's work. If you have the time, your library no doubt has a copy and you can check it out.

Feel better soon; enjoyed talking with you. Am posting a private message now.

Sleep well!

[BipolaRNurse]

I think that's what I'm in right now........couldn't figure out if I was manic OR depressed, because I'm experiencing symptoms of both. I'm agitated, angry, energetic, irritable, can't stop moving or tapping my feet, etc. but I'm also feeling terribly sad and crying every day, and I don't DO that. I feel like I could sooooo flip my cork---I'm definitely sitting on the fence---but I have no intention of doing anything stupid. I couldn't leave my family or friends holding the bag like that......it would be SO unfair to them. I'm just utterly miserable and throwing myself a pity-party is all.

On top of all the other crappy things that have happened recently, I found out today that my health insurance ended a full month before I expected it to. I thought I had all this month to use it. WRONG---it ended on the 30th of last month, even though I wasn't fired till May 2nd. Now I don't even know how I'll be able to see my pdoc on the 31st, unless I can self-pay somehow. And this is not a good time to be unable to see him!!

[~Christina]

Originally Posted by BipolaRNurse

I think that's what I'm in right now........couldn't figure out if I was manic OR depressed, because I'm experiencing symptoms of both. I'm agitated, angry, energetic, irritable, can't stop moving or tapping my feet, etc. but I'm also feeling terribly sad and crying every day, and I don't DO that. I feel like I could sooooo flip my cork---I'm definitely sitting on the fence---but I have no intention of doing anything stupid. I couldn't leave my family or friends holding the bag like that......it would be SO unfair to them. I'm just utterly miserable and throwing myself a pity-party is all.

On top of all the other crappy things that have happened recently, I found out today that my health insurance ended a full month before I expected it to. I thought I had all this month to use it. WRONG---it ended on the 30th of last month, even though I wasn't fired till May 2nd. Now I don't even know how I'll be able to see my pdoc on the 31st, unless I can self-pay somehow. And this is not a good time to be unable to see him!!

Oh damn

Yeah ,you in a mixed right now is not what you needed. Is there a way you can Cobra act your insurance ?.. yeah wicked expensive, I couldn't do.

I'm thinking you should call your Pdoc now and maybe a med tweek would help the mixed hell and you can discuss your situation regarding loss of insurance. You really need to keep seeing him right now with everything that has happened.

Try and be kind to yourself

[BlueInanna]

In CA... If an emp works even 1 day in new month I have to continue their health insurance for that month - got caught in that pickle 5 yrs ago, I consulted an HR attorney. Laws may have changed and may be diff in OR but worth looking into. Really hope u can get insurance.

[BipolaRNurse]

I looked at the COBRA information and found it would cost me over $550 per month just for myself, and I haven't heard a word about my unemployment yet so I'm scared to commit to anything. The company's screwed me over so bad already that I expect them to fight me on UI benefits, even though they said they wouldn't.

Just for the hell of it, I tried getting rate quotes for health insurance online, and most wouldn't even let me get past the part about weight. A couple let me go as far as diabetes and high blood pressure before bringing the hammer down on my application, and then one let me get all the way through the damned thing before saying "Sorry, we cannot insure you at this time".

[UCMATH]

Originally Posted by genetic

Just for your information, Bipolar I is distinguised from Bipolar II based on the facts that mania is not full-blown in Bipolar II, but the depression of Bipolar II is deeper and longer-lasting than in Bipolar I.

I've always been sort of uncomfortable with the way the DSM treats BP I and BP II as separate illnesses.

My pdoc and I are always talking about how I sort of lie somewhere in-between Bipolar I and II. For the most part, I appear to have Bipolar II. My depression lasts for 5 or 6 months every year, and it can get so deep that I have difficulty moving, my thoughts slow, and I become mildly psychotic. I was diagnosed with BP II because of my irritable hypomania, but I had a single full-blown manic episode two years ago and that qualifies me for a BP I diagnosis.

What do you think about the idea that Bipolar Disorder might be more of a spectrum disorder rather than a collection of distinct illnesses?

I think you're right. In past years, I've been diagnosed as Bipolar I, Bipolar II, Cyclothymic, and "you don't need to see a psychiatrist". I'll settle for Bipolar II that has mellowed through the years with careful medication and diet management.

In Manic-Depressive Illness Dr. Goodwin and Dr. Jamison state that Bipolar has a large spectrum of conditions that are dynamic, not static, so therein is the key to all of the various symptoms that occur in probably every episode, I believe.