The change in the DSM-5 classification to accommodate a mixed categorical-dimensional concept of affective mixed states represents a challenge for clinicians who may use it as a basis for a corresponding change in management and treatment choices. The medications that are effective in treating mixed states will be reviewed.
Studies on medical treatments of mixed states (mixed mania and mixed depression) will be considered, together with treatment guidelines and with the most relevant critical debates.
Data on the appropriate pharmacological treatment options for mixed states is limited, and guidelines do not usually recommend specific treatments for these clinical conditions. Among the drugs that showed positive effects in mixed mania, valproate may be considered the best candidate among classic mood stabilizers. The second-generation antipsychotics that showed stronger effects in patients with mixed mania are olanzapine, quetiapine, and asenapine. Patients with mixed mania may be treated with the combination of antipsychotics and mood stabilizers. Concerning mixed depression, considerable uncertainty and controversy remain about the use of antidepressants in management of bipolar depression.
Treatment implications of the revised diagnostic construct of the DSM-5 on mixed affective states warrants study with additional clinical studies.