Mr. Jones, 30 years of age, presents to the office for the first time with symptoms of mania. He had gone through a period of increased spending during which he purchased thousands of dollars worth of audio and video equipment in addition to other items he could not afford. He is currently living with his parents due to his inability to meet these financial obligations. When his parents starting receiving packages at their house, they decided to have Mr. Jones evaluated. They note that he is awake much of the night talking on the phone and browsing the Internet. His bills indicate large charges for phone sex and pornography.

Mixed episode is one of the more difficult-to-treat conditions in bipolar disorder. The presence of mixed features (symptoms of both depression and mania in a single acute episode) is associated with both poorer acute treatment response and poorer longitudinal outcomes, including shorter subsequent inter-episode periods and greater suicidality. Mixed features are indicative of an overall greater severity of both acute and chronic illness (Slide 1).

Bipolar disorder is an illness characterized by inherent mood instability that produces a predisposition to depressive, hypomanic, or manic episodes. This predisposition to affective episodes, rather than the episodes themselves (which can have many causes), is arguably the hallmark of bipolar disorder.

Most episodes of bipolar disorder, including the first episode, are depressive. This exposes an inherent flaw in our nosological system, which requires a manic or hypomanic episode for diagnosis of bipolar disorder. Treatment of a depressive episode in undiagnosed bipolar disorder can entail the use of medications that were developed to treat a different disorder (major depressive illness) and that may have mood-destabilizing or activating properties.