Bipolar disorder with mixed features: symptoms, treatment and getting help in the UK

Bipolar disorder is a mental health condition in which mood changes are extreme. The NHS describes the main symptom as extreme changes to your mood, with high moods (mania or hypomania) and low moods (depression), usually lasting days or weeks at a time. Most people think of these as separate phases, with a stretch of stable mood in between.

In a mixed state the two poles overlap. The Royal College of Psychiatrists describes it as a mixture of mania and depression: you may feel very depressed but also have the restlessness and overactivity that goes with mania. Bipolar UK uses the terms bipolar with mixed features and mixed state for the same pattern, in which symptoms of depression and mania happen at the same time.

Because the person is low in mood but also driven, agitated or unable to sleep, it can be harder to recognise than a clear manic or depressive episode. Friends and family may see a person who looks busy and wound up, while inside they feel hopeless. This is one reason a specialist assessment matters.

There is no separate NHS symptom list for mixed features, so it helps to know the two sets of symptoms that can be combined. The NHS lists the symptoms of high mood as feeling very happy and excited or very irritable, having a lot of energy and not needing much sleep, racing thoughts, talking fast, impulsivity and overconfidence. Low mood symptoms include feeling sad, losing interest in things, low energy, sleeping too much or too little, feeling worthless or hopeless, and having suicidal thoughts.

In a mixed state, some of each can be present on the same day or even the same hour. For example, racing thoughts and an inability to settle may sit alongside despair, or irritability and restlessness alongside very low self-worth. The Royal College of Psychiatrists notes that when a manic or depressive episode becomes very severe, people may also develop delusional ideas or hallucinations.

• Feeling low or hopeless while also feeling wound up, restless or unable to sit still.

• Racing thoughts or talking fast, together with a sense of worthlessness.

• Needing very little sleep but not feeling rested or well.

• Irritability or agitation that is out of character.

• Impulsive decisions, such as spending, made while feeling very low.

• Thoughts of suicide or self-harm, which need prompt attention.

The NHS says to see a GP if you have extreme changes in your moods that last a long time or affect your everyday life, or if you have been diagnosed with bipolar disorder and treatments are not helping. If you already have a mental health specialist, contact them.

If you have thoughts of suicide or of harming yourself, treat that as urgent. The NHS says that if you have seriously harmed yourself, or feel you may be about to, you should call 999 or go to A&E, and that you can call NHS 111 and choose the mental health option for urgent advice. The NHS also states that a mental health emergency should be taken as seriously as a physical one. If doctors are worried that someone is at risk of self-harm, suicide or harming someone else, the NHS says they may need to stay in hospital or have support from a crisis team at home.

The NHS says it is not known exactly what causes bipolar disorder. You are more likely to have it if a parent, brother or sister has it. Childhood trauma or abuse, a stressful event such as relationship problems, bereavement or money problems, and recreational drugs such as cannabis or cocaine can increase the chances.

The Royal College of Psychiatrists explains that genetic and environmental risk factors interact, that having a parent with a severe mental illness is the strongest known risk factor, and that no single factor causes bipolar disorder. Day to day, the NHS lists stress, not getting enough sleep and being too busy as things that can trigger high and low moods.

The NHS explains that a GP who thinks you may have bipolar disorder or another mental health condition will refer you to a mental health specialist, a psychiatrist. The specialist asks about your moods, behaviour, health and family history. The NHS adds that bipolar disorder can take time to diagnose because it affects everyone differently and the symptoms are similar to other mental health conditions.

Mixed features are identified as part of that assessment, by looking at whether symptoms of both poles are present together. Keeping a mood diary, and asking someone who knows you well to describe what they have seen, can help the specialist build an accurate picture. The Royal College of Psychiatrists also says anyone with bipolar disorder must tell the DVLA, as an episode may mean you have to stop driving for a while.

The NHS says a mental health specialist will work with you on a treatment plan that may include medicines to stabilise your mood and talking therapy such as cognitive behavioural therapy. Some medicines are taken all the time, others only when symptoms get worse, and they can cause side effects that vary from person to person.

For mixed states in particular, the Royal College of Psychiatrists says that in mania and mixed depressive episodes any antidepressant should be stopped, and that haloperidol, olanzapine, quetiapine or risperidone can be used, with lithium added if these do not work well. It says symptoms usually improve within a few days, though full recovery can take several weeks. The decision on which medicine suits you belongs with your psychiatrist.

The NHS suggests keeping a regular routine, getting plenty of sleep, eating a healthy diet, exercising regularly and managing stress. It advises avoiding recreational drugs, smoking, too much alcohol, shift work and very long hours where possible, flying at night or across time zones, and lots of caffeinated drinks.

The Royal College of Psychiatrists encourages learning to recognise the early signs that your mood is shifting so you can get help before a full episode develops, and says a mood diary can help show what helps and what does not. Between episodes some people recover completely, but many do not, so ongoing contact with your GP, psychiatrist and community mental health team is usual. Charities including Bipolar UK, Mind and Rethink Mental Illness offer information, peer support and help for family and carers.

On the NHS, the route runs from the GP to a community mental health team and a consultant psychiatrist, with crisis resolution and home treatment teams available if things become urgent. Lithium and other long-term medicines are usually started by a specialist, after which the GP often takes over prescribing and monitoring.

Some people choose to see a private psychiatrist for a quicker first assessment or a second opinion. The principles of treatment are the same, and shared-care arrangements often mean the GP still does the routine blood monitoring. Whichever route you use, ask who coordinates your care and who to contact if your mood changes quickly.