title: 'Bipolar missed states': the diagnosis and clinical salience of bipolar mixed states.
abstract: OBJECTIVE
  To explore diagnostic and treatment issues concerning bipolar mixed states.
  
  
  METHODS
  Bipolar mixed states are described and concerns about diagnostic and treatment difficulties are summarized and discussed.
  
  
  RESULTS
  Mixed states can present with equal admixtures of depressive or manic symptoms, or more commonly one component predominates. There is fair consensus, although little data, regarding the management of manic mixed states. However depressive mixed states are far more complex both in terms of recognition and management. People suffering from mixed states characteristically present with complaints of depression.
  
  
  CONCLUSIONS
  The boundaries between depressive mixed states and agitated depression are vague, yet carry substantial therapeutic implications. Bipolar mixed states are often difficult to treat, and tend to take much longer to settle than either pure mania or depression. Furthermore there is data that treatment with antidepressants can worsen the course of mixed states. Hence missed diagnoses can potentially have negative clinical implications. Therefore in this paper the clinical presentation, diagnosis and therapy of mixed states is reviewed with a view to improving management.
authors.affiliation: Barwon Health and The Geewong Clinic, Swanston Centre, PO Box 281, Geelong, Victoria 3220, Australia. mikebe@barwonhealth.org.au
authors.forename: Michael
authors.initials: M
authors.lastname: Berk
authors.forename: Seetal
authors.initials: S
authors.lastname: Dodd
authors.forename: Gin S
authors.initials: GS
authors.lastname: Malhi
mesh_terms: D000339:Affect; D001714:Bipolar Disorder / Q000175:diagnosis* / Q000453:epidemiology / Q000523:psychology*; D003865:Major Depressive Disorder / Q000175:diagnosis / Q000453:epidemiology / Q000523:psychology; D003937:Diagnosis, Differential; D039721:Diagnostic and Statistical Manual of Mental Disorders; D006801:Humans; D011618:Psychotic Disorders / Q000453:epidemiology