title: [Pharmacotherapy of manic-depressive mixed States].
abstract: OBJECTIVE
  Mixed episodes comprise up to 40 % of acute bipolar admissions. They are difficult-to-treat, complex clinical pictures. This review provides an overview of the available literature on the pharmacotherapy of manic-depressive mixed states and suggests treatment options.
  
  
  METHODS
  Literature was identified by searches in Medline, Embase and the Cochrane Controlled Trials Register. Studies were considered relevant if they contained the keywords mixed mania, mixed state (s), mixed episode (s), treatment, therapy, study or trial.
  
  
  RESULTS
  Overall, there were very few double-blind, placebo-controlled studies specifically designed to treat manic-depressive mixed states. Rather, patients with mixed states comprised a subgroup of the examined patient cohorts. Nevertheless, the data show that acute mixed states do not respond favourably to lithium. Instead, valproate and olanzapine are drugs of first choice. Carbamazepine may play a role in the prevention of mixed states. Antidepressants should be avoided, because they may worsen intraepisodic mood lability. Lamotrigine may be useful in treating mixed states with predominantly depressive symptoms.
  
  
  CONCLUSIONS
  More treatment studies specifically designed to treat the complex clinical picture of mixed states are clearly needed. Current treatment recommendations for clinical practice based on the available literature can only target selected aspects of these episodes.
authors.affiliation: Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Carl-Gustav Carus, Dresden. stephanie.krueger@uniklinikum-dresden.de
authors.forename: Stephanie
authors.initials: S
authors.lastname: Krüger
authors.forename: Trevor
authors.initials: T
authors.lastname: Young
authors.forename: Peter
authors.initials: P
authors.lastname: Bräunig
mesh_terms: D000927:Anticonvulsants / Q000009:adverse effects / Q000627:therapeutic use*; D018692:Antimanic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D014150:Antipsychotic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D001569:Benzodiazepines / Q000009:adverse effects / Q000627:therapeutic use; D001714:Bipolar Disorder / Q000175:diagnosis / Q000188:drug therapy* / Q000523:psychology; D018849:Controlled Clinical Trials as Topic; D004359:Drug Therapy, Combination; D006801:Humans; D016651:Lithium Carbonate / Q000009:adverse effects / Q000627:therapeutic use*; D000077152:Olanzapine; D017410:Practice Guidelines as Topic; D016896:Treatment Outcome; D014635:Valproic Acid / Q000009:adverse effects / Q000627:therapeutic use*
chemical_list: D000927:Anticonvulsants; D018692:Antimanic Agents; D014150:Antipsychotic Agents; D001569:Benzodiazepines; D016651:Lithium Carbonate; D014635:Valproic Acid; D000077152:Olanzapine