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Mixed episodes must meet the criteria for both mania and depression almost every day for at least one week. There is generally a feeling of excitability or agitation concurrent with irritability, depression and trouble sleeping. Mixed episodes are much more common than previously recognized. The mood disturbances are characterized by:

• Being severe enough to cause impairment of functioning in the workplace, in social activities, or in relationships with others
• Requiring hospitalization to prevent harm to the patient as well as to others
• Being accompanied by psychotic features

In addition, the episode must not be related to any other medical condition or be the result of medication side effects or substance abuse.

Mixed episodes may be the most disabling of all since the swings and fluctuations are so rapid and intense. Mixed episodes are associated with a very high risk of suicide.

There are two behavior traits associated with bipolar disorder that may be particularly difficult on patients and their families, namely agitation and suicide ideation.

Agitation

Agitation can occur during any phase of bipolar disorder and when it occurs can significantly impact the person's functioning at all levels as well as relationships with family and friends. During the acute phase of mania, when energy levels are increased and there is less need for sleep, agitation may manifest itself in restless, irritable, or aggressive behavior which can result in significant problems for the bipolar patient since judgment is usually notably impaired. During mixed and depressive states, agitation is associated with fluctuating energy levels and concomitant irritability which can also result in considerable distress for the patient and their family and friends.

Women are as likely as men to exhibit aggressive behavior during states of agitation, however, the pattern of their aggression is different. Whereas men tend to punch, kick and/or use weapons if available, women usually slap and scratch. The pattern of being reasonable and friendly one moment and aggressive or violent the next is common to both men and women.

Children and adolescents also exhibit symptoms of agitation but instead of being related to discreet episodes of mania, mixed, or depressive moods usually found in adults, in children the symptoms, such as irritability, aggression, belligerence, appear to be more diffuse and can be the source of considerable dysfunction.

Suicide Ideation and Bipolar Disorder

Approximately 15-20% of people with bipolar disorder commit suicide. If a person with bipolar disorder speaks of suicide or has thoughts of suicide, it is critical that they be taken seriously and that action is taken immediately to seek help from a professional.

The risk of suicide is thought to be higher earlier in the course of bipolar disorder. In addition, the American Psychiatric Association notes that the overwhelming majority of suicides take place during a depressive episode or during the depressive interval of a mixed episode.

Factors that may place the bipolar patients at higher risk for suicide include:

• Substance abuse
• Psychosis
• Untreated depression
• Discouragement that medications are not working fast enough
• Recovering from depression and the patient realizes what a burden they may have been and how much trouble they have caused