When most people think of bipolar disorder, they picture two separate emotional states: the high energy of mania and the deep lows of depression. What often goes unrecognized—even by many people living with bipolar disorder—is that these two states can happen at the same time. This is called a mixed episode, and for many, it can be one of the most confusing and distressing experiences in bipolar disorder.

Mixed episodes aren’t new, but awareness of them is. Let’s talk about what they are, why we’re hearing more about them now, and how to cope if you or someone you love goes through one.

What Is a Mixed Episode?

A mixed episode (or “mixed features”) is when symptoms of mania/hypomania and depression occur together. Instead of being clearly “up” or “down,” the brain is flooded with competing emotional and physical states.

Common signs include:

• Feeling extremely depressed but also restless or energized
• Intense irritability or agitation
• Racing thoughts combined with hopelessness
• Insomnia
• High risk-taking impulses while simultaneously feeling despair
• Waves of anxiety, panic, or emotional overwhelm
• Feeling like your “mind won’t shut off” yet having very low mood

People often describe mixed episodes as “the worst of both worlds.” The energetic drive of mania can fuel impulsive behaviors, while the depressive symptoms can magnify emotional pain. This combination increases the risk of self-harm, substance use, and emotional dysregulation.

Why Are We Just Now Hearing More About Mixed Episodes?

Several reasons:

1. The DSM-5 Updated the Definition

Historically, mixed episodes required meeting full criteria for both mania and depression at the same time, which is actually rare. In 2013, the DSM-5 introduced the specifier “with mixed features,” broadening the definition to include partial symptoms.

This change made it easier for clinicians to recognize and diagnose mixed states.

2. Better Understanding of Bipolar Presentations

Research has shown that mixed symptoms are far more common than previously thought—especially in Bipolar II. Many people who were once misdiagnosed with major depression or anxiety actually had mixed features that were overlooked.

3. Patients Are Becoming More Vocal

Social media, blogs, and support communities have made it easier for people to describe their internal experiences in real time. Many are recognizing, “Oh—this is me,” and seeking accurate diagnosis and treatment.

4. Clinicians Are Asking Better Questions

Therapists and psychiatrists now routinely assess for mixed symptoms—racing thoughts, agitation, sleeplessness—even when a client looks “depressed.”

How to Cope During a Mixed Episode

Mixed episodes can feel unsafe, confusing, and overwhelming. Coping requires a combination of emotional strategies, environmental adjustments, and professional support.

1. Establish a “Safety Plan” Before You Need One

Plan ahead for the times when symptoms feel out of control. Your plan should include:

• A list of grounding skills
• Your support person(s)
• Crisis numbers
• Medications/doses
• A plan for removing substances or anything unsafe

Mixed episodes can escalate quickly—having a plan already prepared protects you.

2. Reduce Stimulation

Because your brain is already overloaded:

• Lower lights
• Avoid loud music or crowds
• Turn off screens earlier
• Step away from conflict

Mixed episodes often come with agitation, so calming your environment helps calm your mind.

3. Grounding + Sensory Regulation

Try:

• Deep pressure (weighted blankets, tight hugs, pressure holds)
• Slow breathing
• Touching cold water or ice
• 5-4-3-2-1 grounding
• Walking outside or moving your body gently

These techniques help regulate the nervous system and slow racing thoughts.

4. Avoid Substances

This is essential. Alcohol, weed, or stimulants don’t just make symptoms worse—they can prolong the episode and increase impulsivity.

5. Keep Sleep Non-Negotiable

Sleep disruption is one of the biggest triggers for mixed states. Even a small loss of sleep can tip the brain into chaos.

Try:

• Strict bedtime routines
• Melatonin (if approved)
• Avoiding naps
• Winding down early
• Limiting caffeine

6. Track Symptoms, but Don’t Obsess

Journaling or using an app helps you catch patterns:

• Early signs
• Triggers
• Responses to medication
• Length and intensity of episodes

The goal is awareness—not perfection.

7. Stay in Contact with Your Treatment Team

Mixed episodes often require medication adjustments—sometimes mood stabilizers, atypical antipsychotics, or changes in antidepressants.

Reach out early. You don’t need to “wait and see” when symptoms are mixed.

8. Bring Compassion Instead of Judgment

Mixed episodes are not a sign of weakness, bad choices, or lack of willpower. They are neurological events.

Remind yourself:

• “This isn’t my fault.”
• “This will pass.”
• “My brain is overwhelmed—not broken.”

Shame only intensifies symptoms.

When to Seek Immediate Help

Go to urgent care or call crisis support if you experience:

• Suicidal thoughts
• Feeling unsafe with impulsive urges
• Inability to sleep for 48+ hours
• Extreme agitation
• Hallucinations or paranoia

Mixed episodes can shift rapidly, so early intervention is protective.

Final Thoughts

Mixed episodes are finally gaining the recognition they deserve—not because they’re new, but because we’re getting better at naming what many people have always experienced. Understanding these episodes can bring tremendous relief:

You aren’t imagining it, and you aren’t alone.

With the right tools, treatment, and support system, mixed states become manageable—and people with bipolar disorder can absolutely live full, stable, meaningful lives.

Check out our new course page and our brand new course Bipolar Disorder 101

By Katherine Boulware, LMFT