Two separate diagnoses. So how is it you’re seeing symptoms of both depression and bipolar disorder mania at the same time?

It might look like irritability, racing thoughts, or a feeling of inner tension or agitation. At the same time, you might have lost interest in things you previously enjoyed and are persistently sad.

It’s essentially like having a low mood with high levels of energy.

So what does this mean? Is it bipolar disorder or depression?

In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), someone may be described as having “mixed features” if they have symptoms of both depression and mania or hypomania.

Previously this was called mixed episodes and only applied to bipolar disorder. Now, someone can have mixed features in bipolar disorder and depression.

Someone diagnosed with major depressive disorder (MDD) could be described as having mixed features if they’ve had at least 3 symptoms of mania or hypomania during a depressive episode.

This newer addition to the DSM-5 is still a bit controversial.

ConditionDescriptionCan have simultaneous depression & mania?Specifier
Bipolar disorder IMarked by episodes of mania and calm state, euthymia (you-thigh-me-uh), lasting weeks or months. Depression isn’t needed for diagnosis, but possible. Could develop into psychosis.YesMixed features
Bipolar disorder IIMarked by alternating episodes of hypomania, major depression, and euthymia lasting days or weeks. Could develop into psychosis.YesMixed features
Major depressive disorder
(aka clinical depression)
Marked by low mood, loss of interest in daily activities, and despair that lingers throughout the day, almost every day for at least 2 weeks. Can be the most severe form of depression. Could develop into psychosis.YesMixed features

When symptoms of depression occur at the same time as hypomania symptoms, it might look like:

  • racing thoughts
  • inner tension, irritability, or agitation
  • excessive talking
  • unprovoked rage
  • crying spells
  • trouble falling asleep
  • strong emotions

According to 2015 research, mixed features occur in about:

  • 34% of people with bipolar I
  • 33.8% of people with bipolar II
  • 26% of people with MDD

The researchers suggest that mixed features may fit into a continuum — ranging from pure mania to pure depression.

They also note that people who experience mixed features are often younger. Younger folks with mixed features also tend to experience more rapid cycling between depression and mania.

The researchers also found that people of all ages who have mixed features may:

  • encounter greater problems with everyday functioning and substance use
  • be more likely to be unemployed
  • be more likely to have co-occurring heart disease

Major depressive disorder and bipolar disorder are two separate conditions — you can’t be diagnosed with both at the same time. But that’s because diagnostic criteria for bipolar disorder II includes MDD.

Of course, it is possible to be misdiagnosed. It can sometimes be difficult to tell the difference between the two conditions, even for healthcare professionals.

Although the symptoms of depression are often fairly straightforward to spot, it can be more challenging to recognize the symptoms of mania, and particularly hypomania (the less severe form of mania). Plus, someone may be more likely to seek help when experiencing depression than mania.

About 13–20% of people who have MDD with mixed features will eventually meet diagnostic criteria for bipolar disorder I or II.

Misdiagnosis can also happen for other reasons. For example, depression with mixed features can look like depression with borderline personality disorder. Or depression combined with a substance use disorder can resemble hypomania or mania symptoms.

Receiving a misdiagnosis may set back a person’s recovery, since depression and bipolar disorder are typically treated with different medications.

To figure out if you have MDD, bipolar disorder, or another condition altogether, a mental health professional must conduct a thorough evaluation to determine which best fits your symptoms.

Mania in bipolar disorder with mixed features may actually be more common than in bipolar disorder without this specifier.

A 2017 study notes that while about 30% of people with bipolar disorder have recurring episodes of mania, approximately 40% have mania with mixed episodes.

The same research also suggests that mixed states may be linked to an imbalance in the catecholamine-acetylcholine system.

Catecholamines are a type of hormone produced by the adrenal glands. They help the body respond to stress or fear and prepare it for “fight-or-flight” reactions. Hormones of this type include epinephrine (adrenaline), norepinephrine (noradrenaline), and dopamine.

Acetylcholine is a chemical messenger in the brain (aka a neurotransmitter) that plays a role in motivation, learning, and memory.

People with bipolar disorder tend to have repeated episodes of the same type. So those with mixed episodes are likely to keep having more mixed episodes.

The study indicated mixed features in bipolar disorder tend to:

  • lead to more severe outcomes
  • have a more inconsistent treatment response
  • result in more frequent suicide attempts

People experiencing mixed states are usually treated with more than one type of medication. Treatment usually involves atypical antipsychotics and mood stabilizers.

Electroconvulsive therapy (ECT) — a procedure that sends electrical impulses through the brain — is sometimes used in treatment-resistant cases that haven’t responded to medication.

It’s typically only used for severe depression or bipolar disorder with depressive episodes. Though less conventional, some people choose ECT since it’s fast and effective. However, it does come with side effects.

Many people associate bipolar disorder with its highs and lows, and depression as only lows. But mental health is far more complex than that.

We now know that depressive symptoms can happen at the same time as manic symptoms.

If you’re having low moods for days to months, coupled with aggravated energy — despite little to no sleep — don’t hesitate to reach out to a doctor or mental health professional. No matter the condition or symptoms you have, seeking support can help you cope.