Ep. 7: Mixed States and the Bipolar Spectrum: Improving Diagnosis and Treatment Decisions

In this episode of Psychopharmacology Today, Dr. James Phelps explores the diagnostic and treatment challenges associated with bipolar spectrum disorders and mixed mood states. Drawing on decades of clinical experience, he explains why traditional categorical diagnoses (such as unipolar depression versus bipolar disorder) often fail to capture the complexity of real-world presentations. Dr. Phelps introduces the concept of the mood spectrum and highlights the overlapping symptoms between depression, anxiety disorders, ADHD, PTSD, and bipolar mixed states. He emphasizes the importance of evaluating “non-manic markers,” including family history, illness course, and antidepressant response, when determining whether bipolarity may be present. The episode also discusses practical treatment considerations. Dr. Phelps outlines the risks associated with antidepressants in patients with mixed states and reviews alternative strategies, including social rhythm therapy, mood stabilizers such as lamotrigine and low-dose lithium, and the careful tapering of antidepressants. Throughout the discussion, he argues that prescribing psychologists are uniquely positioned to manage these complex cases due to their combined expertise in psychotherapy and medication management. The session concludes with a framework for shared decision-making with patients and a practical approach to stabilizing mood symptoms while navigating diagnostic uncertainty.