a Institute of Neuroscience , Newcastle University , Newcastle upon Tyne , UK.
b Paracelsus Medical University , Nuremberg , Germany.
World J Biol Psychiatry. 2018 Feb;19(1):2-58. doi: 10.1080/15622975.2017.1384850. Epub 2017 Nov 3.
Although clinically highly relevant, the recognition and treatment of bipolar mixed states has played only an underpart in recent guidelines. This WFSBP guideline has been developed to supply a systematic overview of all scientific evidence pertaining to the acute and long-term treatment of bipolar mixed states in adults.
Material used for these guidelines is based on a systematic literature search using various data bases. Their scientific rigour was categorised into six levels of evidence (A-F), and different grades of recommendation to ensure practicability were assigned. We examined data pertaining to the acute treatment of manic and depressive symptoms in bipolar mixed patients, as well as data pertaining to the prevention of mixed recurrences after an index episode of any type, or recurrence of any type after a mixed index episode.
Manic symptoms in bipolar mixed states appeared responsive to treatment with several atypical antipsychotics, the best evidence resting with olanzapine. For depressive symptoms, addition of ziprasidone to treatment as usual may be beneficial; however, the evidence base is much more limited than for the treatment of manic symptoms. Besides olanzapine and quetiapine, valproate and lithium should also be considered for recurrence prevention.
The concept of mixed states changed over time, and recently became much more comprehensive with the release of DSM-5. As a consequence, studies in bipolar mixed patients targeted slightly different bipolar subpopulations. In addition, trial designs in acute and maintenance treatment also advanced in recent years in response to regulatory demands.
Current treatment recommendations are still based on limited evidence, and there is a clear demand for confirmative studies adopting the DSM-5 specifier with mixed features concept.
尽管双相混合状态在临床上具有高度相关性，但在最近的指南中，其识别和治疗仅占很小的比重。本 WFSBP 指南旨在提供有关成人双相混合状态急性和长期治疗的所有科学证据的系统概述。
这些指南中使用的材料基于使用各种数据库进行的系统文献检索。他们的科学严谨性被分为六个证据等级（A-F），并分配了不同级别的推荐以确保实用性。我们检查了有关双相混合患者急性治疗躁狂和抑郁症状的数据，以及有关预防任何类型首发混合发作后混合复发或任何类型首发混合发作后复发的数据。
双相混合状态的躁狂症状似乎对几种非典型抗精神病药物的治疗有反应，最好的证据是奥氮平。对于抑郁症状，在常规治疗上加用齐拉西酮可能有益；然而，证据基础比治疗躁狂症状要有限得多。除了奥氮平和喹硫平，丙戊酸盐和锂也应考虑用于预防复发。
混合状态的概念随着时间的推移而发生变化，并且随着 DSM-5 的发布，最近变得更加全面。因此，针对双相混合患者的研究针对的是略有不同的双相亚群。此外，急性和维持治疗的试验设计近年来也因监管要求而有所改进。
目前的治疗建议仍然基于有限的证据，并且明确需要采用具有混合特征概念的 DSM-5 特定标准的确认性研究。
