For those who get no response, stage three is a two-drug combination of lithium(Drug information on lithium), valproate(Drug information on valproate), an atypical antipsychotic (not two and not clozapine(Drug information on clozapine)), carbamazepine(Drug information on carbamazepine), oxcarbazepine(Drug information on oxcarbazepine) (Trileptal), or a typical antipsychotic.
Stage four includes electroconvulsive therapy or adding clozapine or the combination of lithium, an atypical antipsychotic, and valproate, carbamazepine, or oxcarbazepine.
Controversies about mixed states include gradations of subsyndromal mania or hypomania in depression, she said. "Mixed depression is not operationalized in the DSM but is clinically recognized," she said.
Dr. Suppes defined mixed depression as syndromal depression with intra-episode hypomanic or manic symptoms not meeting DSM criteria.