Your mind feels like it's about to explode and your body feels like lead. It’s the energy and agitation of mania and the hopelessness of depression, at the same time. There's a word for it - a mixed episode or mixed state. And it carries some of the highest suicide risk in bipolar disorder.
(A note on terms: the current diagnostic manual calls this "bipolar disorder with mixed features." Most people say "mixed episode or mixed state”.)
If you're in one right now and thinking about suicide, call or text 988 for immediate support or go to the nearest emergency room. Come back and read this later.
If you love someone who is in, or has experienced, a mixed episode, the skills below are the same ones you'll be helping them reach for, and there's a section just for you at the end.
The immediate steps
Calming skills help take the edge off, but they aren't the plan on their own. Action steps that keep you safe are extremely important if the episode intensifies.
An updated safety plan. A safety plan is a short written plan, made ahead of time and ideally with your therapist or prescriber, for getting through a crisis. It usually lists your personal warning signs, things you can do on your own to get through the moment, people and places that help take your mind off things, people you can ask for help, your therapist's and prescriber's numbers along with 988, and steps to make your surroundings safer. If you have one, pull it out and review it now. If you don't, make one with your therapist, or with a friend or family member you trust. The most widely used version, the Stanley-Brown Safety Plan, is free to download here.
Means restriction. Ask someone you trust to hold onto medications, firearms, or anything else you've identified as a risk until this passes.
A same-day call to your prescriber. Ask for an emergency appointment.
What tends to help
The goal is to steady the brain and body without having to directly think about it. If you're agitated, "just relax" is often impossible, because your ability to problem-solve is often offline, and failing at it feeds hopelessness and self-hatred. So start where your body and mind actually are.
Move first, then slow down. If you can't sit, don't try to. Walk, pace a set path, or press your palms hard into a wall. Brief, moderate movement burns off agitation. Skip intense workouts, because they can ramp you up further.
Make the exhale longer than the inhale. Breathe in for about 4 and out for 6 to 8. If counting feels impossible, try a physiological sigh: two short inhales through the nose, then one long exhale.
Hum. A long hum or a low "voo" sound stretches out your exhale and gives your racing mind something to do, which helps when silent breathing turns into rumination.
Use rhythm. Tap your shoulders alternately with crossed arms (the butterfly hug), press your feet down one at a time, or rock slowly. A predictable rhythm gives your nervous system something to settle into.
Use pressure and weight. A weighted blanket, one hand pressing on your chest and one on your belly, or leaning your back firmly against a wall can calm you without asking anything of your mind.
Keep your eyes open and look around. Slowly name what you see, hear, and feel in the room. Keep it short. Long, eyes-closed body scans can pull you deeper into rumination, numbness, or dark thoughts in this state.
Cool your face, gently. Cool water or a cool pack on your face can slow your heart rate. Cool works better than icy, because intense cold can feel like one more assault. If you have a heart condition, a low heart rate, or a history of an eating disorder, check with your doctor before trying this.
Turn everything down. Dim the lights, consider turning off the screens, and find a quieter room with fewer people. Overstimulation feeds mixed-state irritability more than most people expect.
Color inside a pattern. Pick up a pre-printed design (a mandala, a plaid, or any geometric pattern) and fill it in. Studies show that coloring a structured design lowered anxiety more than free drawing did. The pattern gives a racing mind a container, and you don't have to decide what to make.
Draw your breath. Draw a line up the page as you breathe in, then a longer line down as you breathe out. Repeat until the page is full. It turns extended-exhale breathing into something your hands can do.
What to avoid for now
Skip fast or intense breathwork (Wim Hof, breath of fire, holotropic), long silent meditation, and deep emotional processing. Those can wait until you're steadier.
Sleep is the biggest lever
Sleep loss both drives and comes from mixed states. Protecting even a few hours of sleep may do more than any in-the-moment skill. Keep lights-out and your wake time fixed, and tell your prescriber if you aren't sleeping, because they can help with sleep support.
Make it usable before you need it
In a mixed state, it's hard to remember any skill. Pick two or three that work for you and write them on your safety plan, a sheet of paper, in your phone, whatever works, and in your own words. For example: "Hum for 10 breaths. Walk the hallway. Call ___." Practice them when you're only a little activated, so they're already familiar when things get more intense.
How to help someone in a mixed episode
Know what you're looking at. A mixed state can look like irritability, restlessness, pacing, rapid talking, or picking fights, uncontrollable crying, increased substance use, alongside hopelessness or talk of not wanting to be here. It rarely looks "manic" in the happy sense people expect. If you see agitation and despair together, take it seriously.
Safety comes first, and much of it is something you can do. Ask directly about suicidal thoughts. Asking doesn't plant the idea. If they're in immediate danger, call 988 or 911. For more on what to say and do, the National Institute of Mental Health has a one-page tip sheet: 5 Action Steps to Help Someone Having Thoughts of Suicide.
Reach the prescriber. If your person is an adult and hasn't signed a release, the prescriber may not be able to share information with you. They can still receive information from you, so call and tell them what you're seeing.
Don't ask them to relax. That instruction is impossible in this state, and it can feel like one more thing they're failing at. Offer movement instead: "Want to walk with me?" Lower the lights, quiet the room, and reduce the number of people around.
Lend them your calm. Your steadiness can do more than any technique. Keep your voice low and your sentences short. Don't argue with the hopelessness or try to reason them out of it in the moment. That comes later.
Point them to their plan. If they've written down their two or three skills, read the steps aloud with them. You don't have to come up with anything new. If they don't have a safety plan yet, you can make one together once the worst has passed, using the free form linked above.
You're allowed to have limits. Supporting someone through this is exhausting. You can step out of the room, call someone else, or lean on the crisis line yourself.
Before you go
This only scratches the surface. Mixed states look different from person to person, and from one episode to the next in the same person. Some people feel mostly agitated, others mostly despairing, and the balance can shift within a single day. Medications, sleep, substance use, and what's happening in someone's life all shape how an episode unfolds. No single post can account for all of that, which is why the most important tool is a care team that knows you.
If you're living with bipolar disorder, or loving someone who is, you don't have to figure this out alone. I work with people navigating mood disorders, and with the people who love them, in Colorado and California. Get in touch to learn more.
And if you're in crisis right now, call or text 988, or go to your nearest emergency room.
About Amanda
Amanda Rebel, BFA, MA, LMFT, is a licensed therapist in Colorado and California with more than 15 years of clinical experience working with mood disorders. Through her practice, Open Circle Counseling, she blends evidence-based approaches like DBT and Interpersonal and Social Rhythm Therapy (IPSRT) with mind-body and expressive arts work, the focus of her master's training at the California Institute of Integral Studies. She also works with the parents, partners, and loved ones of people living with mood disorders. A former yoga teacher who comes from a long line of theater and creative people, Amanda is a TEDx speaker and has been featured in the Denver Post for her climate therapy work.