{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T17:50:54Z","timestamp":1792000254413,"version":"4.4.0"},"reference-count":49,"publisher":"FapUNIFESP (SciELO)","issue":"2","license":[{"start":{"date-parts":[[2019,6,1]],"date-time":"2019-06-01T00:00:00Z","timestamp":1559347200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2019,6,1]],"date-time":"2019-06-01T00:00:00Z","timestamp":1559347200000},"content-version":"am","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2019,6,1]],"date-time":"2019-06-01T00:00:00Z","timestamp":1559347200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Trends Psychiatry Psychother."],"abstract":"<jats:p>Abstract  Introduction  The objective of this study was to identify whether mixed states in bipolar disorder (BD) are associated with more frequent suicidal behavior when compared to manic\/hypomanic and depressive episodes.  Method  We performed a systematic search of the scientific literature on the subject using the PubMed, ISI Web Of Science, PsycINFO and SciELO databases. The terms chosen for the search were (bipolar) AND (suicid*) AND (mixed). We selected original studies comparing suicidal behavior of patients in mixed states and suicidal behavior of patients in other BD phases.  Results  Sixteen papers fit the selection criteria. Twelve of the original 16 studies compared suicidal behavior in mixed states and pure mania, and the majority of these studies (n = 11) revealed that suicidal behavior was more frequent among individuals in mixed states. Five of the papers compared suicidal behavior between depressive and mixed phases of BD. One of these five papers reported more severe suicidal behavior in patients in mixed states and another described more frequent suicidal behavior in patients with pure depression. There were no significant statistical differences between groups in the remaining three of these five studies.  Conclusion  During acute BD episodes, suicidal behavior is more strongly associated with mixed states than with pure mania or hypomania. However, it was not possible to demonstrate that the association between suicidal behavior and mixed states is stronger than the association between suicidal behavior and depressive phases. The results hereby presented are worth considering in clinical practice to better evaluate suicide risk and to prevent suicide.<\/jats:p>","DOI":"10.1590\/2237-6089-2018-0042","type":"journal-article","created":{"date-parts":[[2019,7,6]],"date-time":"2019-07-06T15:31:47Z","timestamp":1562427107000},"page":"191-200","source":"Crossref","is-referenced-by-count":16,"title":["Mixed states and suicidal behavior: a systematic review"],"prefix":"10.1590","volume":"41","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2447-3921","authenticated-orcid":false,"given":"Renata Reis","family":"Lage","sequence":"first","affiliation":[{"name":"Universidade Federal do Rio de Janeiro,  Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cristina M. T.","family":"Santana","sequence":"additional","affiliation":[{"name":"Universidade Federal do Rio de Janeiro,  Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio Egidio","family":"Nardi","sequence":"additional","affiliation":[{"name":"Universidade Federal do Rio de Janeiro,  Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elie","family":"Cheniaux","sequence":"additional","affiliation":[{"name":"Universidade Federal do Rio de Janeiro,  Brazil; Universidade do Estado do Rio de Janeiro,  Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"530","published-online":{"date-parts":[[2019,6]]},"reference":[{"key":"ref1","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/S0924-977X(03)00076-2","article-title":"Issues in the treatment of bipolar disorder","volume":"13","author":"Kasper S","year":"2003","journal-title":"Eur Neuropsychopharmacol"},{"key":"ref2","series-title":"Manic-depressive insanity and paranoia","author":"Kraepelin E","year":"1921"},{"key":"ref3","first-page":"103","article-title":"Mixed states: a \u201cnew\u201d nosographic entity","volume":"26","author":"Verdolini N","year":"2014","journal-title":"Psychiatr Danub"},{"key":"ref4","doi-asserted-by":"crossref","first-page":"1633","DOI":"10.1176\/ajp.149.12.1633","article-title":"Clinical and research implications of the diagnosis of dysphoric or mixed mania or hypomania","volume":"149","author":"McElroy SL","year":"1992","journal-title":"Am J Psychiatry"},{"key":"ref5","doi-asserted-by":"crossref","first-page":"659","DOI":"10.1016\/S0278-5846(00)00174-3","article-title":"Frequencies of signs and symptoms in mixed and pure episodes of mania: implications for the study of manic episodes","volume":"25","author":"Cassidy F","year":"2001","journal-title":"Prog Neuropsychopharmacol Biol Psychiatry"},{"key":"ref6","doi-asserted-by":"crossref","first-page":"403","DOI":"10.1017\/S0033291799001312","article-title":"Diagnostic 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