In bipolar I disorder (BD1), manic episodes with depressive symptoms are generally more severe than pure manic episodes, but are not easily identified. The DSM-5 ‘With Mixed Features’ specifier, and accompanying patient-rated Mini-International Neuropsychiatric Interview (M.I.N.I.) module, were designed to aid diagnosis.

To examine patients with BD1 who have mania with depressive symptoms, across countries.

To improve the identification of depressive symptoms during a BD1 manic episode.

This naturalistic study surveyed psychiatrists and their patients with BD1 (manic episode within previous 3 months), in Germany, Italy, Spain, UK, Turkey, Australia, Brazil and Canada. Psychiatrists provided information on depressive symptoms (DSM-5 ‘With Mixed Features’ specifier plus patient-rated M.I.N.I. module); anxiety, irritability, and agitation; suicide attempts; and treatment response.

Of 1,035 bipolar patients, 34% had mania ‘With Mixed Features’(≥05;3 depressive symptoms), and displayed more severe symptoms, and higher rates of attempted suicide than patients without mixed features. Across countries, severe anxiety occurred in 3.5–19.5% of patients; severe irritability in 4.3–17.0%; and severe agitation in 4.3–19.6%. The proportion of patients experiencing ‘prominent dysphoria or depressed mood’ was highest in Italy (64.2%). Recurrent suicidal ideation ranged from 8.0% (Germany) to 25.7% (Spain); lifetime rate of attempted suicide was highest in Canada (64.7%). Between-country differences were also reflected in the M.I.N.I. module outcomes.

Patients with BD1 ‘With Mixed Features’, suffer from a greater burden of disease than patients with pure mania, and there is variation between countries – as detected by physician and patient evaluations.