Objective：Mixed states are difficult to define precisely and to recognize accurately. Moreover, the DSM-IV criteria for diagnosis of a mixed episode might be too restrictive. The purpose of this study was to investigate the possibility of a mixed episode in bipolar inpatients hospitalized with DSM-IV manic episodes using the Cincinnati criteria, which is a broader criteria compared to DSM-IV. Methods：Inpatient charts of manic patients were carefully evaluated to determine the presence of depressive symptoms in the Cincinnati criteria. The probable mixed patient group was compared with the definitely manic patient group on demographic and clinical variables. The predictability of depressive symptoms for a mixed episode was assessed. Results：Twenty-one out of 101 manic inpatients were possibly diagnosed as mixed episodes. They showed more psychiatric family history, comorbid personality disorder and suicide attempts. Two symptoms (suicidal ideation and helplessness or hopelessness) had good positive predictive value. Conclusion：Diagnosis of a mixed episode can be increased with careful interview and by using a broader diagnostic criteria. The presence of suicidal ideation and helplessness or hopelessness may suggest a mixed state
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