Background: DSM-5 proposes the concept of bipolar disorder with “mixed features ”, which is of great benefit to clinical practice. However, the clinical management of BD with mixed features is more challenging.This investigation examined the prescribing patterns and factors influencing guidelines disconcordance for the acute treatment of bipolar disorder with mixed features in mainland China. Methods:This real-world study enrolled 688 patients with acute bipolar disorder through the National Bipolar Pathway Survey Replication (BIPAS-R). We used CUDOS-M and MINI-M scales based on DSM-5 criteria to improve the sensitivity of screening for bipolar disorder with mixed features. Guideline inconsistency judgments were determined by comparison with the Canadian Network for Mood and Anxiety Treatments(CANMAT) guidelines for treatment recommendations for bipolar disorder with mixed features. Logstic regression was used to analyze the influencing factors of guideline disconcordance. Results: Among 688 cases of acute bipolar disorder, 235 cases (34.2%) were (hypo) mania with mixed features and 213 cases (30.9%) were depression with mixed feature. Without considering the order of treatment, the inconsistency rates of (hypo) mania and depression with mixed features with the guidelines were 29.4% and 55.4%, respectively. (Hypo) mania with mixed features BD-II (OR=0.52; 95% CI 0.29-0.93), age at study entry > 24 years (OR=2.4; 95% CI 1.3-4.3), and the number of episodes > 4 in the past year in depression with mixed features (OR=1.9; 95% CI 1.08-3.6), which increased the risk of treatment disconcordance of guidelines. Conclusions:Our findings suggest that BD with mixed features is more common.