A 60-year-old woman with treatment-resistant depression has been referred for electroconvulsive therapy (ECT) after failing adequate trials of four different antidepressants including augmentation strategies. She has severe depression with psychomotor retardation, significant weight loss, and pervasive guilt. Her family is concerned about potential cognitive side effects of ECT. They ask about factors that might be modified to minimise cognitive adverse effects while maintaining treatment efficacy. Which modification would most effectively reduce cognitive side effects while preserving antidepressant efficacy?

Using unilateral electrode placement on the non-dominant hemisphere rather than bilateral placement

Reducing the electrical dose to just above seizure threshold regardless of electrode placement

Extending the interval between treatments from twice weekly to once weekly throughout the course

Using ultra-brief pulse width stimulation with bilateral electrode placement

Limiting the total number of ECT sessions to a maximum of 6 treatments

A 38-year-old solicitor presents with a 10-week history of low mood, anhedonia, fatigue, and reduced concentration. She describes feeling guilty about her work performance despite no objective evidence of problems. She has prominent anxiety symptoms including worry, restlessness, and muscle tension present most days. Her PHQ-9 is 17 and GAD-7 is 14. She has no past psychiatric history. What is the most appropriate initial pharmacological treatment choice?

Commence sertraline as it effectively treats both depressive and anxiety symptoms

Commence mirtazapine for its combined antidepressant and anxiolytic effects with rapid onset

Commence pregabalin for the generalised anxiety disorder with review to add an antidepressant if depression persists

Commence a low-dose benzodiazepine for anxiety symptoms with an SSRI added after anxiety is controlled

Commence venlafaxine as an SNRI is more effective than SSRIs for mixed anxiety-depression

A 35-year-old woman with panic disorder has been stable on escitalopram 20mg daily for 18 months, remaining panic-free for 12 months. She wishes to discontinue medication as she is planning pregnancy. She previously had severe panic disorder with 8-10 attacks weekly and significant agoraphobic avoidance requiring 6 months off work. She received CBT alongside medication. Which approach to discontinuation carries the optimal balance of minimising withdrawal symptoms while reducing recurrence risk?

Gradually taper over at least 4 weeks while reinstating CBT techniques and monitoring for early signs of recurrence

Discontinue escitalopram abruptly as SSRIs can be safely stopped without tapering due to long half-lives

Reduce by 50% every week for 2 weeks then stop, as escitalopram has relatively low discontinuation syndrome risk

Switch to fluoxetine for 2 weeks before discontinuation due to its longer half-life reducing withdrawal symptoms

Reduce dose by 25% every 2 weeks while commencing a tricyclic antidepressant which is safer in pregnancy

A 52-year-old businessman presents with symptoms of both panic disorder and alcohol dependence. He reports drinking 60-80 units per week for the past 3 years. He experiences 3-4 panic attacks weekly, mostly in the morning, with palpitations, sweating, and tremor. He recognises he uses alcohol to manage his anxiety symptoms. He has no history of seizures or delirium tremens. He is motivated to address both problems. What is the most appropriate initial management strategy?

Manage alcohol withdrawal first using a benzodiazepine-assisted reduction regimen before addressing panic disorder

Commence an SSRI immediately for panic disorder while simultaneously initiating alcohol reduction strategies

Start propranolol for panic symptoms and naltrexone for alcohol dependence simultaneously

Refer to specialist dual diagnosis services before initiating any specific treatment

Commence CBT for panic disorder while the patient continues to drink at current levels to establish therapeutic alliance

A 40-year-old man with generalised anxiety disorder has been receiving high-intensity CBT for 14 weeks. Initially his GAD-7 score was 18, and after 8 sessions it has reduced to 15. He reports using thought challenging techniques and has reduced some avoidance behaviours, but continues to experience significant worry about health and work, with persistent muscle tension and poor sleep. What is the most appropriate next step in management?

Add an SSRI while continuing with psychological therapy to optimise treatment response

Continue CBT for a further 6-8 weeks as response is evident and further improvement is likely

Discontinue CBT and commence an SSRI as first-line pharmacological treatment

Switch to a different psychological intervention such as mindfulness-based cognitive therapy

Refer to specialist mental health services for consideration of pregabalin or duloxetine

A 45-year-old teacher presents with a 9-week history of low mood, anhedonia, reduced energy, and poor concentration affecting her work. She has early morning wakening and has lost 4kg in weight. Her past psychiatric history includes two previous depressive episodes, the first 8 years ago requiring 6 months of citalopram, and the second 3 years ago requiring 18 months of sertraline. She achieved full remission after both episodes. What is the most appropriate duration of antidepressant treatment once remission is achieved in this current episode?

At least 2 years following remission due to the recurrent nature of her depression

6 months following remission, as she previously responded well to this duration

12 months following remission, as recommended for a second depressive episode

Treatment should be continued indefinitely given three episodes of depression

9 months following remission to match the duration of the current episode

Panic disorder for UKMLA AKT: High-Yield Mental Health Lessons

Quick Overview

Panic disorder is characterised by recurrent, unexpected panic attacks followed by ≥1 month of persistent worry about further attacks or maladaptive behavioural change. Distinguish from isolated panic attacks (common, not pathological) and other anxiety disorders. NICE CG113 emphasises psychological therapy first-line, with pharmacotherapy reserved for non-responders or patient preference. Critical to screen for developing agoraphobia (avoidance of situations where escape feels difficult).

Core Facts & Concepts

Diagnostic Criteria (DSM-5/ICD-11)

Panic attack: Abrupt surge of intense fear/discomfort peaking within minutes, with ≥4 of 13 symptoms (palpitations, sweating, trembling, dyspnoea, choking, chest pain, nausea, dizziness, paraesthesia, chills/heat, derealisation, fear of losing control, fear of dying)
Panic disorder: Recurrent unexpected panic attacks PLUS ≥1 month of concern about attacks or maladaptive avoidance
Key distinction: Isolated panic attacks ≠ panic disorder; requires persistent worry/behaviour change

Figure 1: Clinical photograph showing patient with acute anxiety displaying hyperventilation posture and distressed facial expression

Epidemiology & Comorbidity

Prevalence: 1-2% adults; F:M ratio 2:1
Peak onset: Late adolescence/early adulthood
50-65% develop agoraphobia if untreated
High comorbidity: Depression (50-60%), GAD, substance misuse

NICE CG113 Treatment Hierarchy

Line	Intervention	Specifics
1st	Psychological therapy	CBT 7-14 hours over 4 months
2nd	SSRI (if CBT declined/ineffective)	Sertraline 50mg OD (start dose)
3rd	Alternative SSRI or imipramine/clomipramine	TCA if 2 SSRIs fail
Avoid	Benzodiazepines long-term	Only short-term crisis (2-4 weeks max)

Problem-Solving Approach

Step-by-Step Assessment

Rule out medical causes (10-15% have organic aetiology):
- 🩺 Cardiovascular: MI, arrhythmia, mitral valve prolapse
- 🫁 Respiratory: Asthma, PE, COPD exacerbation
- 🧠 Neurological: TIA, epilepsy (temporal lobe)
- ⚡ Endocrine: Hyperthyroidism, hypoglycaemia, phaeochromocytoma
- 💊 Substances: Caffeine excess, cocaine, amphetamines, medication withdrawal

Figure 2: ECG showing sinus tachycardia with normal ST segments and T waves

Confirm panic disorder diagnosis:
- Document recurrent unexpected attacks (not just situational)
- Establish ≥1 month persistent worry/avoidance
- Exclude other anxiety disorders (specific phobia triggers, social anxiety)
Screen for agoraphobia (NICE CG113 safety-netting):
- Ask about avoidance of public transport, open/enclosed spaces, crowds, leaving home alone
- If present in ≥2 situations → diagnose agoraphobia (changes management)
Assess severity & risk:
- Frequency of attacks, functional impairment
- 🚩 Suicidal ideation (20-30% attempt suicide)
- Substance use as coping mechanism

Red Flags Requiring Urgent Review

🚩 Chest pain with cardiac risk factors → exclude ACS
🚩 New-onset panic age >45 years → investigate organic causes
🚩 Suicidal ideation with plan/intent
🚩 Severe agoraphobia preventing self-care

Analysis Framework

Differential Diagnosis: Panic Disorder vs Other Presentations

Feature	Panic Disorder	GAD	Social Anxiety	Specific Phobia
Attack pattern	Unexpected, spontaneous	Persistent worry (not attacks)	Situational (social)	Situational (specific object)
Trigger	None (or internal cues)	Multiple life worries	Social evaluation	Specific stimulus
Duration	Minutes (peaks <10 min)	Months (chronic)	During/before event	During exposure
Avoidance	Multiple situations (if agoraphobia)	Difficult to avoid worries	Social situations only	Specific object/situation
Physical symptoms	Intense autonomic surge	Muscle tension, restlessness	Blushing, tremor	Varies by phobia

CBT Components (NICE CG113 Recommended)

Psychoeducation: Normalise physical symptoms, explain fight/flight response
Cognitive restructuring: Challenge catastrophic misinterpretations
Interoceptive exposure: Induce physical sensations (hyperventilation, spinning) to reduce fear
In vivo exposure: Gradual confrontation of avoided situations (if agoraphobia)
Breathing retraining: Controversial (may increase focus on symptoms)

SSRI Prescribing Considerations

Start low: Sertraline 25-50mg OD (anxiety patients sensitive to activation)
Warn: Symptoms may worsen first 2 weeks before improvement at 4-6 weeks
Target dose: Sertraline 50-200mg, escitalopram 10-20mg
Duration: Continue 12 months after remission, then taper slowly (6 months)
📊 Response rate: 60-80% with adequate dose/duration

Visual Aid

Quick Comparison: Panic Disorder Management Options

Intervention	Evidence Strength	Time to Effect	Relapse Prevention
CBT	High (NNT=3)	4-8 weeks	Excellent (skills retained)
SSRIs	High (NNT=5)	4-6 weeks	Moderate (relapse if stopped)
Benzodiazepines	Moderate (short-term)	Immediate	Poor (dependence risk)
Self-help	Moderate	Variable	Good (if engaged)

Key Points Summary

✓ Diagnosis requires: Recurrent unexpected panic attacks PLUS ≥1 month persistent concern/maladaptive behaviour change (not just isolated attacks)

✓ First-line treatment: CBT (7-14 hours over 4 months) including interoceptive exposure and cognitive restructuring per NICE CG113

✓ SSRI dosing: Start sertraline 50mg OD; warn about initial 2-week worsening; continue 12 months post-remission before tapering

✓ Safety-netting: Screen for agoraphobia development (50-65% risk) and assess suicidal ideation (20-30% attempt rate)

✓ Exclude medical causes: Cardiac (MI, arrhythmia), thyroid, hypoglycaemia, substance use - especially if new-onset age >45 years

✓ Benzodiazepine caution: Avoid long-term use (dependence risk); only short-term crisis management (2-4 weeks maximum)

✓ Red flag: Chest pain with cardiac risk factors → urgent ECG/troponin to exclude ACS before attributing to panic

⭐ Clinical Pearl: Panic disorder patients often present repeatedly to A&E with "heart attack" symptoms - document thorough cardiac workup once, then provide reassurance card for future episodes to reduce healthcare utilisation.

Continue reading on Oncourse

CONTINUE READING — FREE

or get the app

App Store|Google Play

Panic disorder