Common Mental Disorders — MCQs
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A 61-year-old woman with recurrent depression has been taking mirtazapine 45mg at night for 4 years with excellent control of her symptoms. She now presents with drowsiness, confusion, and general malaise. Blood tests show: sodium 118 mmol/L, potassium 4.2 mmol/L, serum osmolality 245 mOsm/kg, urine osmolality 520 mOsm/kg, urine sodium 45 mmol/L. She takes no other regular medications. What is the most likely cause of her hyponatraemia?
A 27-year-old man presents with recurrent panic attacks occurring 3-4 times per week for the past 2 months. He describes intense fear with palpitations, sweating, and a feeling of impending doom. Between attacks, he worries constantly about having another attack. He has started avoiding crowded places. He has no other medical history. What is the most appropriate first-line treatment according to NICE guidelines?
A 35-year-old woman with moderate depression has been taking fluoxetine 40mg daily for 7 weeks with good response. She now presents at 8 weeks gestation with an unplanned but wanted pregnancy. She is concerned about continuing fluoxetine. What is the most appropriate advice regarding her antidepressant treatment?
A 49-year-old woman with chronic generalised anxiety disorder has tried sertraline, venlafaxine, and duloxetine over the past 2 years with minimal benefit. She has also completed two courses of CBT with limited response. Her anxiety significantly impacts her work and relationships. Physical health screening is unremarkable. According to NICE guidelines, which medication option should be considered next?
A 31-year-old man with panic disorder has been experiencing nocturnal panic attacks occurring 1-2 times per week, waking him from sleep. He is currently taking sertraline 100mg daily and has good control of his daytime panic symptoms. He asks whether these night-time episodes are truly panic attacks. Which feature would most strongly support that these are genuine nocturnal panic attacks?
A 43-year-old woman presents with a 12-week history of persistent low mood, anhedonia, fatigue, and weight gain of 4kg. She reports feeling worse in the evenings and has been sleeping 10-11 hours per night. She has increased her appetite, particularly craving carbohydrates. She has no past psychiatric history. What is the most likely diagnosis?
What is the minimum duration for which antidepressant treatment should be continued after remission of a first episode of depression in an adult, according to NICE guidelines?
A 58-year-old man with severe recurrent depression has failed trials of three different antidepressants at adequate doses and durations. He has significant functional impairment and expresses feelings of hopelessness but denies active suicidal ideation. His past medical history includes well-controlled hypertension and type 2 diabetes. Which treatment option should be considered at this stage?
A 39-year-old woman with panic disorder experiences sudden chest pain, breathlessness, and tingling in her hands while shopping. She is brought to A&E by ambulance. Her observations show: heart rate 110 bpm, blood pressure 145/88 mmHg, respiratory rate 26/min, oxygen saturation 99% on air. ECG shows sinus tachycardia. She has a history of similar episodes. What is the most likely cause of her hyperventilation-related symptoms?
A 24-year-old university student presents with a 4-month history of excessive, uncontrollable worry about academic performance, finances, and health. She reports difficulty concentrating, muscle tension, and poor sleep. She has no significant past medical history and takes no regular medications. Physical examination and routine blood tests are normal. Which initial management approach is most appropriate according to NICE guidelines?
Common Mental Disorders UK Medical PG Practice Questions and MCQs
Question 101: A 61-year-old woman with recurrent depression has been taking mirtazapine 45mg at night for 4 years with excellent control of her symptoms. She now presents with drowsiness, confusion, and general malaise. Blood tests show: sodium 118 mmol/L, potassium 4.2 mmol/L, serum osmolality 245 mOsm/kg, urine osmolality 520 mOsm/kg, urine sodium 45 mmol/L. She takes no other regular medications. What is the most likely cause of her hyponatraemia?
- A. Primary polydipsia
- B. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) (Correct Answer)
- C. Adrenal insufficiency
- D. Hypothyroidism
- E. Cerebral salt wasting syndrome
Explanation: ***Syndrome of inappropriate antidiuretic hormone secretion (SIADH)*** - The patient presents with **hypotonic hyponatraemia** (sodium 118, serum osmolality 245), inappropriately **concentrated urine** (urine osmolality 520 >100 mOsm/kg), and **elevated urine sodium** (45 mmol/L >20 mmol/L), all characteristic findings of SIADH. - **Mirtazapine**, an antidepressant, is known to cause SIADH by increasing ADH release or enhancing its renal effects, even after prolonged use. *Primary polydipsia* - Primary polydipsia is characterized by excessive water intake leading to **dilute urine** (urine osmolality typically <100 mOsm/kg) as the kidneys try to excrete the excess water. - This patient's **urine osmolality of 520 mOsm/kg** is highly concentrated, ruling out primary polydipsia as the cause of her hyponatraemia. *Adrenal insufficiency* - Adrenal insufficiency can cause hyponatraemia, but it typically presents with **hyperkalaemia** due to aldosterone deficiency, which is not seen here (potassium 4.2 mmol/L). - Patients are also often **hypovolaemic** and may have symptoms of hypotension or hyperpigmentation, none of which are described. *Hypothyroidism* - Severe **hypothyroidism** can lead to hyponatraemia, but it is usually associated with other classic symptoms such as fatigue, cold intolerance, and bradycardia, and would typically show a **high TSH**. - The acute presentation of confusion and drowsiness, combined with the specific electrolyte imbalance, points more strongly towards drug-induced SIADH rather than hypothyroidism as the primary cause. *Cerebral salt wasting syndrome* - **Cerebral salt wasting syndrome** is almost exclusively associated with **acute intracranial pathology** (e.g., subarachnoid hemorrhage, brain tumor) and is characterized by **hypovolaemia** due to increased natriuresis. - This patient has no history of neurological injury or signs of hypovolaemia, and the biochemical picture is more consistent with euvolaemic hyponatraemia seen in SIADH.
Question 102: A 27-year-old man presents with recurrent panic attacks occurring 3-4 times per week for the past 2 months. He describes intense fear with palpitations, sweating, and a feeling of impending doom. Between attacks, he worries constantly about having another attack. He has started avoiding crowded places. He has no other medical history. What is the most appropriate first-line treatment according to NICE guidelines?
- A. Cognitive behavioural therapy (CBT) focused on panic (Correct Answer)
- B. Sertraline 50mg daily
- C. Propranolol 40mg as required before situations that trigger anxiety
- D. Diazepam 5mg as required during panic attacks
- E. Applied relaxation therapy
Explanation: ***Cognitive behavioural therapy (CBT) focused on panic*** - According to **NICE guidelines**, **CBT** is a highly recommended first-line psychological intervention for **panic disorder**, often preferred or offered alongside medication. - CBT helps patients identify and challenge **catastrophic misinterpretations** of bodily sensations and develop coping strategies, directly addressing the core symptoms of panic. *Sertraline 50mg daily* - While **SSRIs** like sertraline are considered first-line pharmacological options for panic disorder, NICE guidelines suggest discussing both **CBT** and medication to determine patient preference. - In a question asking for the
Question 103: A 35-year-old woman with moderate depression has been taking fluoxetine 40mg daily for 7 weeks with good response. She now presents at 8 weeks gestation with an unplanned but wanted pregnancy. She is concerned about continuing fluoxetine. What is the most appropriate advice regarding her antidepressant treatment?
- A. Stop fluoxetine immediately as it is contraindicated in pregnancy
- B. Continue fluoxetine as benefits likely outweigh risks given good response (Correct Answer)
- C. Switch to sertraline as it is safer in pregnancy than fluoxetine
- D. Gradually reduce and stop fluoxetine, then start CBT
- E. Reduce fluoxetine to 20mg daily to minimize fetal exposure
Explanation: ***Continue fluoxetine as benefits likely outweigh risks given good response*** - In a patient stable on an **SSRI** with a good clinical response, the risk of **relapse of depression** during pregnancy often outweighs the potential risks of fetal exposure. - **Fluoxetine** is considered safe in pregnancy with extensive safety data; maintaining the established effective dose is prioritized to ensure **maternal mental stability**. *Stop fluoxetine immediately as it is contraindicated in pregnancy* - SSRIs are not **contraindicated** in pregnancy; sudden cessation carries a high risk of **discontinuation syndrome** and relapse. - Untreated depression is associated with poor **antenatal care**, low birth weight, and increased risk of **postnatal depression**. *Switch to sertraline as it is safer in pregnancy than fluoxetine* - While **sertraline** is often a preferred SSRI in pregnancy, switching a patient who is currently **stable and responsive** to fluoxetine is not routinely recommended as it risks destabilization. - There is no strong evidence that sertraline is clinically "safer" than fluoxetine to justify disrupting effective treatment, especially given fluoxetine's extensive safety data in pregnancy. *Gradually reduce and stop fluoxetine, then start CBT* - Although **Cognitive Behavioral Therapy (CBT)** is an excellent adjunct, relying solely on it after stopping a successful medication risks a severe **relapse** in moderate depression. - The decision to stop medication should be based on the patient's **psychiatric history** and risk of relapse, which is high if stopped shortly after achieving response. *Reduce fluoxetine to 20mg daily to minimize fetal exposure* - Reducing the dose below the **therapeutic level** that achieved remission increases the risk of recurrence without significantly eliminating fetal risk. - Sub-therapeutic dosing during pregnancy is generally discouraged; the goal is to use the **minimum effective dose**, which in this patient's case is 40mg.
Question 104: A 49-year-old woman with chronic generalised anxiety disorder has tried sertraline, venlafaxine, and duloxetine over the past 2 years with minimal benefit. She has also completed two courses of CBT with limited response. Her anxiety significantly impacts her work and relationships. Physical health screening is unremarkable. According to NICE guidelines, which medication option should be considered next?
- A. Propranolol 40mg three times daily
- B. Buspirone 5mg three times daily
- C. Pregabalin 150mg twice daily (Correct Answer)
- D. Hydroxyzine 25mg three times daily
- E. Lorazepam 1mg twice daily
Explanation: ***Pregabalin 150mg twice daily***- According to **NICE guidelines**, when a patient with **Generalised Anxiety Disorder (GAD)** has not responded to initial treatments including two **SSRIs/SNRIs** (sertraline, venlafaxine, duloxetine) and **CBT**, **pregabalin** is the recommended next pharmacological step.- It is a **gamma-aminobutyric acid (GABA) analogue** specifically licensed for GAD, acting to modulate voltage-gated calcium channels and reduce neurotransmitter release, providing an anxiolytic effect.*Propranolol 40mg three times daily*- **Propranolol** is a **beta-blocker** primarily effective for managing the **physical symptoms of anxiety**, such as palpitations, tremor, and sweating, but it does not address the underlying psychological components of GAD.- **NICE guidelines** do not endorse beta-blockers as a primary or sequential treatment option for the psychological aspects of chronic GAD after the failure of multiple antidepressants and CBT.*Buspirone 5mg three times daily*- **Buspirone** acts as a 5-HT1A receptor partial agonist, but its evidence for efficacy in **chronic GAD**, particularly in treatment-resistant cases, is less robust compared to other recommended agents.- It is not typically recommended by **NICE guidelines** as a subsequent pharmacological option after the failure of multiple first-line treatments due to its generally lower efficacy and slower onset of action.*Hydroxyzine 25mg three times daily*- **Hydroxyzine** is a sedating antihistamine that may provide **short-term relief** for acute anxiety symptoms due to its sedative effects, but it is not suitable for chronic management.- Concerns regarding its long-term efficacy, sedative side effects, and potential for **QT prolongation** make it an inappropriate next-line treatment for chronic, treatment-resistant GAD as per NICE recommendations.*Lorazepam 1mg twice daily*- **Benzodiazepines** like **lorazepam** are highly effective for acute anxiety but carry significant risks of **dependence, tolerance, and withdrawal** with prolonged use.- **NICE guidelines** strongly advise against the long-term use of benzodiazepines for chronic GAD, reserving them only for **short-term (2-4 weeks)** management of severe acute crises, not as a sequential maintenance therapy.
Question 105: A 31-year-old man with panic disorder has been experiencing nocturnal panic attacks occurring 1-2 times per week, waking him from sleep. He is currently taking sertraline 100mg daily and has good control of his daytime panic symptoms. He asks whether these night-time episodes are truly panic attacks. Which feature would most strongly support that these are genuine nocturnal panic attacks?
- A. They occur during REM sleep and he recalls vivid dreams
- B. They occur during non-REM sleep without preceding dreams or triggers (Correct Answer)
- C. They are preceded by sleep paralysis
- D. They are associated with abnormal movements witnessed by his partner
- E. They occur only in the early hours of the morning between 3-5am
Explanation: ***They occur during non-REM sleep without preceding dreams or triggers*** - **Nocturnal panic attacks** characteristically occur during **non-REM sleep**, most commonly in late **Stage 2** or early **Stage 3 (slow-wave) sleep**, often within the first few hours of sleep. - Unlike nightmares, these episodes are **not preceded by dreams** or specific psychological triggers; the individual awakens abruptly with intense **autonomic arousal** and fear. *They occur during REM sleep and he recalls vivid dreams* - Episodes occurring during **REM sleep** that are associated with vivid, frightening dream content are diagnostic of **nightmares**, not panic attacks. - Panic attacks are characterized by a sudden surge of physiological symptoms without the cognitive narrative typical of REM-related dream imagery. *They are preceded by sleep paralysis* - **Sleep paralysis** involves an inability to move or speak upon waking or falling asleep, often accompanied by **hypnagogic/hypnopompic hallucinations**. - While distressing, sleep paralysis is a distinct parasomnia and does not involve the intense autonomic activation and fear associated with a full-blown panic attack. *They are associated with abnormal movements witnessed by his partner* - Significant abnormal movements during sleep, especially complex or violent ones, are more indicative of a **parasomnia** (e.g., REM sleep behavior disorder, sleepwalking) or a **nocturnal seizure**. - Genuine panic attacks involve intense internal autonomic symptoms (e.g., palpitations, dyspnea, sweating) but do not typically manifest with complex motor automatisms. *They occur only in the early hours of the morning between 3-5am* - The **timing** of a nocturnal panic attack is not a definitive diagnostic feature; they can occur at any point during the sleep cycle, though often earlier in the night. - Events more consistently occurring in the early hours of the morning (late in the sleep cycle) are often associated with **REM-sleep phenomena**, like nightmares, as REM sleep predominates then.
Question 106: A 43-year-old woman presents with a 12-week history of persistent low mood, anhedonia, fatigue, and weight gain of 4kg. She reports feeling worse in the evenings and has been sleeping 10-11 hours per night. She has increased her appetite, particularly craving carbohydrates. She has no past psychiatric history. What is the most likely diagnosis?
- A. Major depressive disorder with melancholic features
- B. Major depressive disorder with atypical features (Correct Answer)
- C. Hypothyroidism
- D. Seasonal affective disorder
- E. Adjustment disorder with depressed mood
Explanation: ***Major depressive disorder with atypical features*** - This diagnosis is characterized by **atypical features** such as **hypersomnia** (sleeping 10-11 hours), **increased appetite** (especially **carbohydrate craving**), and **weight gain** (4kg), all of which align with the patient's presentation. - Patients with atypical features often report **mood reactivity** and may experience a **reverse diurnal variation**, where symptoms feel worse in the **evenings**, consistent with the patient's report. *Major depressive disorder with melancholic features* - Melancholic depression typically presents with **insomnia** (often early morning awakening), **significant weight loss** or **anorexia**, and profound **anhedonia**, which are the opposite of this patient's symptoms. - Symptoms are usually **worse in the morning** and there is a marked **lack of mood reactivity**, differentiating it from the given case. *Hypothyroidism* - While **fatigue**, **low mood**, and **weight gain** can be present, the specific pattern of **hypersomnia** and **carbohydrate craving** is more indicative of atypical depression. - Hypothyroidism usually includes other physical signs like **cold intolerance**, **dry skin**, or **bradycardia**, which are not mentioned in the patient's history. *Seasonal affective disorder* - This diagnosis requires a clear **seasonal pattern** of depressive episodes, typically recurring for at least **two consecutive years**, which is not indicated in the vignette. - Although often presenting with atypical features, the defining criterion of **seasonal periodicity** is absent from the information provided. *Adjustment disorder with depressed mood* - This diagnosis requires an **identifiable psychosocial stressor** within three months of symptom onset, which is not mentioned in the patient's history. - The symptoms must not meet the full criteria for a **Major Depressive Episode**, whereas this patient's prolonged and severe symptoms (12 weeks of low mood, anhedonia, fatigue) clearly meet those criteria.
Question 107: What is the minimum duration for which antidepressant treatment should be continued after remission of a first episode of depression in an adult, according to NICE guidelines?
- A. 4 weeks after remission
- B. 3 months after remission
- C. 6 months after remission (Correct Answer)
- D. 12 months after remission
- E. 24 months after remission
Explanation: ***6 months after remission*** - For a **first episode** of depression, **NICE guidelines** recommend continuing antidepressant therapy for at least **6 months** after remission to significantly reduce the **risk of relapse**. - The medication should be maintained at the **same dose** that was effective during the acute phase of treatment to ensure maximal preventative effect.*4 weeks after remission* - This duration is insufficient to ensure **neurochemical stabilization** and provides negligible protection against early relapse. - While initial symptomatic improvement may be seen in 2-4 weeks, stopping treatment this early almost guarantees a **high rate of recurrence**.*3 months after remission* - While longer than the acute phase, 3 months is still considered an **inadequate duration** for a first depressive episode according to clinical standards. - Studies show that stopping medication this early markedly increases the likelihood of symptoms returning shortly after cessation, as the brain has not fully recovered.*12 months after remission* - A duration of **12 months** or longer is often recommended for patients with **recurrent depression** (e.g., two or more previous episodes) or those with higher risk factors for relapse. - It is not the standard minimum requirement for a first, uncomplicated episode of depression in an adult, which typically requires a shorter maintenance phase.*24 months after remission* - **NICE guidelines** reserve a **2-year** (24 months) maintenance period for patients who have had **two or more severe depressive episodes**, frequent relapses, or those with chronic depression. - This extended timeframe is intended to provide long-term stability for chronic or severely recurrent cases.
Question 108: A 58-year-old man with severe recurrent depression has failed trials of three different antidepressants at adequate doses and durations. He has significant functional impairment and expresses feelings of hopelessness but denies active suicidal ideation. His past medical history includes well-controlled hypertension and type 2 diabetes. Which treatment option should be considered at this stage?
- A. Electroconvulsive therapy (ECT)
- B. Transcranial magnetic stimulation (TMS)
- C. Lithium augmentation of current antidepressant (Correct Answer)
- D. Deep brain stimulation
- E. Cognitive behavioural therapy (CBT) alone without medication
Explanation: ***Lithium augmentation of current antidepressant*** - This patient meets the criteria for **Treatment-Resistant Depression (TRD)**, having failed three trials of antidepressants, and **Lithium augmentation** is a primary evidence-based strategy in this scenario. - Augmentation involves adding a second agent to enhance the therapeutic effect, and **Lithium** has strong evidence for reducing **hopelessness** and preventing further relapse in TRD. *Electroconvulsive therapy (ECT)* - While highly effective, ECT is typically reserved for **life-threatening** situations such as severe **suicidality**, **catatonia**, or when a rapid clinical response is indispensable. - This patient denies active **suicidal ideation**, making less invasive pharmacological augmentation like Lithium the more appropriate next step. *Transcranial magnetic stimulation (TMS)* - TMS is a non-invasive procedure used for depression, but it is often considered later in the treatment algorithm or when patients prefer to avoid medication side effects. - It is generally not the first-line recommendation in guideline-driven care compared to the established efficacy of **Lithium augmentation** for severe functional impairment. *Deep brain stimulation* - This is an **invasive/surgical** intervention that remains largely **experimental** and is not standard clinical practice for depression management. - It is only considered in highly specialized centers for **extreme treatment resistance** that has failed all other conventional somatic therapies. *Cognitive behavioural therapy (CBT) alone without medication* - **CBT monotherapy** is insufficient for severe recurrent depression with significant functional impairment and a history of multiple medication failures. - Guidelines suggest that **psychotherapy** should be used as an **adjunct** to medication in TRD, rather than replacing it, to address complex psychosocial stressors.
Question 109: A 39-year-old woman with panic disorder experiences sudden chest pain, breathlessness, and tingling in her hands while shopping. She is brought to A&E by ambulance. Her observations show: heart rate 110 bpm, blood pressure 145/88 mmHg, respiratory rate 26/min, oxygen saturation 99% on air. ECG shows sinus tachycardia. She has a history of similar episodes. What is the most likely cause of her hyperventilation-related symptoms?
- A. Metabolic acidosis due to lactic acid accumulation
- B. Respiratory alkalosis leading to decreased ionised calcium (Correct Answer)
- C. Hypoxia causing peripheral paraesthesia
- D. Hypercapnia resulting in cerebral vasoconstriction
- E. Hypokalaemia secondary to catecholamine release
Explanation: ***Respiratory alkalosis leading to decreased ionised calcium***- Hyperventilation causes excessive exhalation of **carbon dioxide (CO2)**, leading to an increase in blood pH and the development of **respiratory alkalosis**.- Alkalosis promotes the binding of **calcium** to **albumin**, which reduces the concentration of **ionised calcium**, resulting in symptoms like **paraesthesia** and tingling.*Metabolic acidosis due to lactic acid accumulation*- Hyperventilation specifically results in **alkalosis** due to the loss of carbon dioxide, not **acidosis**.- Lactic acid accumulation is associated with anaerobic metabolism, which is not the physiological driver of acute **panic disorder** symptoms.*Hypoxia causing peripheral paraesthesia*- The patient's **oxygen saturation** is 99% on room air, which objectively rules out **hypoxia** as a cause of her symptoms.- Paraesthesia in hyperventilation is a direct result of **electrolyte shifts** rather than a lack of oxygen delivery to tissues.*Hypercapnia resulting in cerebral vasoconstriction*- Hyperventilation leads to **hypocapnia** (low CO2), not **hypercapnia** (high CO2).- It is **hypocapnia** that triggers **cerebral vasoconstriction**, potentially causing the lightheadedness often felt during a panic attack.*Hypokalaemia secondary to catecholamine release*- While catecholamines can cause a transient shift of potassium into cells, this is not the primary mechanism for **peripheral tingling** in panic attacks.- The characteristic **neuromuscular irritability** seen here is classically driven by the reduction in **ionised calcium** levels.
Question 110: A 24-year-old university student presents with a 4-month history of excessive, uncontrollable worry about academic performance, finances, and health. She reports difficulty concentrating, muscle tension, and poor sleep. She has no significant past medical history and takes no regular medications. Physical examination and routine blood tests are normal. Which initial management approach is most appropriate according to NICE guidelines?
- A. Start sertraline 50mg daily immediately
- B. Offer low-intensity psychological intervention and psychoeducation (Correct Answer)
- C. Prescribe diazepam 2mg three times daily for 2 weeks
- D. Refer directly to specialist mental health services
- E. Start pregabalin 150mg twice daily
Explanation: ***Offer low-intensity psychological intervention and psychoeducation***- The patient's 4-month history of excessive, uncontrollable worry about various aspects of life, along with difficulty concentrating, muscle tension, and poor sleep, strongly suggests **Generalised Anxiety Disorder (GAD)**. Physical examination and routine blood tests being normal rule out other medical causes.- According to **NICE guidelines** for GAD, the initial recommended management (after simple psychoeducation, which is often combined) is to offer **low-intensity psychological interventions**, such as guided self-help, group psychoeducation, or low-intensity Cognitive Behavioural Therapy (CBT). This aligns with the **stepped-care model** before considering pharmacotherapy.*Start sertraline 50mg daily immediately*- While **SSRIs like sertraline** are a first-line pharmacological option for GAD (considered at Step 3 of the NICE stepped-care model), they are typically offered if **low-intensity psychological interventions** have been ineffective or if the patient expresses a strong preference for medication over psychological therapies.- Starting medication immediately as the very first step, without attempting psychological interventions, is generally not in line with the initial management recommendations for mild-to-moderate GAD.*Prescribe diazepam 2mg three times daily for 2 weeks*- **Benzodiazepines** like diazepam are not recommended for the long-term management of GAD due to a high risk of **dependence, tolerance, and withdrawal symptoms**.- Their use should be limited to very short-term (e.g., a few days) management of severe **crisis** or extreme agitation, and they are not a primary treatment for ongoing anxiety symptoms.*Refer directly to specialist mental health services*- Direct referral to **specialist mental health services** (Step 4 in NICE guidelines) is reserved for individuals with severe GAD, significant **functional impairment**, co-occurring severe mental health conditions, a high risk of self-harm, or those who have not responded to multiple interventions in primary care.- The current presentation does not meet criteria for immediate specialist referral, as initial interventions should be attempted in **primary care**.*Start pregabalin 150mg twice daily*- **Pregabalin** is an alternative pharmacological treatment for GAD, but it is typically considered after a patient has not responded to or cannot tolerate **SSRIs or SNRIs** (selective serotonin and noradrenaline reuptake inhibitors).- It is not an initial management strategy and should only be offered after attempting first-line psychological and pharmacological treatments.
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