A 67-year-old man with moderate depression is being reviewed 6 weeks after starting citalopram 20mg daily. His PHQ-9 score has reduced from 18 to 10. He reports significant improvement in mood and sleep but continues to experience some residual symptoms including reduced concentration and low energy. He tolerates the medication well with no adverse effects. What is the most appropriate next step in management?
Q112
A 43-year-old woman presents with symptoms of depression including low mood, anhedonia, poor sleep, and reduced appetite for 6 weeks. During assessment, she mentions she has been taking St John's wort for the past 2 weeks, which she purchased from a health food shop. Her PHQ-9 score is 18. You decide pharmacological treatment with an SSRI is indicated. What is the most important consideration regarding her herbal medication?
Q113
A 36-year-old woman with generalised anxiety disorder has persistent moderate symptoms (GAD-7 score 12) despite completing 10 weeks of guided self-help and 14 sessions of individual CBT. She has declined medication throughout. She continues to experience excessive worry affecting multiple life domains and has significant functional impairment at work. What is the most appropriate next management step?
Q114
A 52-year-old woman with depression has been taking venlafaxine 150mg daily for 4 months with good response. She presents to the GP having abruptly stopped her medication 4 days ago due to a stomach upset. She now reports dizziness, electric shock sensations in her head, nausea, and feeling generally unwell. Her observations are: BP 128/78, HR 82, temperature 36.7°C. What is the most likely diagnosis?
Q115
A 47-year-old man with severe depression (PHQ-9 score 23) has been treated with sertraline 200mg daily for 6 weeks, then venlafaxine 225mg daily for 8 weeks, both without significant improvement. He has declined psychological therapy. His depression includes prominent psychomotor retardation and early morning wakening. He has no active suicidal ideation. What is the most appropriate next step in management?
Q116
A 34-year-old woman presents with a 4-month history of constant worry about her health, her children's safety, household finances, and work deadlines. She reports feeling restless, easily fatigued, difficulty concentrating, muscle tension, and poor sleep. Her GAD-7 score is 14. She has no past psychiatric history. She is a full-time teacher and feels these symptoms are significantly affecting her work performance. What is the most appropriate first-line treatment approach?
Q117
What is the typical time course for response to SSRI treatment in panic disorder according to evidence-based guidelines?
Q118
A 42-year-old man presents with a 10-week history of persistent low mood, anhedonia, poor concentration, and fatigue. He reports passive suicidal ideation but no plans or intent. His PHQ-9 score is 16. He is a recovering alcoholic, abstinent for 2 years, and attends regular AA meetings. Physical examination is unremarkable. What is the most appropriate initial management approach?
Q119
A 55-year-old woman with recurrent depressive disorder is currently in remission on fluoxetine 20mg daily, which she has been taking for 18 months following her third depressive episode. She asks about stopping her medication as she feels well. Her previous episodes occurred 3 years ago and 6 years ago, each lasting 4-6 months. What is the most appropriate advice regarding continuation of antidepressant therapy?
Q120
A 38-year-old woman with panic disorder has been experiencing frequent panic attacks in crowded places. She has started avoiding supermarkets, public transport, and social gatherings. Her panic attacks are well controlled on sertraline 100mg daily, but the avoidance behaviour persists. What is the most appropriate psychological intervention to address her avoidance behaviour?
Common Mental Disorders UK Medical PG Practice Questions and MCQs
Question 111: A 67-year-old man with moderate depression is being reviewed 6 weeks after starting citalopram 20mg daily. His PHQ-9 score has reduced from 18 to 10. He reports significant improvement in mood and sleep but continues to experience some residual symptoms including reduced concentration and low energy. He tolerates the medication well with no adverse effects. What is the most appropriate next step in management?
A. Continue citalopram 20mg daily and review in 2 weeks
B. Increase citalopram to 40mg daily (Correct Answer)
C. Switch to venlafaxine 75mg daily
D. Add mirtazapine 15mg at night
E. Reduce citalopram to 10mg daily and continue for 2 more weeks
Explanation: ***Increase citalopram to 40mg daily***- In patients with a **partial response** to an antidepressant after 4-6 weeks and continued **residual symptoms**, increasing the dose of the current well-tolerated medication is the most appropriate next step.- This strategy aims to achieve **full remission** by optimizing the therapeutic effect before considering alternative or augmentation therapies.*Continue citalopram 20mg daily and review in 2 weeks*- The patient has shown a **partial response** but still experiences significant residual symptoms, indicating that the current dose is not fully effective.- Continuing the same dose without adjustment fails to address the persistent symptoms and may delay the achievement of **full remission**.*Switch to venlafaxine 75mg daily*- Switching antidepressants is typically reserved for patients who have shown **no response** or have experienced intolerable side effects with the initial treatment.- Given the patient's **significant improvement** and good tolerability, switching at this stage would be premature.*Add mirtazapine 15mg at night*- **Augmentation therapy** is generally considered for **treatment-resistant depression** after monotherapy optimization (including dose escalation) has failed.- It adds complexity and potential for additional side effects, making it a later-line strategy.*Reduce citalopram to 10mg daily and continue for 2 more weeks*- Reducing the dose of an antidepressant is indicated for managing **adverse effects**, which this patient does not report.- Lowering the dose in a partially responsive patient would likely lead to a **worsening of depressive symptoms** and loss of achieved benefits.
Question 112: A 43-year-old woman presents with symptoms of depression including low mood, anhedonia, poor sleep, and reduced appetite for 6 weeks. During assessment, she mentions she has been taking St John's wort for the past 2 weeks, which she purchased from a health food shop. Her PHQ-9 score is 18. You decide pharmacological treatment with an SSRI is indicated. What is the most important consideration regarding her herbal medication?
A. St John's wort can be continued alongside SSRI treatment safely
B. St John's wort must be stopped immediately before starting SSRI due to serotonin syndrome risk (Correct Answer)
C. St John's wort should be tapered gradually over 4 weeks before starting SSRI
D. St John's wort has no interactions and can be ignored in treatment planning
E. St John's wort is contraindicated only with MAOIs, not SSRIs
Explanation: ***St John's wort must be stopped immediately before starting SSRI due to serotonin syndrome risk***- **St John's wort** has serotonergic properties and, when combined with **SSRIs**, significantly increases the risk of life-threatening **serotonin syndrome**.- Because she has only been taking the herbal remedy for **two weeks**, it can be discontinued immediately rather than requiring a prolonged tapering period.*St John's wort can be continued alongside SSRI treatment safely*- This combined use is **contraindicated** due to the high risk of **pharmacodynamic interactions** leading to neuromuscular and autonomic overactivity.- **St John's wort** is a potent **CYP450 enzyme inducer**, which can also alter the metabolism of many other co-administered medications.*St John's wort should be tapered gradually over 4 weeks before starting SSRI*- A **4-week taper** is unnecessary given the short duration of her herbal medicine use (2 weeks) and the clinical urgency to prevent **interaction risks**.- While a small **washout period** is advisable, delaying standard antidepressant treatment for a month would unnecessarily prolong her **PHQ-9 score of 18** (moderate-to-severe depression).*St John's wort has no interactions and can be ignored in treatment planning*- This is medically incorrect; it interacts with numerous drugs, including **warfarin**, **digoxin**, and **oral contraceptives**, by reducing their plasma levels.- Ignoring herbal supplements during assessment can lead to severe **adverse drug reactions** or treatment failure of standard medications.*St John's wort is contraindicated only with MAOIs, not SSRIs*- While it is indeed contraindicated with **MAOIs**, the risk extends to all **serotonergic agents**, including SSRIs and SNRIs.- Clinical guidelines emphasize that any agent that increases **synaptic serotonin** levels constitutes a risk when combined with St John's wort.
Question 113: A 36-year-old woman with generalised anxiety disorder has persistent moderate symptoms (GAD-7 score 12) despite completing 10 weeks of guided self-help and 14 sessions of individual CBT. She has declined medication throughout. She continues to experience excessive worry affecting multiple life domains and has significant functional impairment at work. What is the most appropriate next management step?
A. Refer for long-term psychodynamic psychotherapy
B. Repeat CBT with focus on remaining problem areas
C. Recommend sertraline and arrange close monitoring (Correct Answer)
D. Discharge with crisis contact details for future exacerbation
E. Refer to specialist anxiety disorders service
Explanation: ***Recommend sertraline and arrange close monitoring***- After failing both **low-intensity** (guided self-help) and **high-intensity** (CBT) psychological interventions, medication should be strongly recommended to address persistent **moderate symptoms**.- **Sertraline** is often the first-line SSRI recommended by NICE guidelines for GAD; the clinician must discuss its benefits to overcome the patient's previous refusal.*Refer for long-term psychodynamic psychotherapy*- Psychodynamic psychotherapy is not a standard recommended treatment for **generalized anxiety disorder** over established CBT protocols.- Focus should remain on **evidence-based** treatments for GAD that target the specific cognitive patterns of worry and rumination.*Repeat CBT with focus on remaining problem areas*- Completing **14 sessions** of CBT constitutes a full trial; repeating it immediately after failure is unlikely to result in significant clinical improvement.- Moving to the next step in the **stepped-care model** (pharmacology) is more appropriate than repeating failed Step 3 interventions.*Discharge with crisis contact details for future exacerbation*- Discharge is inappropriate because the patient has a **GAD-7 score of 12** and significant **functional impairment** at work.- Professional duty of care requires exploring further therapeutic options (medication) rather than abandoning treatment while the patient is symptomatic.*Refer to specialist anxiety disorders service*- Specialist referral is usually reserved for **treatment-refractory** cases that have failed both high-intensity psychological therapy and multiple pharmacological trials.- Pharmacological options must be thoroughly explored and exhausted in primary or secondary care before escalating to a **tertiary specialist service**.
Question 114: A 52-year-old woman with depression has been taking venlafaxine 150mg daily for 4 months with good response. She presents to the GP having abruptly stopped her medication 4 days ago due to a stomach upset. She now reports dizziness, electric shock sensations in her head, nausea, and feeling generally unwell. Her observations are: BP 128/78, HR 82, temperature 36.7°C. What is the most likely diagnosis?
A. Serotonin syndrome
B. Antidepressant discontinuation syndrome (Correct Answer)
C. Viral gastroenteritis with dehydration
D. Relapse of depressive episode
E. Hyponatraemia secondary to venlafaxine
Explanation: ***Antidepressant discontinuation syndrome***- Abrupt cessation of antidepressants, particularly those with a **short half-life** like **venlafaxine**, often leads to symptoms like **dizziness**, nausea, and flu-like sensations.- The pathognomonic reporting of **'electric shock sensations'** (brain zaps) and timing (2–4 days post-cessation) is classic for this syndrome.*Serotonin syndrome*- This condition is caused by **excessive serotonin** levels and typically presents with a triad of **autonomic instability**, altered mental status, and **neuromuscular hyperactivity** (e.g., clonus).- It occurs upon initiation or dose increase of serotonergic agents, not upon **discontinuation**.*Viral gastroenteritis with dehydration*- While a stomach upset was the reason for stopping the medication, it does not explain the neurological **'electric shock' sensations**.- The patient's **vital signs** (BP 128/78 and HR 82) are stable, which is inconsistent with significant **dehydration**.*Relapse of depressive episode*- A clinical relapse of **major depressive disorder** usually takes several weeks to manifest and presents with low mood and **anhedonia**.- The acute onset of physical and **sensory symptoms** within 4 days of stopping medication is indicative of withdrawal rather than a return of the primary psychiatric illness.*Hyponatraemia secondary to venlafaxine*- **Hyponatraemia** is a known side effect of daily SSRI/SNRI use, particularly in the elderly, but it occurs while the patient is **taking the drug**.- The specific sensory neurological symptoms described here are not typical for low sodium; **headaches**, confusion, or seizures are more common presentations.
Question 115: A 47-year-old man with severe depression (PHQ-9 score 23) has been treated with sertraline 200mg daily for 6 weeks, then venlafaxine 225mg daily for 8 weeks, both without significant improvement. He has declined psychological therapy. His depression includes prominent psychomotor retardation and early morning wakening. He has no active suicidal ideation. What is the most appropriate next step in management?
A. Augment venlafaxine with lithium carbonate (Correct Answer)
B. Switch to mirtazapine monotherapy
C. Augment venlafaxine with quetiapine
D. Refer for electroconvulsive therapy
E. Switch to tranylcypromine
Explanation: ***Augment venlafaxine with lithium carbonate***
- This patient meets the criteria for **treatment-resistant depression**, having failed two adequate trials of different antidepressants (**SSRI** and **SNRI**) at maximum doses.
- **Lithium augmentation** has the most robust evidence base for treatment resistance and is recommended by clinical guidelines as a first-line augmentation strategy to enhance antidepressant response.
*Switch to mirtazapine monotherapy*
- While switching to a third monotherapy class is possible, clinical guidelines generally favor **augmentation strategies** after two failed trials to exploit synergistic pharmacological effects.
- **Mirtazapine** is often used in combination with an SNRI (e.g., California Rocket Fuel) rather than as another monotherapy switch in refractory cases.
*Augment venlafaxine with quetiapine*
- Adding a **second-generation antipsychotic** like quetiapine is a valid evidence-based option for augmentation in treatment-resistant depression.
- However, **lithium** is typically preferred as the first augmenting agent due to its longer-standing evidence base and specific mortality-reducing benefits.
*Refer for electroconvulsive therapy*
- **ECT** is generally reserved for patients with **life-threatening** depression, severe psychomotor retardation with poor oral intake, or high **suicide risk**.
- Although this patient has psychomotor retardation, he is not acutely suicidal or physically endangered, making further pharmacological steps appropriate before ECT.
*Switch to tranylcypromine*
- **Tranylcypromine**, an irreversible MAOI, is typically reserved for highly resistant cases due to its complex dietary restrictions and **hypertensive crisis risk**.
- It should only be initiated by specialists when standard augmentation strategies with **lithium** or antipsychotics have already been exhausted.
Question 116: A 34-year-old woman presents with a 4-month history of constant worry about her health, her children's safety, household finances, and work deadlines. She reports feeling restless, easily fatigued, difficulty concentrating, muscle tension, and poor sleep. Her GAD-7 score is 14. She has no past psychiatric history. She is a full-time teacher and feels these symptoms are significantly affecting her work performance. What is the most appropriate first-line treatment approach?
A. Low-intensity psychological intervention such as guided self-help (Correct Answer)
B. High-intensity CBT alone
C. Sertraline 50mg daily alone
D. High-intensity CBT with sertraline 50mg daily
E. Applied relaxation therapy
Explanation: ***Low-intensity psychological intervention such as guided self-help***
- The patient's **GAD-7 score of 14** indicates **moderate anxiety**, and according to **NICE guidelines** for Generalised Anxiety Disorder (GAD), **low-intensity psychological interventions** are the recommended first-line treatment in this step (Step 2).
- **Guided self-help** allows the patient to actively participate in managing their symptoms with structured support, aligning with the initial conservative approach for moderate GAD.
*High-intensity CBT alone*
- **High-intensity CBT** is typically a **Step 3 intervention** in the stepped-care model, reserved for patients who have not responded to low-intensity treatments or those with **more severe anxiety**.
- Starting immediately with high-intensity therapy bypasses the standard, less intensive interventions recommended for initial management of moderate GAD.
*Sertraline 50mg daily alone*
- While **SSRIs** like sertraline are effective for GAD, they are generally considered **Step 3 pharmacological interventions**, usually offered if psychological interventions are declined or have failed.
- Guidelines prioritize **psychological interventions** as the initial approach for newly diagnosed GAD, particularly when symptoms are moderate.
*High-intensity CBT with sertraline 50mg daily*
- **Combination therapy** is typically reserved for cases of **severe GAD** or when monotherapy (either psychological or pharmacological) has been insufficient to achieve symptom control.
- Initiating both high-intensity CBT and medication simultaneously is considered an **over-treatment** for a patient presenting with moderate GAD who is new to psychiatric care.
*Applied relaxation therapy*
- **Applied relaxation therapy** is categorized as a **high-intensity psychological intervention** (Step 3) for GAD, similar to full CBT.
- As a Step 3 intervention, it is not the recommended first-line treatment for a patient with **moderate anxiety** who has not yet tried Step 2 interventions.
Question 117: What is the typical time course for response to SSRI treatment in panic disorder according to evidence-based guidelines?
A. Immediate improvement within 2-3 days
B. Gradual improvement starting at 2-4 weeks with full effect by 8-12 weeks (Correct Answer)
C. No improvement until week 6, then rapid response
D. Steady linear improvement throughout the first 4 weeks
E. Initial worsening for 2 weeks followed by improvement
Explanation: ***Gradual improvement starting at 2-4 weeks with full effect by 8-12 weeks***
- **SSRIs** for panic disorder typically show initial symptomatic relief after **2 to 4 weeks** of consistent dosing.
- **Full therapeutic effect** and panic attack remission are usually assessed after **8 to 12 weeks** of treatment, as per clinical guidelines.
*Immediate improvement within 2-3 days*
- This rapid response time is characteristic of **benzodiazepines**, which act quickly but are not suitable for long-term panic disorder management due to dependence risk.
- **SSRIs** require time for **neurotransmitter reuptake inhibition** to lead to receptor downregulation and other adaptive changes in the brain, thus immediate effects are not expected.
*No improvement until week 6, then rapid response*
- Response to **SSRIs** is generally **gradual**, not an abrupt onset after a prolonged period of no effect.
- Lack of any improvement by week 4-6 usually prompts a reassessment of **dosage**, adherence, or diagnosis, rather than anticipating a sudden late response.
*Steady linear improvement throughout the first 4 weeks*
- The improvement with **SSRIs** is often not perfectly linear; there can be fluctuations and a delayed onset of noticeable benefits.
- Many patients experience an **initial period of adaptation** or even transient side effects before a more consistent improvement phase begins.
*Initial worsening for 2 weeks followed by improvement*
- While some individuals may experience **transient anxiety** or **jitteriness** at the start of SSRI treatment (often called the "jitteriness syndrome"), this is a potential side effect, not the typical therapeutic time course.
- Describing this as the expected course might discourage **medication adherence**; worsening is a possible side effect, not a universal or desired phase.
Question 118: A 42-year-old man presents with a 10-week history of persistent low mood, anhedonia, poor concentration, and fatigue. He reports passive suicidal ideation but no plans or intent. His PHQ-9 score is 16. He is a recovering alcoholic, abstinent for 2 years, and attends regular AA meetings. Physical examination is unremarkable. What is the most appropriate initial management approach?
A. Commence sertraline 50mg daily and arrange follow-up in 2 weeks
B. Refer for high-intensity CBT and review in 4 weeks
C. Commence mirtazapine 15mg at night and arrange weekly follow-up
D. Admit to psychiatric inpatient unit for stabilisation
E. Commence sertraline 50mg daily and refer for high-intensity CBT (Correct Answer)
Explanation: ***Commence sertraline 50mg daily and refer for high-intensity CBT***
- A **PHQ-9 score of 16** indicates **moderate depression**, for which NICE guidelines recommend a **combination** of antidepressant medication and high-intensity psychological intervention.
- **Sertraline** is an appropriate first-line SSRI choice due to its safety profile, especially in patients with a history of alcohol-related issues.
*Commence sertraline 50mg daily and arrange follow-up in 2 weeks*
- This approach offers pharmacological treatment alone, which is less effective than **combination therapy** for moderate-to-severe depressive episodes.
- While follow-up is necessary, the initial management plan must address the need for a **high-intensity psychological intervention** like CBT.
*Refer for high-intensity CBT and review in 4 weeks*
- For **moderate depression**, managing the patient with psychological therapy alone is generally insufficient without offering **concurrent antidepressant medication**.
- Relying solely on CBT may delay the stabilization of mood and physiological symptoms like **anhedonia and fatigue** provided by pharmacological support.
*Commence mirtazapine 15mg at night and arrange weekly follow-up*
- **Mirtazapine** is often a second-line option and is typically reserved for patients who cannot tolerate SSRIs or have specific needs like **severe insomnia** or **weight loss**.
- Although weekly follow-up is safe, **combination therapy** with psychological intervention is still standard practice for this severity level.
*Admit to psychiatric inpatient unit for stabilisation*
- **Inpatient admission** is not indicated as the patient reports only **passive suicidal ideation** and lacks active plans, intent, or means.
- He possesses strong **protective factors**, including two years of alcohol abstinence and active engagement with **support groups** like AA.
Question 119: A 55-year-old woman with recurrent depressive disorder is currently in remission on fluoxetine 20mg daily, which she has been taking for 18 months following her third depressive episode. She asks about stopping her medication as she feels well. Her previous episodes occurred 3 years ago and 6 years ago, each lasting 4-6 months. What is the most appropriate advice regarding continuation of antidepressant therapy?
A. Continue fluoxetine for at least another 6 months then review
B. Continue fluoxetine for at least 2 years from achieving remission (Correct Answer)
C. Begin gradual dose reduction over 4 weeks
D. Switch to a lower dose of 10mg daily for maintenance
E. Continue fluoxetine indefinitely given the recurrent nature
Explanation: ***Continue fluoxetine for at least 2 years from achieving remission***- For patients with a history of **two or more depressive episodes**, like this patient with her third, NICE guidelines recommend continuing antidepressant therapy for at least **2 years** from achieving remission to significantly reduce the risk of relapse.- Maintaining the **full therapeutic dose** that led to remission (fluoxetine 20mg) is crucial for effective long-term prevention of future depressive episodes.*Continue fluoxetine for at least another 6 months then review*- A **6-month continuation period** is the standard recommendation for a **single episode** of depression after remission, not for recurrent cases.- Given this patient's history of **three depressive episodes**, a 6-month period is insufficient and would put her at a high risk of early relapse.*Begin gradual dose reduction over 4 weeks*- Initiating a **dose reduction** or stopping medication now is premature as the patient has not yet completed the recommended **2-year prophylaxis** period for recurrent depression.- Premature cessation of antidepressants in a patient with **recurrent depressive disorder** carries a very high risk of immediate or early relapse.*Switch to a lower dose of 10mg daily for maintenance*- Current practice guidelines advise against using a **lower
Question 120: A 38-year-old woman with panic disorder has been experiencing frequent panic attacks in crowded places. She has started avoiding supermarkets, public transport, and social gatherings. Her panic attacks are well controlled on sertraline 100mg daily, but the avoidance behaviour persists. What is the most appropriate psychological intervention to address her avoidance behaviour?
A. Mindfulness-based cognitive therapy
B. Brief dynamic interpersonal therapy
C. Graded exposure therapy (Correct Answer)
D. Acceptance and commitment therapy
E. Eye movement desensitisation and reprocessing
Explanation: ***Graded exposure therapy*** - This patient exhibits **agoraphobia** and significant **avoidance behavior** related to panic disorder, for which **graded exposure therapy** is the psychological treatment of choice. - It involves systematically and gradually exposing the patient to feared situations in a **hierarchical manner**, allowing for **habituation** and reduction of anxiety and avoidance.*Mindfulness-based cognitive therapy* - This intervention is primarily indicated for preventing **relapse in recurrent depression** and managing chronic pain or stress, rather than treating specific phobic avoidance.- It focuses on changing the patient's relationship with thoughts and feelings through **mindfulness practices**, not direct behavioral modification for agoraphobia.*Brief dynamic interpersonal therapy* - This is an evidence-based treatment primarily for **depression** that focuses on current interpersonal relationships and social functioning.- It is not considered a first-line or most appropriate treatment for **panic disorder with agoraphobia** or specific avoidance behaviors.*Acceptance and commitment therapy* - While it incorporates mindfulness and aims to increase **psychological flexibility**, it is not the primary gold-standard intervention for targeted avoidance in panic disorder with agoraphobia.- Unlike **graded exposure therapy**, its evidence base for directly correcting **agoraphobic avoidance behaviors** is less robust than standard CBT approaches that include exposure.*Eye movement desensitisation and reprocessing* - This specialized therapy is primarily used for the treatment of **Post-Traumatic Stress Disorder (PTSD)** and other trauma-related conditions.- It has no established role as a first-line treatment for **panic disorder with agoraphobia** or general avoidance of crowded places.
