A 56-year-old man with depression has been taking sertraline 100mg daily for 8 weeks with good response. However, he reports new-onset sexual dysfunction including delayed ejaculation and reduced libido. He wishes to continue antidepressant treatment but is distressed by these side effects. What is the most appropriate management strategy?
Q162
A 38-year-old woman presents with recurrent panic attacks and has developed significant avoidance of situations where escape might be difficult. She has begun cognitive behavioral therapy (CBT) but requests medication to help manage her symptoms more quickly. According to NICE guidelines, what is the most appropriate initial pharmacological approach for panic disorder?
Q163
A 52-year-old man with a 4-week history of low mood, anhedonia, and early morning wakening is started on citalopram 20mg daily. He returns after 10 days reporting no improvement in symptoms and requests a change of medication. What is the most appropriate management?
Q164
A 28-year-old woman describes experiencing sudden episodes of intense fear accompanied by palpitations, sweating, trembling, shortness of breath, and a sense of impending doom. These episodes peak within 10 minutes and last approximately 20-30 minutes. She has started avoiding crowded places where previous episodes occurred. Between episodes, she constantly worries about having another attack. What is the core diagnostic feature of her condition?
Q165
A 32-year-old man presents with a 3-month history of persistent worry about multiple aspects of his life including finances, health, and work performance. He reports difficulty controlling these worries, muscle tension, irritability, and poor concentration. He experiences restlessness and fatigue. His symptoms occur on most days and significantly impact his daily functioning. What is the most likely diagnosis?
Q166
A 45-year-old woman presents to her GP with low mood, poor sleep, and reduced appetite for the past 6 weeks. She describes feeling worthless and has difficulty concentrating at work. She denies suicidal ideation. On examination, she appears tearful and has psychomotor retardation. Her PHQ-9 score is 18. What is the most appropriate first-line pharmacological treatment?
Common Mental Disorders UK Medical PG Practice Questions and MCQs
Question 161: A 56-year-old man with depression has been taking sertraline 100mg daily for 8 weeks with good response. However, he reports new-onset sexual dysfunction including delayed ejaculation and reduced libido. He wishes to continue antidepressant treatment but is distressed by these side effects. What is the most appropriate management strategy?
A. Add sildenafil as needed
B. Switch to mirtazapine (Correct Answer)
C. Reduce sertraline dose to 50mg daily
D. Add bupropion to current treatment
E. Continue sertraline and provide reassurance that symptoms will resolve
Explanation: ***Switch to mirtazapine***
- **Mirtazapine** is a noradrenergic and specific serotonergic antidepressant (**NaSSA**) known for its very low incidence of **sexual dysfunction** compared to **SSRIs**.
- It is an excellent choice for patients experiencing distressing sexual side effects like **delayed ejaculation** or **reduced libido** because it does not have the same direct serotonergic effects on 5-HT2 and 5-HT3 receptors implicated in SSRI-induced sexual side effects.
*Add sildenafil as needed*
- While **sildenafil** can be effective for **erectile dysfunction**, it typically does not address **reduced libido** or **delayed ejaculation** caused by SSRIs.
- This strategy adds an additional medication and does not resolve the underlying antidepressant-induced sexual side effect that is distressing to the patient.
*Reduce sertraline dose to 50mg daily*
- Reducing the dose of **sertraline** may potentially alleviate some side effects, but it carries a significant risk of **depressive relapse** or loss of the previously achieved therapeutic response.
- Furthermore, **sexual dysfunction** can often persist even at lower therapeutic doses of **SSRIs**, meaning this approach might not fully resolve the patient's distress.
*Add bupropion to current treatment*
- While **bupropion** is known for its favorable sexual side effect profile, adding it to **sertraline** in this context (especially in the UK where it's not a licensed monotherapy for depression) increases the complexity of **polypharmacy** and potential drug interactions.
- This strategy might not definitively resolve the SSRI-induced sexual dysfunction and could introduce new side effects or compliance issues.
*Continue sertraline and provide reassurance that symptoms will resolve*
- **SSRI-induced sexual dysfunction** is often persistent and does not spontaneously resolve over time; it is a leading cause of **medication non-adherence**.
- Simply offering reassurance is insufficient given the patient's reported distress, and there are more proactive and effective management strategies available.
Question 162: A 38-year-old woman presents with recurrent panic attacks and has developed significant avoidance of situations where escape might be difficult. She has begun cognitive behavioral therapy (CBT) but requests medication to help manage her symptoms more quickly. According to NICE guidelines, what is the most appropriate initial pharmacological approach for panic disorder?
A. Propranolol 40mg as needed before anxiety-provoking situations
B. Diazepam 5mg three times daily for 2 weeks
C. Sertraline 50mg once daily (Correct Answer)
D. Buspirone 5mg three times daily
E. Pregabalin 75mg twice daily
Explanation: ***Sertraline 50mg once daily***
- **SSRIs** like sertraline are the **first-line pharmacological treatment** for **panic disorder** according to **NICE guidelines** due to their proven efficacy and safety profile.
- Patients should be advised that while SSRIs may initially increase anxiety, they should be continued for at least **6 months** after remission to prevent relapse.
*Propranolol 40mg as needed before anxiety-provoking situations*
- **Beta-blockers** are only effective at managing the **autonomic symptoms** of anxiety, such as palpitations and tremors, but they do not treat the underlying panic disorder or cognitive symptoms.
- They are not recommended as a primary treatment for **panic attacks** or the cognitive components of the disorder like **avoidance behavior**.
*Diazepam 5mg three times daily for 2 weeks*
- **Benzodiazepines** are generally avoided in the long-term management of panic disorder due to the significant risk of **dependence** and **tolerance**.
- While they provide rapid relief in acute crises, they are not recommended for routine management and can interfere with the efficacy of **CBT**.
*Buspirone 5mg three times daily*
- **Buspirone** is primarily used in the management of **Generalized Anxiety Disorder (GAD)** rather than panic disorder.
- Evidence for its effectiveness in treating recurrent **panic attacks** or agoraphobia is insufficient, making it an inappropriate choice here.
*Pregabalin 75mg twice daily*
- **Pregabalin** is licensed and recommended by NICE as a subsequent option for **GAD**, but it is not a first-line agent for panic disorder.
- Its use is typically reserved for cases where multiple **SSRIs** or **SNRIs** have failed or are not tolerated well by the patient.
Question 163: A 52-year-old man with a 4-week history of low mood, anhedonia, and early morning wakening is started on citalopram 20mg daily. He returns after 10 days reporting no improvement in symptoms and requests a change of medication. What is the most appropriate management?
A. Switch to venlafaxine immediately
B. Increase citalopram to 40mg daily
C. Add mirtazapine to current treatment
D. Continue current dose and review in 2-3 weeks (Correct Answer)
E. Switch to fluoxetine 20mg daily
Explanation: ***Continue current dose and review in 2-3 weeks***
- Antidepressants like **citalopram** typically require **2 to 4 weeks** of consistent use before a significant therapeutic effect is observed.
- Since the patient has only been on the medication for **10 days**, it is premature to assess efficacy, and clinical guidelines recommend waiting **4 weeks** before considering a change.
*Switch to venlafaxine immediately*
- **Venlafaxine**, an SNRI, is generally reserved as a second-line option for patients who do not respond to an adequate trial of an **SSRI**.
- Switching so early (10 days) unnecessarily exposes the patient to **withdrawal symptoms** or new side effects before the first treatment has been tested.
*Increase citalopram to 40mg daily*
- Increasing the dose is only indicated if there is a **partial response** or no response after a full **4 to 6-week trial** at the therapeutic starting dose.
- Raising the dose prematurely increases the risk of **dose-dependent adverse effects**, such as **QT interval prolongation**, without providing therapeutic benefit yet.
*Add mirtazapine to current treatment*
- **Augmentation therapy** is a specialized strategy used for **treatment-resistant depression**, not for patients just beginning their first course of medication.
- Combining antidepressants at this stage significantly increases the risk of **serotonin syndrome** and is not supported by initial treatment protocols.
*Switch to fluoxetine 20mg daily*
- Switching from one SSRI to another like **fluoxetine** is a valid strategy for non-responders, but only after the initial drug is proven ineffective over a **full course**.
- There is no clinical evidence that the patient is failing citalopram; they simply have not reached the **pharmacodynamic window** required for mood improvement.
Question 164: A 28-year-old woman describes experiencing sudden episodes of intense fear accompanied by palpitations, sweating, trembling, shortness of breath, and a sense of impending doom. These episodes peak within 10 minutes and last approximately 20-30 minutes. She has started avoiding crowded places where previous episodes occurred. Between episodes, she constantly worries about having another attack. What is the core diagnostic feature of her condition?
A. Avoidance of crowded places
B. Persistent worry about future attacks
C. Presence of autonomic symptoms during episodes
D. Recurrent unexpected panic attacks (Correct Answer)
E. Duration of individual episodes being less than 30 minutes
Explanation: ***Recurrent unexpected panic attacks***
- The hallmark of **panic disorder** is the presence of **recurrent, unexpected panic attacks** that occur without an obvious external trigger.
- Diagnosis requires these attacks to be followed by at least one month of **persistent concern** regarding future episodes or **maladaptive behavioral changes**.
*Avoidance of crowded places*
- This behavior is consistent with **agoraphobia**, which often co-occurs with panic disorder but is considered a distinct diagnosis or a **secondary manifestation**.
- While important for clinical management, it is a consequence of the underlying attacks rather than the **primary diagnostic criterion**.
*Persistent worry about future attacks*
- Termed **anticipatory anxiety**, this is a crucial component of panic disorder that follows the initial attacks.
- It acts as a **complicating feature** or criterion for the disorder, but it must be preceded by the **unexpected panic attacks** themselves.
*Presence of autonomic symptoms during episodes*
- Autonomic symptoms like **palpitations** and **sweating** are used to define a **panic attack** itself, requiring at least four such symptoms.
- Their presence indicates an episode has occurred but does not distinguish **panic disorder** from other anxiety disorders where situational attacks may occur.
*Duration of individual episodes being less than 30 minutes*
- The **rapid peaking** (usually within 10 minutes) and short duration are descriptive characteristics of a **panic attack profile**.
- However, specific **time limits** for the total duration of an attack are not core diagnostic criteria for the disorder itself.
Question 165: A 32-year-old man presents with a 3-month history of persistent worry about multiple aspects of his life including finances, health, and work performance. He reports difficulty controlling these worries, muscle tension, irritability, and poor concentration. He experiences restlessness and fatigue. His symptoms occur on most days and significantly impact his daily functioning. What is the most likely diagnosis?
A. Panic disorder
B. Social anxiety disorder
C. Generalised anxiety disorder (Correct Answer)
D. Obsessive-compulsive disorder
E. Adjustment disorder
Explanation: ***Generalised anxiety disorder***- This patient exhibits **excessive worry** about various life domains (finances, health, work) along with physical symptoms like **muscle tension**, **restlessness**, and **fatigue**.- While the DSM-5 typically requires symptoms for **6 months**, the cluster of persistent, uncontrollable worries and clinical distress strongly points to GAD as the most fitting diagnosis.*Panic disorder*- Characterized by recurrent, **unexpected panic attacks** which are discrete periods of intense fear with physical symptoms like palpitations or shortness of breath.- It involves a persistent concern about having **future attacks** rather than a generalized worry about daily life events.*Social anxiety disorder*- Primarily involves an intense fear of **scrutiny by others** or embarrassment in **social situations**.- The symptoms here are pervasive across multiple non-social areas such as work performance and finances, making social anxiety less likely.*Obsessive-compulsive disorder*- Defined by the presence of **obsessions** (intrusive, repetitive thoughts) and **compulsions** (repetitive behaviors performed to reduce anxiety).- This patient's worries are related to real-life concerns rather than the stereotypical, ego-dystonic themes seen in **OCD**.*Adjustment disorder*- Occurs in response to a **specific, identifiable stressor** within three months of its onset.- This patient's symptoms are generalized and multifaceted, lacking a single triggering event that would define an adjustment reaction.
Question 166: A 45-year-old woman presents to her GP with low mood, poor sleep, and reduced appetite for the past 6 weeks. She describes feeling worthless and has difficulty concentrating at work. She denies suicidal ideation. On examination, she appears tearful and has psychomotor retardation. Her PHQ-9 score is 18. What is the most appropriate first-line pharmacological treatment?
A. Mirtazapine 15mg once daily
B. Venlafaxine 75mg twice daily
C. Amitriptyline 75mg once daily
D. Sertraline 50mg once daily (Correct Answer)
E. Lofepramine 70mg twice daily
Explanation: ***Sertraline 50mg once daily***- In accordance with **NICE guidelines**, selective serotonin reuptake inhibitors (**SSRIs**) like sertraline are the first-line pharmacological treatment for **moderate depression** (PHQ-9 score 15-19).- Sertraline is preferred due to its **favorable side-effect profile**, lower toxicity in overdose, and cost-effectiveness compared to other antidepressant classes.*Amitriptyline 75mg once daily*- This is a **tricyclic antidepressant (TCA)**, which is generally avoided as first-line therapy because it is **highly toxic in overdose**.- It is associated with significant **anticholinergic side effects** such as dry mouth, blurred vision, and urinary retention, which reduce patient compliance.*Mirtazapine 15mg once daily*- While effective, this **NaSSA** (Noradrenergic and specific serotonergic antidepressant) is typically reserved as a **second-line** option or for patients with prominent insomnia/weight loss.- Common side effects include **sedation and weight gain**, making it less appropriate than an SSRI for initial management in most patients.*Venlafaxine 75mg twice daily*- This is a **Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)** usually indicated for **treatment-resistant depression** or after the failure of two SSRIs.- It requires careful monitoring due to the risk of **increased blood pressure** and more severe withdrawal symptoms upon discontinuation.*Lofepramine 70mg twice daily*- Despite being one of the **safer TCAs** regarding cardiovascular toxicity, it remains a secondary option behind SSRIs.- SSRIs are still prioritized as they are **better tolerated** and have fewer interactions with other medications compared to lofepramine.
