Common Mental Disorders — MCQs
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A 29-year-old man presents with panic disorder and reports that his panic attacks are always triggered by being in crowded places like supermarkets or public transport. Between attacks, he experiences persistent anticipatory anxiety about these situations. He has started avoiding shopping and using buses. What is the most accurate description of his clinical presentation?
According to the ICD-10 diagnostic criteria, what is the minimum number of symptoms required from the list of cognitive and somatic symptoms to diagnose a depressive episode, assuming both core symptoms are present?
A 33-year-old woman with panic disorder has been taking paroxetine 40mg daily for 9 months with excellent response. She has had no panic attacks for 6 months and has successfully overcome her agoraphobic avoidance. She now wishes to conceive and is concerned about medication risks in pregnancy. What is the most appropriate management regarding her paroxetine?
A 41-year-old teacher with a 9-month history of generalised anxiety disorder has completed 16 weeks of high-intensity CBT with good engagement but minimal symptom improvement. She has tried sertraline 200mg daily for 12 weeks (maximum tolerated dose due to gastrointestinal side effects) with no response. She continues to experience severe anxiety affecting her work performance. What is the most appropriate next pharmacological step?
A 57-year-old woman presents with an 8-week history of low mood, anhedonia, fatigue, and weight loss. She also reports subjective memory problems and difficulty making simple decisions. Her daughter mentions she has become increasingly withdrawn. The patient expresses concern that she has early-onset dementia. Cognitive screening with MMSE scores 28/30. What feature of her presentation most strongly suggests a depressive disorder rather than a neurodegenerative condition?
A 43-year-old woman with recurrent depressive disorder has been taking citalopram 40mg daily for 14 months following her third depressive episode. She has been in full remission for 10 months with no residual symptoms. She asks about stopping her antidepressant. According to evidence-based guidelines, what is the most appropriate recommendation regarding continuation of treatment?
A 34-year-old man with generalised anxiety disorder presents with a 6-month history of excessive worry about work performance, finances, and family health. He reports constant muscle tension, difficulty concentrating, and irritability. He has tried cognitive behavioural therapy for 10 weeks with minimal improvement. He has no significant past medical history and takes no regular medications. What is the most appropriate pharmacological intervention?
A 51-year-old woman presents to her GP with a 7-week history of low mood, reduced concentration, and disturbed sleep. She reports loss of appetite with 4kg weight loss. She describes feeling guilty about minor past events and has thoughts that life is not worth living, though no active suicidal plans. Her PHQ-9 score is 18. Physical examination and blood tests including thyroid function are normal. What is the most appropriate initial management?
A 47-year-old man presents with a 12-week history of low mood, anhedonia, fatigue, poor concentration, and insomnia with early morning wakening. He has lost interest in previously enjoyed activities and describes feeling hopeless about the future. His PHQ-9 score is 22. He works as a bus driver and mentions he has been having occasional thoughts that life is not worth living, but denies any suicidal plans or intent. He has no past psychiatric history. What is the most important initial assessment that must be completed before considering treatment options?
A 31-year-old woman with a new diagnosis of panic disorder is commenced on escitalopram 5mg daily. On day 4 of treatment, she contacts the surgery reporting that her anxiety has worsened, with increased restlessness and one additional panic attack. She is concerned the medication is making her worse and wants to stop it. What is the most appropriate management advice?
Common Mental Disorders UK Medical PG Practice Questions and MCQs
Question 21: A 29-year-old man presents with panic disorder and reports that his panic attacks are always triggered by being in crowded places like supermarkets or public transport. Between attacks, he experiences persistent anticipatory anxiety about these situations. He has started avoiding shopping and using buses. What is the most accurate description of his clinical presentation?
- A. Panic disorder with agoraphobia (Correct Answer)
- B. Agoraphobia without panic disorder
- C. Social anxiety disorder with panic attacks
- D. Situationally-bound panic attacks indicating specific phobia
- E. Panic disorder with situational triggers only
Explanation: ***Panic disorder with agoraphobia*** - The patient experiences recurrent **panic attacks** and persistent **anticipatory anxiety**, indicative of panic disorder. - The **avoidance of crowded places** like supermarkets and public transport, fearing panic symptoms where escape is difficult, is a hallmark of **agoraphobia**. *Agoraphobia without panic disorder* - This diagnosis is used when agoraphobia occurs in the absence of a history of **panic attacks**, which is not the case for this patient. - The patient clearly reports experiencing **panic attacks**, making this option inaccurate. *Social anxiety disorder with panic attacks* - **Social anxiety disorder** is characterized by a fear of **negative evaluation** in social situations, whereas this patient's primary fear is of having a **panic attack** itself. - His avoidance is driven by the potential for panic symptoms, not by fear of judgment from others. *Situationally-bound panic attacks indicating specific phobia* - While the attacks are situationally bound, **specific phobias** involve a much more circumscribed fear of a particular object or situation, not the broad pattern of **agoraphobic avoidance**. - The pervasive avoidance across multiple distinct public environments and the presence of **panic disorder** rule out a simple specific phobia. *Panic disorder with situational triggers only* - This option does not fully capture the clinical picture, as the patient also exhibits significant **agoraphobic avoidance** and **anticipatory anxiety** related to these situations. - The development of **agoraphobia** is a distinct and crucial component of his presentation, extending beyond mere situational triggers.
Question 22: According to the ICD-10 diagnostic criteria, what is the minimum number of symptoms required from the list of cognitive and somatic symptoms to diagnose a depressive episode, assuming both core symptoms are present?
- A. At least 2 additional symptoms for mild, 3 for moderate, and 4 for severe (Correct Answer)
- B. At least 2 additional symptoms regardless of severity
- C. At least 3 additional symptoms for mild, 4 for moderate, and 5 for severe
- D. At least 4 additional symptoms regardless of severity
- E. At least 1 additional symptom for mild, 2 for moderate, and 3 for severe
Explanation: ***At least 2 additional symptoms for mild, 3 for moderate, and 4 for severe*** - In **ICD-10**, the diagnosis of a depressive episode requires a combination of **core symptoms** (mood, anhedonia, energy) and **additional symptoms** (e.g., sleep, guilt, concentration). - To reach the diagnostic threshold, a **mild episode** requires 2 core + 2 additional (total 4), a **moderate episode** requires 2 core + 3-4 additional (total 6), and a **severe episode** requires 3 core + 4 or more additional (total 7+). *At least 2 additional symptoms regardless of severity* - This violates the tiered **severity classification** used in the ICD-10, which scales symptoms based on the intensity of the clinical presentation. - While 2 additional symptoms satisfy the criteria for a **mild episode**, they are insufficient for categorizing **moderate or severe** depression. *At least 3 additional symptoms for mild, 4 for moderate, and 5 for severe* - This overestimates the requirements for a **mild depressive episode**, which only requires a minimum of **two additional symptoms** alongside two core symptoms. - This scale shifts the threshold higher than what is clinically defined in the **ICD-10 Blue Book** criteria. *At least 4 additional symptoms regardless of severity* - Using a fixed number of additional symptoms ignores the **diagnostic hierarchy** and fails to differentiate between levels of **functional impairment**. - A requirement of 4 additional symptoms would exclude patients who clinically present with **mild depression**, leading to under-diagnosis. *At least 1 additional symptom for mild, 2 for moderate, and 3 for severe* - These thresholds are too low; a **mild depressive episode** must have a total of at least **four symptoms** in total to meet diagnostic standards. - Using these criteria would lead to the **over-diagnosis** of depression by including patients with transient or normal sadness that does not meet the clinical duration or symptom count.
Question 23: A 33-year-old woman with panic disorder has been taking paroxetine 40mg daily for 9 months with excellent response. She has had no panic attacks for 6 months and has successfully overcome her agoraphobic avoidance. She now wishes to conceive and is concerned about medication risks in pregnancy. What is the most appropriate management regarding her paroxetine?
- A. Continue paroxetine as the risk of relapse outweighs teratogenic risk
- B. Switch to sertraline as it has a better safety profile in pregnancy (Correct Answer)
- C. Gradually discontinue paroxetine and remain off medication during pregnancy
- D. Continue paroxetine in first trimester then switch to sertraline in second trimester
- E. Stop paroxetine immediately and commence propranolol
Explanation: ***Switch to sertraline as it has a better safety profile in pregnancy*** - **Paroxetine** is specifically avoided in women planning pregnancy due to an increased risk of **congenital heart defects** (such as ventricular septal defects) during the first trimester. - **Sertraline** is often the preferred SSRI during pregnancy and breastfeeding because it has a **well-established safety profile** and lower rates of placental transfer. *Continue paroxetine as the risk of relapse outweighs teratogenic risk* - While preventing relapse is critical, paroxetine's specific association with **fetal malformations** makes it less desirable than other SSRIs with better safety data. - Since the patient is in the **pre-conception planning** phase, there is an ideal window to switch to a safer alternative like **sertraline** or fluoxetine. *Gradually discontinue paroxetine and remain off medication during pregnancy* - This patient has a history of **panic disorder with agoraphobia**, which carries a high risk of **relapse** during the physiological and psychological stress of pregnancy. - Untreated maternal mental illness is associated with poor neonatal outcomes, making **maintenance therapy** with a safer medication preferable to total discontinuation. *Continue paroxetine in first trimester then switch to sertraline in second trimester* - This approach is incorrect because the **first trimester** is the period of organogenesis when the teratogenic risk of paroxetine is most significant. - Switching mid-pregnancy unnecessarily exposes the fetus to **multiple different medications**, which is generally avoided in perinatal pharmacology. *Stop paroxetine immediately and commence propranolol* - **Propranolol** is used to manage physical symptoms of anxiety but is not an effective primary treatment for maintaining remission in **panic disorder**. - Stopping paroxetine abruptly can cause **discontinuation syndrome** (especially likely with paroxetine due to its short half-life) and rapid symptom recurrence.
Question 24: A 41-year-old teacher with a 9-month history of generalised anxiety disorder has completed 16 weeks of high-intensity CBT with good engagement but minimal symptom improvement. She has tried sertraline 200mg daily for 12 weeks (maximum tolerated dose due to gastrointestinal side effects) with no response. She continues to experience severe anxiety affecting her work performance. What is the most appropriate next pharmacological step?
- A. Switch to venlafaxine 75mg daily and titrate
- B. Add pregabalin 150mg twice daily to sertraline
- C. Switch to mirtazapine 30mg at night
- D. Add quetiapine 50mg at night to sertraline
- E. Switch to duloxetine 60mg daily (Correct Answer)
Explanation: ***Switch to duloxetine 60mg daily*** - Per **NICE guidelines**, if a patient with **Generalized Anxiety Disorder (GAD)** fails to respond to an SSRI (like sertraline), the next recommended step is switching to an **SNRI** such as duloxetine. - **Duloxetine 60mg** is an effective starting dose and offers a straightforward trial since the patient has already completed adequate **high-intensity CBT** and maximum-dose SSRI therapy. *Switch to venlafaxine 75mg daily and titrate* - While **venlafaxine** is also an SNRI recommended for GAD, the starting dose of 75mg often requires **careful titration** to reach an effective therapeutic range compared to duloxetine. - It is a valid alternative, but typically considered alongside or after other SNRI options depending on the clinical profile. *Add pregabalin 150mg twice daily to sertraline* - **Pregabalin** is used if SSRIs and SNRIs are not tolerated or are contraindicated, rather than as a primary augmentation for a partial SSRI failure. - Switching to a different class of mainline antidepressants (SNRI) is prioritized over **augmentation** after only one failed medication trial. *Switch to mirtazapine 30mg at night* - **Mirtazapine** is not considered a first-line pharmacological treatment for GAD according to evidence-based guidelines. - It is more commonly utilized for **Major Depressive Disorder**, particularly when insomnia or weight loss are concurrent symptoms. *Add quetiapine 50mg at night to sertraline* - **Atypical antipsychotics** like quetiapine are generally reserved for highly treatment-resistant cases under **specialist supervision**. - NICE guidelines do not support routine augmentation with quetiapine for GAD until multiple standard monotherapies have been exhausted.
Question 25: A 57-year-old woman presents with an 8-week history of low mood, anhedonia, fatigue, and weight loss. She also reports subjective memory problems and difficulty making simple decisions. Her daughter mentions she has become increasingly withdrawn. The patient expresses concern that she has early-onset dementia. Cognitive screening with MMSE scores 28/30. What feature of her presentation most strongly suggests a depressive disorder rather than a neurodegenerative condition?
- A. The relatively short duration of symptoms (8 weeks)
- B. The presence of anhedonia and low mood
- C. The pattern of cognitive complaints being subjective with preserved objective testing (Correct Answer)
- D. The presence of weight loss
- E. The social withdrawal reported by family
Explanation: ***The pattern of cognitive complaints being subjective with preserved objective testing*** - In **pseudodementia** (depression-related cognitive impairment), patients are often **highly distressed** and vocal about their memory loss, while **objective testing** (like the MMSE score of 28/30) remains largely normal. - Conversely, patients with **neurodegenerative dementia** typically lack insight into their deficits (**anosognosia**) and attempt to minimize or hide cognitive failures that are evident on objective screening. *The relatively short duration of symptoms (8 weeks)* - While an **acute/subacute onset** favors depression, some neurodegenerative conditions like **Creutzfeldt-Jakob disease** or rapidly progressive dementias can present within short timeframes. - Duration alone is less specific than the discrepancy between **subjective distress** and **objective performance** in distinguishing the two. *The presence of anhedonia and low mood* - Although these are core symptoms of **Major Depressive Disorder**, they frequently occur as **comorbidities** or prodromal symptoms in the early stages of dementia. - The presence of mood symptoms does not rule out a neurodegenerative process, making it a weaker discriminator than the **cognitive testing pattern**. *The presence of weight loss* - **Weight loss** is a non-specific biological symptom that occurs in severe depression but is also common in various dementias due to **forgetting to eat** or metabolic changes. - Because it is a feature of both systemic illness and psychiatric disorders, it cannot reliably differentiate between **pseudodementia** and true dementia. *The social withdrawal reported by family* - **Social withdrawal** is common in depression due to **anergy** and lack of interest, but it is also a hallmark of **frontotemporal dementia** or early Alzheimer's as patients struggle with social cues. - Since both conditions result in the patient becoming increasingly withdrawn, this feature lacks the **diagnostic specificity** provided by formal cognitive screening.
Question 26: A 43-year-old woman with recurrent depressive disorder has been taking citalopram 40mg daily for 14 months following her third depressive episode. She has been in full remission for 10 months with no residual symptoms. She asks about stopping her antidepressant. According to evidence-based guidelines, what is the most appropriate recommendation regarding continuation of treatment?
- A. Continue citalopram for at least another 10 months as she has had multiple episodes (Correct Answer)
- B. Gradually reduce and stop citalopram over 4 weeks as she has been well for 10 months
- C. Switch to a lower dose of 20mg and continue indefinitely
- D. Continue citalopram indefinitely as she has had three episodes
- E. Stop citalopram immediately as the risk of relapse is now minimal
Explanation: ***Continue citalopram for at least another 10 months as she has had multiple episodes*** - For patients with **Recurrent Depressive Disorder** (three or more episodes), clinical guidelines like **NICE** recommend continuing antidepressant therapy for at least **2 years**. - Since she has completed 14 months of treatment, she requires at least another 10 months to fulfill the recommended duration for **relapse prevention**. *Gradually reduce and stop citalopram over 4 weeks as she has been well for 10 months* - While a 6-9 month continuation is standard for a single episode, **recurrent episodes** carry a much higher risk of relapse, necessitating longer-term therapy. - Stopping after only 10 months of remission in a patient with three episodes significantly increases the risk of a **depressive relapse**. *Switch to a lower dose of 20mg and continue indefinitely* - Maintenance therapy should generally be conducted at the **full therapeutic dose** that achieved remission, rather than a sub-therapeutic "maintenance" dose. - Lowering the dose prematurely (before the 2-year mark) does not provide the evidence-based **prophylactic effect** needed for recurrent depression. *Continue citalopram indefinitely as she has had three episodes* - While indefinite treatment is an option for some high-risk patients, guidelines prioritize a **review after 2 years** rather than an automatic lifetime prescription. - The immediate recommendation is to complete the 2-year course before reassessing the need for **lifelong maintenance** based on patient preference and risk factors. *Stop citalopram immediately as the risk of relapse is now minimal* - Abrupt cessation is contraindicated as it can cause **antidepressant discontinuation syndrome**, characterized by flu-like symptoms and irritability. - The risk of relapse remains high in the **first year** of remission for patients with a history of multiple depressive episodes.
Question 27: A 34-year-old man with generalised anxiety disorder presents with a 6-month history of excessive worry about work performance, finances, and family health. He reports constant muscle tension, difficulty concentrating, and irritability. He has tried cognitive behavioural therapy for 10 weeks with minimal improvement. He has no significant past medical history and takes no regular medications. What is the most appropriate pharmacological intervention?
- A. Propranolol 40mg three times daily
- B. Diazepam 5mg twice daily for 2 weeks
- C. Sertraline 50mg once daily (Correct Answer)
- D. Buspirone 10mg three times daily
- E. Pregabalin 150mg twice daily
Explanation: ***Sertraline 50mg once daily*** - **Selective Serotonin Reuptake Inhibitors (SSRIs)** like sertraline are the **first-line pharmacological treatment** for Generalized Anxiety Disorder (GAD), especially when cognitive behavioral therapy (CBT) has shown minimal improvement. - Sertraline effectively addresses the **chronic excessive worry**, muscle tension, and difficulty concentrating, which are core symptoms of GAD, making it the most appropriate long-term intervention. *Propranolol 40mg three times daily* - **Propranolol**, a beta-blocker, is effective for managing **autonomic symptoms of anxiety** such as palpitations, tremor, and sweating, but it does not treat the cognitive aspects of worry and tension in GAD. - It is typically used for **situational anxiety** or as an adjunct for specific somatic symptoms, not as a primary monotherapy for the overall disorder. *Diazepam 5mg twice daily for 2 weeks* - **Benzodiazepines** like diazepam are useful for **short-term, acute anxiety relief** due to their rapid onset of action, but they carry a high risk of **dependence, tolerance, and withdrawal symptoms** with prolonged use. - They are not recommended for long-term management of chronic GAD, especially for a 6-month history, and should be limited to very brief durations (2-4 weeks) if used at all. *Buspirone 10mg three times daily* - **Buspirone** is a non-benzodiazepine anxiolytic that can be used for GAD, but its **onset of action is delayed** (often 2-4 weeks) and its efficacy is generally considered less robust than SSRIs. - It is often reserved as a **second-line agent** for GAD, particularly in patients who cannot tolerate or do not respond to SSRIs/SNRIs. *Pregabalin 150mg twice daily* - **Pregabalin** is an effective treatment for GAD but is typically considered a **second-line or alternative treatment** for patients who have not responded to or tolerated SSRIs or SNRIs. - It is also associated with potential side effects such as **sedation and dizziness**, and has a risk of **misuse and dependence**, making it less ideal as a first-line choice.
Question 28: A 51-year-old woman presents to her GP with a 7-week history of low mood, reduced concentration, and disturbed sleep. She reports loss of appetite with 4kg weight loss. She describes feeling guilty about minor past events and has thoughts that life is not worth living, though no active suicidal plans. Her PHQ-9 score is 18. Physical examination and blood tests including thyroid function are normal. What is the most appropriate initial management?
- A. Start fluoxetine 20mg daily and arrange review in 2 weeks (Correct Answer)
- B. Refer urgently to the community mental health team
- C. Prescribe a 2-week course of zopiclone for sleep disturbance
- D. Recommend self-help materials and review in 4 weeks
- E. Start mirtazapine 15mg at night and arrange review in 1 week
Explanation: ***Start fluoxetine 20mg daily and arrange review in 2 weeks*** - A **PHQ-9 score of 18** indicates **moderate to severe depression**, for which NICE guidelines recommend starting a first-line antidepressant like a **Selective Serotonin Reuptake Inhibitor (SSRI)** such as fluoxetine. - Reviewing the patient in **2 weeks** is the standard safety protocol to monitor for early side effects and assess for any increases in **suicidal ideation** following the initiation of treatment. *Refer urgently to the community mental health team* - Urgent referral is reserved for patients at **immediate risk** of self-harm, active suicidal plans, or those demonstrating **psychotic symptoms**. - This patient reports only **passive suicidal ideation** without active plans, making initial primary care management with close monitoring appropriate. *Prescribe a 2-week course of zopiclone for sleep disturbance* - **Zopiclone** is a hypnotic agent that treats a symptom (insomnia) but does not address the **underlying depressive episode**, which is the primary cause of the sleep disturbance. - Use of **Z-drugs** should be restricted due to the high risk of **dependency** and tolerance, especially when the core mood disorder remains untreated. *Recommend self-help materials and review in 4 weeks* - Guided **self-help** or watchful waiting is typically reserved for **subthreshold or mild depression** (PHQ-9 scores below 10-15). - Given the **biological symptoms** (weight loss, sleep disturbance) and severity (PHQ-9 18), relying solely on self-help would be inadequate management. *Start mirtazapine 15mg at night and arrange review in 1 week* - While **mirtazapine** is an effective antidepressant and can assist with sleep and appetite, **SSRIs** are generally preferred as first-line therapy due to their superior safety profile and tolerability for initial treatment. - A **one-week review** is usually reserved for patients under 25 or those identified as high-risk for specific reasons, whereas two weeks is a standard initial review for this demographic.
Question 29: A 47-year-old man presents with a 12-week history of low mood, anhedonia, fatigue, poor concentration, and insomnia with early morning wakening. He has lost interest in previously enjoyed activities and describes feeling hopeless about the future. His PHQ-9 score is 22. He works as a bus driver and mentions he has been having occasional thoughts that life is not worth living, but denies any suicidal plans or intent. He has no past psychiatric history. What is the most important initial assessment that must be completed before considering treatment options?
- A. Full cardiovascular assessment including exercise ECG due to his occupation
- B. Thyroid function tests to exclude organic causes
- C. Cognitive assessment to exclude early dementia
- D. Comprehensive suicide risk assessment (Correct Answer)
- E. Assessment for bipolar disorder through detailed mood history
Explanation: ***Comprehensive suicide risk assessment*** - The patient's **low mood**, **anhedonia**, **hopelessness**, and reported **thoughts that life is not worth living** (passive suicidal ideation) necessitate an immediate and thorough assessment of **suicide risk**. - A PHQ-9 score of 22 indicates **severe depression**, which is a significant risk factor, making patient safety the **highest priority** before any other diagnostic or treatment steps. *Full cardiovascular assessment including exercise ECG due to his occupation* - While his occupation as a **bus driver** implies a responsibility for public safety, a cardiovascular assessment is **not the most urgent initial step** compared to addressing immediate mental health risks. - This assessment would be more relevant later, especially if considering certain **antidepressants** that can affect cardiac function, but not as the first step for suicidal ideation. *Thyroid function tests to exclude organic causes* - **Thyroid dysfunction** can mimic depressive symptoms and is part of a routine workup for depression to rule out organic causes. - However, excluding a physical cause is secondary to ensuring the patient's **immediate safety** when **suicidal thoughts** are present. *Cognitive assessment to exclude early dementia* - **Poor concentration** and other cognitive complaints are common symptoms of severe depression, sometimes referred to as **pseudodementia**, and are expected given his presentation. - A cognitive assessment is generally considered after addressing acute mood symptoms or in cases with more prominent or persistent **memory deficits** not explained by mood. *Assessment for bipolar disorder through detailed mood history* - It is crucial to screen for **bipolar disorder** before initiating antidepressant monotherapy to prevent **manic or hypomanic switches**, especially as this patient has no past psychiatric history. - Nevertheless, the presence of **suicidal ideation** makes a comprehensive **suicide risk assessment** the absolute first priority to ensure the patient's safety.
Question 30: A 31-year-old woman with a new diagnosis of panic disorder is commenced on escitalopram 5mg daily. On day 4 of treatment, she contacts the surgery reporting that her anxiety has worsened, with increased restlessness and one additional panic attack. She is concerned the medication is making her worse and wants to stop it. What is the most appropriate management advice?
- A. Stop escitalopram and switch immediately to propranolol
- B. Stop escitalopram and arrange urgent psychiatric assessment
- C. Continue escitalopram, provide reassurance about transient initial anxiety increase, and review in one week (Correct Answer)
- D. Increase escitalopram dose to 10mg immediately to achieve faster therapeutic effect
- E. Stop escitalopram and trial a different SSRI such as sertraline
Explanation: ***Continue escitalopram, provide reassurance about transient initial anxiety increase, and review in one week*** - Initial worsening of anxiety, known as **'jitteriness syndrome'** or **SSRI activation syndrome**, is a common and **transient** side effect occurring within the first **1-2 weeks** of starting SSRIs, especially for anxiety disorders like panic disorder. - Patients need **reassurance** that this effect is temporary and that continued treatment is essential for achieving the full **therapeutic benefits** and long-term symptom control. A **review in one week** is appropriate to monitor progress and reinforce adherence. *Stop escitalopram and switch immediately to propranolol* - **Propranolol** is a beta-blocker primarily used to manage **somatic symptoms** of anxiety (e.g., palpitations, tremor) but is not an effective **first-line monotherapy** for the core symptoms of panic disorder. - Abruptly stopping an SSRI during the initial phase prevents the patient from reaching the **therapeutic window** and misses the opportunity for the medication to become effective. *Stop escitalopram and arrange urgent psychiatric assessment* - The described symptoms (worsened anxiety, restlessness, one additional panic attack) are expected **initial side effects** of SSRIs and do not typically indicate a **psychiatric emergency** or severe deterioration warranting urgent assessment. - Such a response is a predictable pharmacological effect, not necessarily a sign of **suicidal ideation** or severe functional impairment requiring immediate specialist intervention. *Increase escitalopram dose to 10mg immediately to achieve faster therapeutic effect* - Increasing the dose of escitalopram would likely **exacerbate** the initial anxiety, restlessness, and risk of panic attacks, making the side effects even more pronounced and potentially leading to **treatment non-adherence**. - SSRIs for panic disorder are usually started at **very low doses** (e.g., 5mg for escitalopram) precisely to mitigate the **initial activation syndrome** and improve tolerability. *Stop escitalopram and trial a different SSRI such as sertraline* - The **initial activation syndrome** (worsened anxiety, restlessness) is a **class effect** of SSRIs; switching to another SSRI like sertraline would likely induce similar initial side effects. - The issue is not the specific SSRI but the **physiological adjustment** period, which requires patient education and reassurance, not a change in medication at this early stage.
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