Common Mental Disorders — MCQs
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A 56-year-old woman with recurrent depressive disorder has been taking escitalopram 20mg daily for 3 years following her second depressive episode. She has been completely well for the past 2.5 years and wishes to discontinue her medication. She has no current symptoms and her PHQ-9 score is 2. What is the most appropriate advice regarding discontinuation?
A 39-year-old man with a 5-month history of generalised anxiety disorder has been taking sertraline 100mg daily for 10 weeks with only partial response. He continues to experience significant worry, muscle tension, and sleep disturbance. His GAD-7 score remains at 14. He has not engaged with any psychological therapy. What is the most appropriate next step in management?
A 42-year-old woman presents with a 6-week history of low mood, poor concentration, and disturbed sleep. She reports feeling tearful most days and has lost interest in her usual hobbies. She denies any suicidal thoughts. Her medical history includes well-controlled hypothyroidism on levothyroxine 100mcg daily. Recent thyroid function tests are within normal range. PHQ-9 score is 16. What is the most appropriate initial management?
A 34-year-old woman with panic disorder and moderate agoraphobia has been taking sertraline 150mg daily for 6 months with good control of panic attacks (reduced from daily to monthly). However, she remains significantly limited by avoidance of situations where escape might be difficult, including public transport, crowds, and enclosed spaces. She has not received any psychological therapy. Evaluating her current management, which intervention would be expected to provide the greatest additional benefit in addressing her residual functional impairment?
A 50-year-old woman presents with low mood, reduced energy, and anhedonia for 7 weeks. She also describes feeling extremely anxious most days, with palpitations, tremor, heat intolerance, and unintentional weight loss of 6 kg. On examination, her pulse is 102 bpm and irregular, she has a fine tremor, and a smooth goitre is palpable. What is the most appropriate initial investigation to guide management?
A 42-year-old man with generalised anxiety disorder has completed 12 weeks of individual CBT with good engagement but minimal symptom improvement. His GAD-7 score remains at 16 (moderate-severe anxiety). He has tried sertraline previously but discontinued it after 3 weeks due to gastrointestinal side effects. What is the most appropriate next step in his management?
A 37-year-old woman with recurrent depressive disorder has experienced three episodes in the past 6 years, each requiring treatment with antidepressants and each followed by full remission. She is currently well on citalopram 40mg daily, having been symptom-free for 18 months. She asks about stopping her medication. Which factor in her history would most strongly indicate the need for long-term maintenance antidepressant therapy?
Which neurotransmitter system dysfunction is most consistently implicated in the pathophysiology of major depressive disorder based on neuroimaging and cerebrospinal fluid studies?
A 29-year-old woman with panic disorder has been taking escitalopram 10mg daily for 12 weeks. Her panic attacks have reduced from daily to once weekly, but she still experiences significant anticipatory anxiety about having attacks in public places. She is motivated for further treatment. According to evidence-based practice, what is the most appropriate next step to optimise her treatment outcome?
A 54-year-old man with severe depression and significant suicidal ideation is started on venlafaxine. Three weeks into treatment at 150mg daily, his mood has improved slightly but he continues to report low mood and suicidal thoughts. Blood pressure monitoring shows readings of 158/98 mmHg on two separate occasions (baseline 128/82 mmHg). He has no previous history of hypertension. What is the most appropriate next step in management?
Common Mental Disorders UK Medical PG Practice Questions and MCQs
Question 81: A 56-year-old woman with recurrent depressive disorder has been taking escitalopram 20mg daily for 3 years following her second depressive episode. She has been completely well for the past 2.5 years and wishes to discontinue her medication. She has no current symptoms and her PHQ-9 score is 2. What is the most appropriate advice regarding discontinuation?
- A. Stop escitalopram immediately as she has been symptom-free for over 2 years
- B. Reduce to 10mg for 2 weeks then stop completely
- C. Continue indefinitely as she has had two episodes
- D. Gradually reduce the dose over at least 4 weeks while monitoring for symptoms (Correct Answer)
- E. Switch to fluoxetine before stopping to minimize discontinuation effects
Explanation: ***Gradually reduce the dose over at least 4 weeks while monitoring for symptoms*** - For patients who have been on antidepressants for a long duration, **NICE guidelines** recommend a gradual **tapering** process over at least **4 weeks** to reduce the risk of discontinuation syndrome. - This approach allows for close monitoring of **relapse symptoms** and ensures that any **discontinuation symptoms** (like dizziness or nausea) are managed by adjusting the rate of reduction. *Stop escitalopram immediately as she has been symptom-free for over 2 years* - **Abrupt cessation** of SSRIs like escitalopram is associated with a high risk of **discontinuation syndrome**, causing flu-like symptoms, irritability, and sensory disturbances. - Immediate withdrawal does not allow for the clinical assessment of whether **depressive symptoms** will return as the drug levels drop. *Reduce to 10mg for 2 weeks then stop completely* - This constitutes a **rapid taper**, which may still be too abrupt for a patient who has been on the medication for **3 years**. - A more **prolonged taper** is preferred for long-term users to minimize the profound physiological shift in **serotonergic signaling**. *Continue indefinitely as she has had two episodes* - While **maintenance therapy** for at least 2 years is recommended after a second episode, the decision to continue **indefinitely** must be a **shared decision** and is not mandated if the patient is stable and wishes to stop. - Given the patient has been well for 2.5 years and has a low **PHQ-9 score**, a trial of discontinuation is a clinically reasonable request. *Switch to fluoxetine before stopping to minimize discontinuation effects* - **Fluoxetine** has a very long **half-life**, making it useful for tapering off drugs with short half-lives (like paroxetine), but this is not standard protocol for **escitalopram**. - Escitalopram can generally be tapered directly by decreasing the dose of the **original medication** without the need for a cross-taper.
Question 82: A 39-year-old man with a 5-month history of generalised anxiety disorder has been taking sertraline 100mg daily for 10 weeks with only partial response. He continues to experience significant worry, muscle tension, and sleep disturbance. His GAD-7 score remains at 14. He has not engaged with any psychological therapy. What is the most appropriate next step in management?
- A. Switch to venlafaxine as an alternative pharmacological treatment
- B. Augment sertraline with pregabalin
- C. Offer cognitive behavioural therapy or applied relaxation (Correct Answer)
- D. Increase sertraline to 150mg daily
- E. Add short-term benzodiazepine therapy
Explanation: ***Offer cognitive behavioural therapy or applied relaxation*** - According to **NICE guidelines** for Generalised Anxiety Disorder (GAD), the stepped care model recommends offering **evidence-based psychological interventions** like **CBT** or **applied relaxation** alongside or after a drug trial. - This patient has had a partial response to an adequate dose and duration of an **SSRI (Sertraline)** but has not yet utilized any **psychological therapy**, making it the priority next step. *Switch to venlafaxine as an alternative pharmacological treatment* - While **Venlafaxine (an SNRI)** is a valid second-line pharmacological option, switching medications is usually reserved for when a patient has failed to respond to the initial trial or combined therapy, especially when psychological intervention has not been attempted. - **NICE guidelines** prioritize adding psychological therapy (like CBT) as a next step when there's a partial response to an SSRI, before switching to a different antidepressant. *Augment sertraline with pregabalin* - **Pregabalin** can be used as an alternative treatment if the patient cannot tolerate SSRIs or SNRIs, or as an augmentation strategy in severe or resistant GAD, but not typically as the *first* augmentation step when psychological therapy is untried. - Priority is given to **CBT** as a non-pharmacological addition before escalating polypharmacy, which increases the risk of side effects and dependency. *Increase sertraline to 150mg daily* - Although the dose of **Sertraline** can be titrated up to 200mg, the patient has already reached an adequate dose (100mg) for an adequate time (10 weeks) with a **GAD-7 score** that remains high, indicating a partial rather than complete non-response. - **NICE guidelines** recommend offering a high-intensity psychological intervention (like **CBT** or **applied relaxation**) in this scenario, rather than simply increasing the antidepressant dose further, especially as the patient has not engaged in any psychological therapy yet. *Add short-term benzodiazepine therapy* - **Benzodiazepines** are generally not recommended for the long-term management of GAD due to the high risk of **tolerance and dependence**, and they do not address the underlying cognitive and behavioral patterns of anxiety. - They may be used briefly for an acute crisis, but they are inferior to **CBT** as an adjunctive or standalone treatment for sustained symptom reduction and are not a recommended next step for partial response to SSRI without prior psychological therapy.
Question 83: A 42-year-old woman presents with a 6-week history of low mood, poor concentration, and disturbed sleep. She reports feeling tearful most days and has lost interest in her usual hobbies. She denies any suicidal thoughts. Her medical history includes well-controlled hypothyroidism on levothyroxine 100mcg daily. Recent thyroid function tests are within normal range. PHQ-9 score is 16. What is the most appropriate initial management?
- A. Commence sertraline 50mg once daily
- B. Refer urgently to secondary care mental health services
- C. Increase levothyroxine dose to 125mcg daily
- D. Offer a low-intensity psychosocial intervention such as guided self-help (Correct Answer)
- E. Arrange review in 2 weeks with no specific intervention
Explanation: ***Offer a low-intensity psychosocial intervention such as guided self-help*** - A **PHQ-9 score of 16** indicates **moderate depression**, for which **NICE guidelines** recommend low-intensity psychological interventions as a first-line option. - Following the **stepped-care model**, these interventions are preferred initially for patients without high-risk features like active suicidal ideation. *Commence sertraline 50mg once daily* - While **SSRIs** like **sertraline** are effective for moderate depression, **psychological therapies** are often prioritized as the initial step, especially when there is no patient preference for medication or history of non-response to therapy. - **Antidepressant medication** is typically considered if psychosocial interventions are ineffective, or for more severe presentations of depression. *Refer urgently to secondary care mental health services* - **Urgent referral** to secondary care or crisis teams is indicated for patients with **active suicidal intent**, severe self-harm, psychotic symptoms, or severe functional impairment. - This patient explicitly **denies suicidal thoughts** and presents with moderate, not severe, depression, making primary care management appropriate. *Increase levothyroxine dose to 125mcg daily* - The patient's **recent thyroid function tests** are **within the normal range**, confirming her **hypothyroidism is well-controlled** and not contributing to her depressive symptoms. - Increasing **levothyroxine** without clinical indication could lead to **iatrogenic hyperthyroidism**, causing adverse effects and failing to address the depression. *Arrange review in 2 weeks with no specific intervention* - This approach, known as **watchful waiting**, is reserved for patients with **subthreshold** or **mild depressive symptoms** (e.g., PHQ-9 < 10) and minimal functional impairment. - A **PHQ-9 score of 16** signifies **moderate depression** requiring active clinical intervention, not just observation, to prevent worsening symptoms.
Question 84: A 34-year-old woman with panic disorder and moderate agoraphobia has been taking sertraline 150mg daily for 6 months with good control of panic attacks (reduced from daily to monthly). However, she remains significantly limited by avoidance of situations where escape might be difficult, including public transport, crowds, and enclosed spaces. She has not received any psychological therapy. Evaluating her current management, which intervention would be expected to provide the greatest additional benefit in addressing her residual functional impairment?
- A. Increase sertraline to 200mg daily to target residual anxiety symptoms
- B. Add CBT with graded in vivo exposure to feared situations (Correct Answer)
- C. Add pregabalin 75mg twice daily for residual anxiety
- D. Add propranolol 10mg as required before entering feared situations
- E. Switch to venlafaxine 150mg daily which may have superior efficacy
Explanation: ***Add CBT with graded in vivo exposure to feared situations*** - Although **Sertraline** has successfully reduced the frequency of panic attacks, **agoraphobic avoidance** is a behavioral pattern that typically requires **Cognitive Behavioral Therapy (CBT)**, specifically **exposure therapy**, to resolve. - **Graded in vivo exposure** is the most effective intervention for reducing functional impairment related to avoidance by facilitating **habituation** to feared situations and correcting catastrophic misinterpretations of bodily sensations. *Increase sertraline to 200mg daily to target residual anxiety symptoms* - The patient is already on a high dose (150mg) with good control of the primary **panic attacks**, and further titration is unlikely to fully resolve established **avoidance behaviors**. - High-dose SSRI monotherapy without behavioral intervention often leaves patients with persistent **functional impairment** due to avoidance, even if panic attacks are controlled. *Add pregabalin 75mg twice daily for residual anxiety* - While **Pregabalin** can be effective for generalized anxiety disorder, it is not a first-line or primary augmentation strategy for **panic disorder with agoraphobia**, particularly for addressing avoidance. - Adding more medication focuses on **symptom suppression** rather than directly addressing the **learned behavioral avoidance** through exposure and fear extinction. *Add propranolol 10mg as required before entering feared situations* - **Beta-blockers** like propranolol primarily mask peripheral **autonomic symptoms** (e.g., palpitations, tremor) and do not address the core cognitive or behavioral components of **agoraphobia**. - Using medication "as required" for feared situations can act as a **safety behavior**, which paradoxically prevents the necessary process of **habituation** and learning that feared situations are not dangerous. *Switch to venlafaxine 150mg daily which may have superior efficacy* - Switching to another antidepressant like **Venlafaxine** is generally considered when the initial medication is ineffective, but **Sertraline** has already shown good efficacy in reducing panic attack frequency. - The residual impairment is not due to a lack of antidepressant efficacy but rather the untreated **agoraphobic avoidance**, which is best addressed with **psychological intervention**.
Question 85: A 50-year-old woman presents with low mood, reduced energy, and anhedonia for 7 weeks. She also describes feeling extremely anxious most days, with palpitations, tremor, heat intolerance, and unintentional weight loss of 6 kg. On examination, her pulse is 102 bpm and irregular, she has a fine tremor, and a smooth goitre is palpable. What is the most appropriate initial investigation to guide management?
- A. PHQ-9 depression questionnaire
- B. Thyroid function tests (TSH, free T4, free T3) (Correct Answer)
- C. ECG to assess for atrial fibrillation
- D. 24-hour urinary free cortisol
- E. MRI brain to exclude organic pathology
Explanation: ***Thyroid function tests (TSH, free T4, free T3)*** - The patient exhibits classic signs of **hyperthyroidism**, including anxiety, palpitations, tremor, heat intolerance, unintentional **weight loss**, and a **goitre**, alongside an irregular pulse. - Since psychiatric symptoms like **low mood**, **reduced energy**, and **anhedonia** can be secondary to thyroid dysfunction, establishing a biochemical diagnosis is the priority to guide appropriate medical management. *PHQ-9 depression questionnaire* - While the patient reports **low mood** and **anhedonia**, this tool only screens for the severity of depressive symptoms and does not address the underlying **organic cause**. - Initiating psychiatric treatment without ruling out **hyperthyroidism** would be inappropriate given the prominent physical examination findings. *ECG to assess for atrial fibrillation* - An ECG is indicated given the **irregular pulse** of 102 bpm to assess for cardiac arrhythmias like **atrial fibrillation**, a known complication of hyperthyroidism. - However, it is a diagnostic tool for a *complication* rather than the primary **underlying etiology**, which thyroid function tests would identify. *24-hour urinary free cortisol* - This test is used to screen for **Cushing's syndrome**, which typically presents with **weight gain**, central obesity, hypertension, and proximal muscle weakness. - The patient’s clinical picture of **weight loss**, tachycardia, and heat intolerance is much more consistent with **thyrotoxicosis** than Cushing's. *MRI brain to exclude organic pathology* - A brain MRI is generally reserved for patients with **focal neurological deficits**, seizures, or symptoms highly suggestive of a **space-occupying lesion**. - It is not a standard initial investigation for a patient with clear systemic signs of **thyroid disease** and a palpable goitre.
Question 86: A 42-year-old man with generalised anxiety disorder has completed 12 weeks of individual CBT with good engagement but minimal symptom improvement. His GAD-7 score remains at 16 (moderate-severe anxiety). He has tried sertraline previously but discontinued it after 3 weeks due to gastrointestinal side effects. What is the most appropriate next step in his management?
- A. Refer for psychodynamic psychotherapy
- B. Offer pregabalin 150mg twice daily
- C. Restart sertraline with antiemetic cover
- D. Offer an alternative SSRI such as escitalopram or an SNRI such as duloxetine (Correct Answer)
- E. Add buspirone to augment psychological therapy
Explanation: ***Offer an alternative SSRI such as escitalopram or an SNRI such as duloxetine*** - According to **NICE guidelines** for GAD, if an initial SSRI is not tolerated or is ineffective after a sufficient trial, the next step is to offer an **alternative SSRI** or an **SNRI** (e.g., duloxetine or venlafaxine). - The patient's previous trial of **sertraline** was brief (3 weeks) due to **gastrointestinal side effects**, making a switch to a different agent a reasonable strategy to find a tolerable and effective pharmacological treatment. *Refer for psychodynamic psychotherapy* - While psychological therapies are important, **CBT** and **applied relaxation** are the primary evidence-based psychological interventions recommended for GAD; **psychodynamic psychotherapy** lacks a strong evidence base for this condition. - Given the patient has already completed 12 weeks of CBT with minimal improvement and has not had a full trial of effective medication, the next step typically involves optimizing pharmacological treatment. *Offer pregabalin 150mg twice daily* - **Pregabalin** is a recommended treatment option for GAD, but it is usually considered after trials of both **SSRIs** and **SNRIs** have been unsuccessful or not tolerated. - Since the patient has only briefly tried one SSRI and SNRIs are still an option, pregabalin is not the immediate next step in the treatment algorithm. *Restart sertraline with antiemetic cover* - Restarting a medication that caused significant **gastrointestinal side effects** leading to early discontinuation is likely to result in poor **adherence** and distress for the patient. - Guidelines generally advise switching to a different antidepressant with a potentially different **side effect profile** rather than attempting to manage the side effects of a previously failed agent. *Add buspirone to augment psychological therapy* - **Buspirone** is not considered a first-line treatment for GAD in UK guidelines and is not typically used as an **augmentation agent** to psychological therapy. - The immediate focus should be on establishing a successful **monotherapy** with an appropriately chosen antidepressant before considering augmentation strategies, especially given the lack of robust evidence for this specific approach.
Question 87: A 37-year-old woman with recurrent depressive disorder has experienced three episodes in the past 6 years, each requiring treatment with antidepressants and each followed by full remission. She is currently well on citalopram 40mg daily, having been symptom-free for 18 months. She asks about stopping her medication. Which factor in her history would most strongly indicate the need for long-term maintenance antidepressant therapy?
- A. Age under 40 years at current episode
- B. History of three or more depressive episodes (Correct Answer)
- C. Duration of current remission exceeding 12 months
- D. Previous good response to the same antidepressant
- E. Female gender and associated hormonal factors
Explanation: ***History of three or more depressive episodes*** - Guidelines (e.g., **NICE**) strongly recommend long-term maintenance antidepressant therapy for individuals with **three or more prior depressive episodes**, as the risk of relapse is significantly high, often exceeding **70-80%**. - For these patients, maintenance treatment should ideally continue for **at least 2 years**, or even indefinitely in some cases, to effectively prevent future relapses. *Age under 40 years at current episode* - While an **early age of onset** (under 40) is recognized as a risk factor for future depressive episodes, it is not as strong an indicator for the necessity of long-term maintenance therapy as the **total number of previous episodes**. - This factor alone, without a high number of recurrent episodes, does not typically mandate indefinite antidepressant treatment. *Duration of current remission exceeding 12 months* - A sustained period of **remission** (such as 18 months) indicates that the current antidepressant treatment is effective, but it does not mitigate the inherent **high risk of recurrence** associated with a history of multiple depressive episodes. - Discontinuing medication based on prolonged remission in a patient with recurrent depression is a common trigger for **relapse**. *Previous good response to the same antidepressant* - This factor is highly valuable for guiding the **choice of medication** for maintenance therapy, confirming its efficacy for the individual patient. - However, it does not determine the fundamental **clinical need** for maintenance treatment; that decision is primarily driven by the patient's history of recurrence. *Female gender and associated hormonal factors* - While **female gender** is linked to a higher prevalence of depression and potential hormonal influences, it is not a primary or independent criterion for deciding the **duration of maintenance antidepressant therapy** in clinical practice guidelines. - The decision for long-term treatment is predominantly based on the **severity and recurrence pattern** of depressive episodes rather than demographic factors.
Question 88: Which neurotransmitter system dysfunction is most consistently implicated in the pathophysiology of major depressive disorder based on neuroimaging and cerebrospinal fluid studies?
- A. Reduced gamma-aminobutyric acid (GABA) in the prefrontal cortex
- B. Excessive glutamate activity in the hippocampus
- C. Decreased serotonin metabolite 5-HIAA in cerebrospinal fluid (Correct Answer)
- D. Elevated dopamine in the mesolimbic pathway
- E. Reduced noradrenaline in the locus coeruleus
Explanation: ***Decreased serotonin metabolite 5-HIAA in cerebrospinal fluid*** - Low levels of **5-hydroxyindoleacetic acid (5-HIAA)** in the cerebrospinal fluid are the most consistent and replicated neurochemical findings indicating reduced **serotonergic activity** in depression. - This finding supports the **monoamine hypothesis** and is closely linked to suicidal behavior and mood dysregulation in patients with major depressive disorder. *Reduced gamma-aminobutyric acid (GABA) in the prefrontal cortex* - While some studies show lower **GABA levels** in depression, this finding is less consistent across neuroimaging studies compared to serotonergic markers. - GABAergic dysfunction is often more specifically associated with **anxiety symptoms** or comorbid anxiety disorders rather than core depressive pathology. *Excessive glutamate activity in the hippocampus* - Excessive **glutamate** is associated with the **neurotoxicity hypothesis** of stress and hippocampal atrophy, but direct evidence in CSF is variable. - While ketamine (a glutamate modulator) treats depression, primary glutamate excess is not as consistently demonstrated as the **monoamine deficit**. *Elevated dopamine in the mesolimbic pathway* - Elevated dopamine is typically associated with **psychosis** or mania; in contrast, depression is generally linked to **dopaminergic deficiency**, contributing to **anhedonia**. - Dysregulation of the **mesolimbic reward system** is a feature of depression, but the most consistent biomarker remains serotonin metabolites. *Reduced noradrenaline in the locus coeruleus* - Although **noradrenaline** is implicated in depression (the basis for SNRIs), studies measuring its metabolites like **MHPG** in CSF show inconsistent results. - Noradrenaline dysfunction often correlates with deficits in **attention and physical energy**, but it lacks the robust evidence base of the **serotonin system**.
Question 89: A 29-year-old woman with panic disorder has been taking escitalopram 10mg daily for 12 weeks. Her panic attacks have reduced from daily to once weekly, but she still experiences significant anticipatory anxiety about having attacks in public places. She is motivated for further treatment. According to evidence-based practice, what is the most appropriate next step to optimise her treatment outcome?
- A. Increase escitalopram to 20mg daily
- B. Add propranolol 10mg as required before anxiety-provoking situations
- C. Add diazepam 5mg twice daily for ongoing anxiety
- D. Refer for cognitive behavioural therapy with graded exposure (Correct Answer)
- E. Switch to paroxetine as it has better evidence for panic disorder
Explanation: ***Refer for cognitive behavioural therapy with graded exposure***- Combining **pharmacotherapy (SSRIs)** with **cognitive behavioural therapy (CBT)** is more effective for panic disorder than medication alone, particularly when addressing **anticipatory anxiety** and **avoidance behavior**.- CBT techniques like **interoceptive exposure** and **graded exposure** help the patient process feared bodily sensations and public situations that medication alone often fails to resolve.*Increase escitalopram to 20mg daily*- While increasing the dose is a common pharmacological step, this patient has already had a **partial response** over 12 weeks, and the residual symptoms are heavily **cognitive/behavioral**.- Evidence suggests that at this stage, adding **specialized psychotherapy** provides a more significant clinical benefit than simply escalating the **SSRI dose**.*Add propranolol 10mg as required before anxiety-provoking situations*- **Beta-blockers** like propranolol are generally not recommended for the core treatment of **panic disorder** as they do not address the underlying psychopathology or anticipate attacks effectively.- These medications focus on **peripheral somatic symptoms** (like palpitations) but do not help with the **catastrophic misinterpretations** central to panic disorder.*Add diazepam 5mg twice daily for ongoing anxiety*- **Benzodiazepines** should be avoided for long-term management of panic disorder due to the high risk of **tolerance, dependence**, and withdrawal issues.- Guidelines generally recommend against their use for chronic anxiety as they can interfere with the efficacy of **exposure-based therapies** by preventing the patient from habituating to anxiety.*Switch to paroxetine as it has better evidence for panic disorder*- Most **SSRIs**, including escitalopram and paroxetine, have comparable efficacy in treating panic disorder, and the patient has already shown a **reduction in attack frequency** on her current regimen.- Switching medications is usually reserved for cases of **treatment failure** or intolerable side effects, whereas this patient is a **partial responder** who needs behavioral intervention.
Question 90: A 54-year-old man with severe depression and significant suicidal ideation is started on venlafaxine. Three weeks into treatment at 150mg daily, his mood has improved slightly but he continues to report low mood and suicidal thoughts. Blood pressure monitoring shows readings of 158/98 mmHg on two separate occasions (baseline 128/82 mmHg). He has no previous history of hypertension. What is the most appropriate next step in management?
- A. Stop venlafaxine and switch to mirtazapine (Correct Answer)
- B. Continue venlafaxine and add amlodipine for blood pressure control
- C. Reduce venlafaxine dose to 75mg daily and review in 2 weeks
- D. Continue venlafaxine at current dose and monitor blood pressure more frequently as hypertension may be transient
- E. Arrange urgent psychiatric admission for electroconvulsive therapy
Explanation: ***Stop venlafaxine and switch to mirtazapine*** - **Venlafaxine**, a Serotonin-Norepinephrine Reuptake Inhibitor (SNRI), is known to cause **dose-dependent hypertension** due to its norepinephrinergic effects, especially at doses of 150mg or higher. - Switching to **mirtazapine** is appropriate as it lacks the hypertensive side effect profile and is effective for **severe depression** with suicidal ideation due to its sedating and anxiolytic properties. *Continue venlafaxine and add amlodipine for blood pressure control* - It is clinically inappropriate to prescribe a second medication to treat the **side effects** of the first when an equally effective alternative class is available. - Managing the patient with **polypharmacy** increases the risk of further side effects and complications in a patient already struggling with severe depression. *Reduce venlafaxine dose to 75mg daily and review in 2 weeks* - While a lower dose may reduce **blood pressure**, it is likely to be sub-therapeutic for a patient with **severe depression** and significant **suicidal ideation**. - Dose reduction may delay the stabilization of the patient's mental health, which is a critical priority given the risk of self-harm. *Continue venlafaxine at current dose and monitor blood pressure more frequently as hypertension may be transient* - The hypertension associated with SNRIs is typically sustained rather than **transient**; persistent readings of 158/98 mmHg pose an immediate **cardiovascular risk**. - Current clinical guidelines recommend either reducing the dose or discontinuing the drug if blood pressure increases significantly during treatment. *Arrange urgent psychiatric admission for electroconvulsive therapy* - **Electroconvulsive therapy (ECT)** is generally reserved for life-threatening depression or cases resistant to multiple pharmacological trials, not as a first-line response to a medication's side effect. - The patient has shown a **slight improvement** in mood on venlafaxine, suggesting that optimized pharmacotherapy should be explored before resorting to invasive treatments.
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