A 32-year-old woman with bipolar affective disorder type I presents to the emergency department 3 weeks postpartum. Her partner reports that over the past 5 days she has become increasingly agitated, sleeping only 2 hours per night, talking rapidly about having special powers, and expressing beliefs that the baby is in danger from demons. She has attempted to perform an exorcism. She is hostile and uncooperative with assessment. She stopped taking quetiapine during pregnancy. On examination she is agitated, with pressured speech and grandiose and persecutory delusions. What is the most appropriate immediate management setting?
Q112
A 40-year-old woman with schizoaffective disorder has been maintained on depot risperidone 37.5mg every 2 weeks for 3 years. She presents to her psychiatrist with new-onset involuntary movements. Examination reveals repetitive lip-smacking, tongue protrusion, and choreiform finger movements. These movements persist during distraction and partially suppress with voluntary effort. She is not distressed by them and has not noticed them herself. Her psychotic symptoms are well controlled. What is the most appropriate management?
Q113
A 24-year-old man is assessed by the early intervention in psychosis team. He has experienced a first episode of psychosis 6 months ago and has been treated with risperidone 4mg daily with good response. He now has minimal residual symptoms. According to NICE guidance on the management of first-episode psychosis, what is the recommended duration of antipsychotic treatment after remission of first episode, assuming he remains well?
Q114
A 51-year-old man with bipolar affective disorder has been taking lithium carbonate 900mg daily for 8 years. He presents to his GP feeling generally unwell. Blood tests show: serum lithium 1.6 mmol/L (therapeutic range 0.6-1.0 mmol/L), urea 12.4 mmol/L, creatinine 156 µmol/L (baseline 95 µmol/L), eGFR 42 ml/min/1.73m². He was recently started on ramipril 5mg daily by the cardiology team for hypertension. He reports no symptoms of toxicity, tremor, or confusion. What is the most appropriate immediate management?
Q115
A 29-year-old woman with schizophrenia is reviewed in the community mental health team. She has been stable on paliperidone 6mg daily for 18 months. She and her partner are planning to start a family. She asks about the safety of continuing her medication during pregnancy. What is the most appropriate advice?
Q116
A 44-year-old man with paranoid schizophrenia has been on clozapine 550mg daily for 3 years with good symptom control. He presents to his GP with a 3-week history of constipation, only opening his bowels once in the past 10 days with great difficulty. He reports some abdominal discomfort and bloating. He has not taken any laxatives. Examination reveals a distended, tympanic abdomen with reduced bowel sounds. There is mild generalized tenderness but no guarding or rebound. Temperature is 37.2°C, heart rate 78 bpm, blood pressure 128/82 mmHg. What is the most appropriate immediate management?
Q117
A 37-year-old woman with a 12-year history of bipolar affective disorder attends the psychiatry clinic. She describes episodes where her mood becomes persistently low for several weeks, with reduced energy, hypersomnia (sleeping 12-14 hours per day), increased appetite with carbohydrate craving, and feeling extremely sensitive to interpersonal rejection. Between episodes, she functions well. She has never had a manic episode requiring hospitalization but has had brief periods of elevated mood lasting 3-4 days with increased energy and reduced sleep. What is the most appropriate diagnosis?
Q118
A 26-year-old woman with bipolar affective disorder type I has had three admissions in the past 2 years for manic episodes. She has tried lithium, sodium valproate, and quetiapine as mood stabilizers but discontinued each due to side effects or poor efficacy. She is currently stable on olanzapine 20mg daily but has gained 18kg over 18 months. Her fasting glucose is 6.4 mmol/L, HbA1c is 43 mmol/mol, and lipid profile shows total cholesterol 6.2 mmol/L. She is very distressed about the weight gain. Which medication would be the most appropriate alternative mood stabilizer to consider?
Q119
A 30-year-old man presents to the emergency department brought by police under Section 136 of the Mental Health Act. He was found shouting in the street that he is Jesus Christ and can perform miracles. He is extremely agitated, has pressured speech, and demonstrates flight of ideas. His girlfriend reports he has had no sleep for 5 days, has spent £15,000 on a new car, and has been increasingly sexually disinhibited. He has no past psychiatric history. Physical examination reveals temperature 37.8°C, heart rate 110 bpm, blood pressure 145/92 mmHg, and pupils that are 4mm and reactive. What investigation is most important to perform immediately?
Q120
A 42-year-old woman with bipolar affective disorder type I has been taking sodium valproate 1200mg daily for 5 years with excellent mood stability. She attends her GP to discuss contraception as she is in a new relationship. She is currently not using any contraception. Her body mass index is 32 kg/m². She has no other medical conditions and does not smoke. What is the most appropriate advice regarding contraception?
Severe Mental Illness UK Medical PG Practice Questions and MCQs
Question 111: A 32-year-old woman with bipolar affective disorder type I presents to the emergency department 3 weeks postpartum. Her partner reports that over the past 5 days she has become increasingly agitated, sleeping only 2 hours per night, talking rapidly about having special powers, and expressing beliefs that the baby is in danger from demons. She has attempted to perform an exorcism. She is hostile and uncooperative with assessment. She stopped taking quetiapine during pregnancy. On examination she is agitated, with pressured speech and grandiose and persecutory delusions. What is the most appropriate immediate management setting?
A. Admission to general psychiatric ward and restart quetiapine
B. Admission to mother and baby unit with mental health act assessment (Correct Answer)
C. Home treatment team with daily visits
D. Voluntary admission to mother and baby unit
E. Outpatient crisis team with partner supervision
Explanation: ***Admission to mother and baby unit with mental health act assessment***
- This patient presents with **Postpartum Psychosis**, a psychiatric emergency with high risks of **infanticide** and maternal suicide, requiring the specialized care of a **Mother and Baby Unit (MBU)** to preserve the bond while ensuring safety.
- An assessment under the **Mental Health Act** is necessary because she is hostile, uncooperative, and lacks **insight**, making voluntary admission unsafe or impossible.
*Admission to general psychiatric ward and restart quetiapine*
- While inpatient care is needed, a **general psychiatric ward** often separates the mother from the infant, which can disrupt **bonding** and negatively affect recovery.
- This option is generally reserved for when an **MBU bed** is unavailable and the risk is too high for the community.
*Home treatment team with daily visits*
- The presence of **delusions concerning the baby** (demons/exorcism) indicates a high and immediate **risk of harm** to the infant that cannot be safely managed in the community.
- **Postpartum psychosis** is characterized by rapid clinical fluctuations, making the monitoring provided by daily visits insufficient for safety.
*Voluntary admission to mother and baby unit*
- Although admission to an MBU is correct, the patient is currently **hostile and uncooperative**, suggesting she does not recognize her illness or need for care.
- A **voluntary admission** is unlikely to be successful or sustainable given her **delusional state** and agitation.
*Outpatient crisis team with partner supervision*
- This management plan is inadequate for **manic psychosis**, which requires intensive clinical monitoring and stabilization that a partner cannot provide at home.
- The **safeguarding concerns** for the baby and the severity of **pressured speech** and agitation necessitate a more restrictive environment.
Question 112: A 40-year-old woman with schizoaffective disorder has been maintained on depot risperidone 37.5mg every 2 weeks for 3 years. She presents to her psychiatrist with new-onset involuntary movements. Examination reveals repetitive lip-smacking, tongue protrusion, and choreiform finger movements. These movements persist during distraction and partially suppress with voluntary effort. She is not distressed by them and has not noticed them herself. Her psychotic symptoms are well controlled. What is the most appropriate management?
A. Stop depot risperidone immediately and switch to oral quetiapine
B. Add tetrabenazine to treat the movement disorder
C. Continue depot risperidone as she is psychiatrically stable
D. Switch to clozapine as it has the lowest risk of tardive dyskinesia (Correct Answer)
E. Reduce depot risperidone to 25mg and review in 3 months
Explanation: ***Switch to clozapine as it has the lowest risk of tardive dyskinesia***
- The patient's symptoms, including **repetitive lip-smacking**, **tongue protrusion**, and **choreiform finger movements** after long-term risperidone, are characteristic of **tardive dyskinesia (TD)**.
- **Clozapine** is the antipsychotic of choice for TD due to its unique pharmacology, including a very low affinity for **dopamine D2 receptors**, which minimizes EPS risk and can often improve existing TD while maintaining psychiatric stability.
*Stop depot risperidone immediately and switch to oral quetiapine*
- **Abrupt cessation** of depot risperidone can lead to severe **withdrawal dyskinesia** and significantly increase the risk of an acute **psychotic relapse** in a patient with a chronic condition like schizoaffective disorder.
- While **quetiapine** has a lower EPS risk than risperidone, it is not as effective as **clozapine** for the management of established **tardive dyskinesia**.
*Add tetrabenazine to treat the movement disorder*
- **Tetrabenazine** (a VMAT2 inhibitor) can help reduce the symptoms of TD but does not address the underlying **dopamine receptor hypersensitivity** caused by the offending antipsychotic.
- Adding symptomatic treatment without addressing the cause increases **polypharmacy** and potential side effects, which is less ideal than switching to a safer antipsychotic.
*Continue depot risperidone as she is psychiatrically stable*
- Continuing the causative agent would allow the **tardive dyskinesia** to potentially worsen and become **irreversible**, significantly impacting the patient's quality of life.
- Psychiatric stability does not justify ignoring a progressive and potentially **disabling movement disorder** when safer and effective alternatives exist.
*Reduce depot risperidone to 25mg and review in 3 months*
- A minor **dose reduction** is often insufficient to halt or reverse established **tardive dyskinesia**, especially with long-acting injectable formulations.
- Waiting **3 months** for a review is an unacceptable delay for a condition that can become permanent, indicating a need for more urgent and definitive management.
Question 113: A 24-year-old man is assessed by the early intervention in psychosis team. He has experienced a first episode of psychosis 6 months ago and has been treated with risperidone 4mg daily with good response. He now has minimal residual symptoms. According to NICE guidance on the management of first-episode psychosis, what is the recommended duration of antipsychotic treatment after remission of first episode, assuming he remains well?
A. 6 months
B. At least 1 year
C. At least 2 years (Correct Answer)
D. 5 years
E. Lifelong treatment
Explanation: ***At least 2 years***
- According to **NICE guidance** on first-episode psychosis, antipsychotic treatment should be continued for **at least 1 to 2 years** after remission to significantly reduce the risk of **relapse**.
- This duration is supported by evidence showing that approximately **80% of patients** relapse if medication is discontinued prematurely after a single episode.
*6 months*
- This duration is generally considered **insufficient** for a first episode of psychosis and significantly increases the **risk of recurrence**.
- 6 months is more commonly associated with the duration of treatment for a first episode of **unipolar depression** after achieving remission, not psychosis.
*At least 1 year*
- While some guidelines mention 1 year as a minimum, **NICE guidance** specifically recommends the **1 to 2-year range**, with **2 years** being the more robust clinical standard for first-episode management.
- A 1-year cutoff may be considered in very specific circumstances, but it is not the preferred **standard of care** in primary guidelines for maintaining stability.
*5 years*
- A 5-year treatment duration is typically reserved for patients who have experienced **multiple relapses** or have a history of **significant risk** to themselves or others.
- For a first episode with **good response** and minimal residual symptoms, 5 years is an unnecessarily long initial recommendation.
*Lifelong treatment*
- **Lifelong treatment** is generally only considered for patients with a diagnosis of **treatment-resistant schizophrenia** or those with a history of **frequent relapses** upon medication withdrawal.
- Most clinicians aim for a supervised **trial of dose reduction** after the initial 2-year stability period rather than indefinite therapy.
Question 114: A 51-year-old man with bipolar affective disorder has been taking lithium carbonate 900mg daily for 8 years. He presents to his GP feeling generally unwell. Blood tests show: serum lithium 1.6 mmol/L (therapeutic range 0.6-1.0 mmol/L), urea 12.4 mmol/L, creatinine 156 µmol/L (baseline 95 µmol/L), eGFR 42 ml/min/1.73m². He was recently started on ramipril 5mg daily by the cardiology team for hypertension. He reports no symptoms of toxicity, tremor, or confusion. What is the most appropriate immediate management?
A. Stop lithium immediately and arrange urgent psychiatric review
B. Continue lithium but reduce dose to 600mg daily
C. Stop ramipril and recheck lithium level in 5-7 days (Correct Answer)
D. Admit for intravenous fluids and haemodialysis
E. Continue both medications but increase monitoring frequency
Explanation: ***Stop ramipril and recheck lithium level in 5-7 days***- The patient presents with **mild lithium toxicity** (1.6 mmol/L) and an **acute kidney injury** (AKI), primarily due to the recent initiation of an **ACE inhibitor (Ramipril)**. Ramipril reduces lithium clearance, leading to elevated levels.- Since the patient is currently **asymptomatic** from lithium toxicity, the most appropriate immediate management is to discontinue the precipitating medication (ramipril) and closely monitor lithium levels and renal function. It is important to recheck lithium levels as the half-life is long.*Stop lithium immediately and arrange urgent psychiatric review*- Abruptly stopping lithium, even with elevated levels, carries a significant risk of **bipolar relapse**, especially when the toxicity is mild and primarily due to a drug interaction.- The immediate priority is to address the **pharmacokinetic interaction** causing the elevated lithium and AKI, rather than discontinuing the essential mood stabilizer directly.*Continue lithium but reduce dose to 600mg daily*- Reducing the lithium dose without addressing the **ACE inhibitor interaction** would not fully resolve the issue, as ramipril continues to impair lithium excretion.- It is unsafe to maintain a patient on a medication known to cause an **AKI** (in this case, by precipitating lithium toxicity) without removing the offending agent.*Admit for intravenous fluids and haemodialysis*- **Haemodialysis** is reserved for severe lithium toxicity (e.g., levels >2.0 mmol/L with significant symptoms, or >3.5 mmol/L regardless of symptoms) or in patients with severe renal impairment where lithium cannot be excreted.- This patient is **asymptomatic**, and his lithium level, while elevated, does not meet the criteria for urgent haemodialysis or aggressive intravenous fluid resuscitation beyond general supportive care if needed.*Continue both medications but increase monitoring frequency*- Continuing both ramipril and lithium would perpetuate the **drug interaction**, leading to further worsening of lithium levels and potentially irreversible kidney damage.- **ACE inhibitors**, along with NSAIDs and thiazide diuretics, are well-known to increase lithium levels by reducing its renal clearance.
Question 115: A 29-year-old woman with schizophrenia is reviewed in the community mental health team. She has been stable on paliperidone 6mg daily for 18 months. She and her partner are planning to start a family. She asks about the safety of continuing her medication during pregnancy. What is the most appropriate advice?
A. Paliperidone should be stopped immediately before attempting conception
B. The risks and benefits should be discussed; if medication is continued, use the lowest effective dose and monitor for complications (Correct Answer)
C. Switch to clozapine as it is safer in pregnancy
D. Switch to a typical antipsychotic as these have better safety data
E. Paliperidone is completely safe in pregnancy with no additional monitoring required
Explanation: ***The risks and benefits should be discussed; if medication is continued, use the lowest effective dose and monitor for complications***- Management requires a **risk-benefit analysis** comparing the risks of untreated maternal illness (relapse, poor prenatal care) against potential fetal risks from **antipsychotic exposure**.- If continued, the **lowest effective dose** should be used, with monitoring for **neonatal withdrawal symptoms** or **extrapyramidal symptoms** following delivery.*Paliperidone should be stopped immediately before attempting conception*- Abruptly stopping medication in a stable patient with **schizophrenia** carries a high risk of **relapse**, which can be dangerous for both mother and fetus.- Discontinuation should only be considered after a thorough consultation and usually involves a gradual **tapering** rather than immediate cessation.*Switch to clozapine as it is safer in pregnancy*- **Clozapine** is generally not recommended for switching during pregnancy due to risks of **maternal agranulocytosis** and potential fetal **seizures**.- It is usually reserved for **treatment-resistant schizophrenia** and requires intensive blood monitoring that complicates pregnancy management.*Switch to a typical antipsychotic as these have better safety data*- While **typical antipsychotics** like haloperidol have longer safety records, they carry a higher risk of **extrapyramidal side effects** for the mother and neonate.- Switching a stable patient from an effective **atypical antipsychotic** to a typical one can lead to **destabilization** and breakthrough symptoms.*Paliperidone is completely safe in pregnancy with no additional monitoring required*- No antipsychotic is considered **completely safe**; they are classified as **Category C** or similar, meaning potential risks cannot be ruled out.- Additional monitoring is mandatory, specifically for **gestational diabetes** due to metabolic side effects and **neonatal distress** post-delivery.
Question 116: A 44-year-old man with paranoid schizophrenia has been on clozapine 550mg daily for 3 years with good symptom control. He presents to his GP with a 3-week history of constipation, only opening his bowels once in the past 10 days with great difficulty. He reports some abdominal discomfort and bloating. He has not taken any laxatives. Examination reveals a distended, tympanic abdomen with reduced bowel sounds. There is mild generalized tenderness but no guarding or rebound. Temperature is 37.2°C, heart rate 78 bpm, blood pressure 128/82 mmHg. What is the most appropriate immediate management?
A. Prescribe lactulose and review in 1 week
B. Arrange urgent surgical review
C. Prescribe senna and increase dietary fiber
D. Arrange same-day abdominal X-ray and surgical assessment (Correct Answer)
E. Stop clozapine immediately and admit to psychiatry ward
Explanation: ***Arrange same-day abdominal X-ray and surgical assessment***
- This patient shows signs of **clozapine-induced gastrointestinal hypomotility (CIGH)**, a potentially fatal complication presenting with severe constipation and a **distended, tympanic abdomen**.
- Same-day assessment and imaging are critical to rule out **paralytic ileus**, bowel obstruction, or **ischaemic colitis**, which have a higher mortality rate than agranulocytosis.
*Prescribe lactulose and review in 1 week*
- **Lactulose** is an osmotic laxative that may worsen **abdominal bloating** and gas in the presence of an underlying obstruction.
- Relies on a delayed review period which is unsafe given the **reduced bowel sounds** and severe frequency of bowel movements (once in 10 days).
*Arrange urgent surgical review*
- While a surgical review is necessary, it is usually coordinated alongside **imaging (X-ray)** to provide a definitive diagnosis of fecal loading or bowel dilation.
- This option is partially correct but less comprehensive as the **abdominal X-ray** is the standard immediate investigation to quantify the severity of hypomotility.
*Prescribe senna and increase dietary fiber*
- Increasing **dietary fiber** can be detrimental in cases of severe hypomotility or fecal impaction as it increases stool bulk against a non-moving colon.
- While **senna** (a stimulant laxative) is part of standard prevention, the current clinical presentation suggests a **surgical emergency** rather than simple constipation.
*Stop clozapine immediately and admit to psychiatry ward*
- Sudden cessation of **clozapine** can lead to **rebound psychosis** or cholinergic rebound; management of bowel complications should take priority in a medical/surgical setting.
- A **psychiatric ward** is not equipped to manage potential **bowel perforation** or obstruction indicated by the physical findings.
Question 117: A 37-year-old woman with a 12-year history of bipolar affective disorder attends the psychiatry clinic. She describes episodes where her mood becomes persistently low for several weeks, with reduced energy, hypersomnia (sleeping 12-14 hours per day), increased appetite with carbohydrate craving, and feeling extremely sensitive to interpersonal rejection. Between episodes, she functions well. She has never had a manic episode requiring hospitalization but has had brief periods of elevated mood lasting 3-4 days with increased energy and reduced sleep. What is the most appropriate diagnosis?
A. Bipolar affective disorder type I
B. Bipolar affective disorder type II (Correct Answer)
C. Recurrent depressive disorder with atypical features
D. Cyclothymia
E. Schizoaffective disorder
Explanation: ***Bipolar affective disorder type II***
- This diagnosis is characterized by at least one **hypomanic episode** (lasting at least 4 consecutive days) and at least one **major depressive episode**, perfectly matching the patient's brief elevated mood and persistent low mood periods.
- The depressive episodes exhibit **atypical features** like **hypersomnia**, **increased appetite with carbohydrate craving**, and **rejection sensitivity**, which are commonly associated with bipolar II depression.
*Bipolar affective disorder type I*
- Requires a history of at least one full **manic episode**, defined by a distinct period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week (or any duration if hospitalization is required).
- The patient explicitly states she has **never had a manic episode requiring hospitalization** and her elevated moods were brief (3-4 days), indicating hypomania, not mania.
*Recurrent depressive disorder with atypical features*
- This diagnosis is ruled out by the patient's history of distinct periods of **elevated mood**, **increased energy**, and **reduced sleep** (hypomanic episodes).
- Recurrent depressive disorder is a unipolar mood disorder, meaning it involves only depressive episodes without any history of manic or hypomanic symptoms.
*Cyclothymia*
- Involves numerous periods of **hypomanic symptoms** and **depressive symptoms** (that do not meet full criteria for hypomanic or major depressive episodes) for at least two years.
- The patient's depressive episodes are described as "persistently low for several weeks" with significant features, suggesting full **major depressive episodes** rather than the milder, more fluctuating symptoms of cyclothymia.
*Schizoaffective disorder*
- This diagnosis requires the presence of **psychotic symptoms** (e.g., delusions, hallucinations) occurring for at least two weeks in the absence of a major mood episode.
- The patient's presentation does not include any mention of **psychosis** or other symptoms characteristic of schizophrenia, only mood disturbances.
Question 118: A 26-year-old woman with bipolar affective disorder type I has had three admissions in the past 2 years for manic episodes. She has tried lithium, sodium valproate, and quetiapine as mood stabilizers but discontinued each due to side effects or poor efficacy. She is currently stable on olanzapine 20mg daily but has gained 18kg over 18 months. Her fasting glucose is 6.4 mmol/L, HbA1c is 43 mmol/mol, and lipid profile shows total cholesterol 6.2 mmol/L. She is very distressed about the weight gain. Which medication would be the most appropriate alternative mood stabilizer to consider?
A. Lamotrigine
B. Aripiprazole (Correct Answer)
C. Carbamazepine
D. Risperidone long-acting injection
E. Increase olanzapine to 30mg
Explanation: ***Aripiprazole***
- **Aripiprazole** is an **atypical antipsychotic** with a significantly more **favorable metabolic profile** compared to olanzapine, making it a suitable choice for patients experiencing **weight gain** and **metabolic syndrome** features.
- It is an effective mood stabilizer for **preventing manic episodes**, addressing the patient's history of recurrent mania while mitigating the severe metabolic side effects of olanzapine.
*Lamotrigine*
- **Lamotrigine** is primarily indicated for the prevention of **bipolar depressive episodes** and has limited efficacy in preventing or treating **acute manic episodes**.
- Given this patient's history of three admissions for **manic episodes**, lamotrigine would not provide adequate anti-manic protection.
*Carbamazepine*
- While effective for bipolar disorder, **carbamazepine** is a potent **enzyme inducer**, leading to significant drug-drug interactions and requiring intensive **therapeutic drug monitoring**.
- Its side effect profile includes risks of **hyponatremia**, **blood dyscrasias**, and **sedation**, which may not be more tolerable than the current issues.
*Risperidone long-acting injection*
- **Risperidone** is associated with a moderate to high risk of **weight gain** and **metabolic side effects**, similar to olanzapine, and would likely exacerbate the patient's current metabolic concerns.
- A long-acting injection primarily addresses **treatment adherence** issues, which is not the main problem; the patient is distressed by specific side effects.
*Increase olanzapine to 30mg*
- Increasing the dose of **olanzapine** would almost certainly worsen the patient's already significant **weight gain**, **dyslipidemia**, and **impaired fasting glucose**.
- The current goal is to mitigate the metabolic risks, not escalate them, as the patient is already experiencing severe distress and clinical complications at 20mg.
Question 119: A 30-year-old man presents to the emergency department brought by police under Section 136 of the Mental Health Act. He was found shouting in the street that he is Jesus Christ and can perform miracles. He is extremely agitated, has pressured speech, and demonstrates flight of ideas. His girlfriend reports he has had no sleep for 5 days, has spent £15,000 on a new car, and has been increasingly sexually disinhibited. He has no past psychiatric history. Physical examination reveals temperature 37.8°C, heart rate 110 bpm, blood pressure 145/92 mmHg, and pupils that are 4mm and reactive. What investigation is most important to perform immediately?
A. Thyroid function tests
B. CT head scan
C. Urine drug screen (Correct Answer)
D. Serum calcium
E. HIV test
Explanation: ***Urine drug screen***- A **urine drug screen** is the most critical immediate step to exclude substance-induced psychosis or mania, especially in a first-time presentation with **sympathomimetic signs** like tachycardia and hypertension.- Stimulants such as **cocaine** or **amphetamines** can closely mimic acute mania with grandiose delusions and pressured speech, requiring different emergency management.*Thyroid function tests*- While **hyperthyroidism** can cause agitation, anxiety, and tachycardia, it rarely presents with such severe **grandiose delusions** and sudden flight of ideas.- These tests are part of the standard baseline workup for psychiatric admissions but are less urgent than screening for acute **intoxication**.*CT head scan*- A **CT head** is indicated if there are focal neurological deficits, a history of trauma, or atypical features like a sudden onset **first-episode psychosis** in an older patient.- In this young patient with classic manic symptoms and autonomic arousal, organic brain lesions are a less likely primary cause than **drug misuse**.*Serum calcium*- **Hypercalcaemia** can lead to psychiatric symptoms, though it more commonly presents as "moans" (depression or confusion) rather than acute **manic psychosis**.- It should be checked during the routine metabolic screen, but it does not take priority over the immediate clinical suspicion of **stimulant-induced mania**.*HIV test*- **Neuropsychiatric HIV** can manifest as mania or psychosis, but these are typically later-stage complications rather than an acute primary presentation in a healthy 30-year-old.- While HIV testing is recommended in a comprehensive workup for **first-episode psychosis**, it is not the most important immediate investigation in the emergency department.
Question 120: A 42-year-old woman with bipolar affective disorder type I has been taking sodium valproate 1200mg daily for 5 years with excellent mood stability. She attends her GP to discuss contraception as she is in a new relationship. She is currently not using any contraception. Her body mass index is 32 kg/m². She has no other medical conditions and does not smoke. What is the most appropriate advice regarding contraception?
A. The combined oral contraceptive pill would be suitable
B. Sodium valproate reduces the efficacy of hormonal contraception
C. She should use barrier methods only due to valproate teratogenicity
D. A copper intrauterine device would be most appropriate (Correct Answer)
E. She should switch to lithium before starting hormonal contraception
Explanation: ***A copper intrauterine device would be most appropriate***- Women of childbearing potential on **sodium valproate** must adhere to a **Pregnancy Prevention Programme**, which mandates the use of **highly effective contraception**.- The **copper intrauterine device (IUD)** is an ideal choice as it is a **long-acting reversible contraceptive (LARC)** that is >99% effective and has no metabolic interactions with valproate.*The combined oral contraceptive pill would be suitable*- The **combined oral contraceptive pill (COCP)** carries a higher risk of failure compared to LARCs and may be contraindicated as her **BMI of 32 kg/m²** approaches threshold limits for cardiovascular risk.- Guidelines prioritize LARCs over oral pills for women on valproate to minimize any possibility of **teratogenic exposure** due to user error.*Sodium valproate reduces the efficacy of hormonal contraception*- Unlike enzyme-inducing antiepileptics (e.g., carbamazepine), **sodium valproate** does not induce hepatic enzymes and therefore **does not reduce the efficacy** of hormonal contraceptives.- However, the high **teratogenic risk** of valproate necessitates the most reliable methods regardless of metabolic interactions.*She should use barrier methods only due to valproate teratogenicity*- **Barrier methods** (condoms) have a high typical-use failure rate and are not considered **highly effective contraception** under the valproate safety guidelines.- While they protect against STIs, they must be used in conjunction with a more reliable method like a **LARC** or an injectable.*She should switch to lithium before starting hormonal contraception*- While valproate use in childbearing age requires annual review, switching a patient with **excellent mood stability** to **lithium** is a complex clinical decision and not a prerequisite for starting contraception.- The immediate priority is establishing **highly effective contraception** while she remains on her current stable regimen.
