A 35-year-old man with a 10-year history of paranoid schizophrenia presents to his psychiatrist. He has been adherent to depot flupentixol decanoate 40mg every 2 weeks for the past 4 years with good symptom control. Over the past 6 months, his family has noticed he has become increasingly withdrawn, speaks very little, and shows minimal emotional expression. He spends most of his day in bed and has lost interest in his previous hobbies. There are no positive psychotic symptoms. Cognitive examination reveals no significant deficits. What is the most likely explanation for his current presentation?
Q122
A 28-year-old woman with schizophrenia attends the community mental health team for review. She has been stable on risperidone 4mg daily for 2 years. She reports no active psychotic symptoms but mentions she has been feeling increasingly restless and has difficulty sitting still during the appointment. She paces around the room and frequently shifts her weight from one foot to the other. Her cognitive function is intact and she denies mood symptoms. Examination reveals no parkinsonian features or dystonia. What is the most appropriate immediate management?
Q123
A 32-year-old woman with bipolar affective disorder type II experiences predominantly depressive episodes with occasional hypomanic episodes lasting 4-5 days. She has had three major depressive episodes in the past 2 years requiring time off work. She has tried lithium (caused tremor and polyuria) and quetiapine (excessive sedation). She is currently depressed with moderate severity. Which medication would be most appropriate as monotherapy for long-term management?
Q124
A 45-year-old woman with chronic paranoid schizophrenia has been on clozapine 600mg daily for 5 years with good symptom control. She presents to A&E with acute onset chest pain and shortness of breath. ECG shows: sinus tachycardia 115 bpm, PR interval 220 ms, QRS duration 95 ms, QTc 485 ms. Troponin is mildly elevated. Echocardiogram reveals left ventricular ejection fraction of 35% with global hypokinesia. She has no cardiac risk factors. What is the most likely diagnosis?
Q125
A 38-year-old man with bipolar affective disorder type I has had three manic episodes over 7 years, each requiring hospitalization. He has been stable on lithium 1000mg daily for 18 months with therapeutic levels (0.8 mmol/L). He now presents with low mood, anhedonia, poor sleep, and suicidal ideation for 3 weeks. There are no psychotic features or mixed features. His lithium level remains therapeutic. What is the most appropriate pharmacological management?
Q126
A 25-year-old man presents with his first episode of psychosis characterized by 8 weeks of auditory hallucinations, persecutory delusions, and social withdrawal. Drug screen is negative. Brain MRI is normal. He is commenced on risperidone with good initial response. According to current evidence and guidelines, what is the recommended minimum duration of antipsychotic treatment following complete remission of his first psychotic episode?
Q127
A 34-year-old woman with paranoid schizophrenia has been stable on olanzapine 20mg daily for 4 years. She attends for routine monitoring. Her BMI has increased from 24 to 32 kg/m² over this period. Fasting blood tests show: glucose 6.8 mmol/L, HbA1c 44 mmol/mol, total cholesterol 6.2 mmol/L, LDL 4.1 mmol/L, triglycerides 2.8 mmol/L, HDL 0.9 mmol/L. She is reluctant to change antipsychotic due to previous relapses. What is the most appropriate management?
Q128
A 50-year-old man with bipolar affective disorder has been taking lithium carbonate 800mg daily for 6 years. He is admitted to hospital with pneumonia and treated with IV fluids and antibiotics. On day 3 of admission, he becomes confused, ataxic, and develops coarse tremor. Blood tests show: sodium 138 mmol/L, potassium 4.2 mmol/L, urea 8.5 mmol/L, creatinine 145 μmol/L (baseline 85), lithium level 1.8 mmol/L. What is the most appropriate immediate management?
Q129
A 41-year-old woman with treatment-resistant schizophrenia has been on clozapine 400mg daily for 6 months with partial response. Her psychiatrist is considering increasing the dose. Clozapine level is checked at 12 hours post-dose and returns at 280 ng/mL. She smokes 20 cigarettes daily and takes no other medications. Her FBC, U&Es, LFTs, and ECG are normal. What is the most appropriate next step?
Q130
A 29-year-old man with bipolar affective disorder type I presents to A&E with a 4-day history of elevated mood, grandiose beliefs about being a prophet, pressured speech, and decreased need for sleep. He stopped taking his medication 2 weeks ago. He is agitated, intrusive with staff, and attempting to leave. Physical examination reveals: HR 110 bpm, BP 145/90 mmHg, temperature 37.2°C. He has no medical comorbidities. What is the most appropriate initial pharmacological management?
Severe Mental Illness UK Medical PG Practice Questions and MCQs
Question 121: A 35-year-old man with a 10-year history of paranoid schizophrenia presents to his psychiatrist. He has been adherent to depot flupentixol decanoate 40mg every 2 weeks for the past 4 years with good symptom control. Over the past 6 months, his family has noticed he has become increasingly withdrawn, speaks very little, and shows minimal emotional expression. He spends most of his day in bed and has lost interest in his previous hobbies. There are no positive psychotic symptoms. Cognitive examination reveals no significant deficits. What is the most likely explanation for his current presentation?
A. Relapse of positive symptoms of schizophrenia
B. Predominant negative symptoms of schizophrenia
C. Depot-induced parkinsonism (Correct Answer)
D. Comorbid depressive episode
E. Development of dementia
Explanation: ***Depot-induced parkinsonism***- The patient is on a **first-generation antipsychotic** (flupentixol decanoate) known to cause **extrapyramidal symptoms (EPS)**, including **drug-induced parkinsonism**.- Symptoms like **withdrawal**, **alogia** (speaking very little), **apathy** (lost interest, spends day in bed), and **blunted affect** (minimal emotional expression) are consistent with **bradykinesia** and **hypokinesia** seen in parkinsonism, often referred to as **pseudonegative symptoms**.*Relapse of positive symptoms of schizophrenia*- The patient explicitly **lacks positive psychotic symptoms** such as **hallucinations** or **delusions**, which are hallmarks of a positive symptom relapse.- He has been **adherent to medication** with good symptom control for years, making a sudden relapse without typical positive symptoms less likely than a medication side effect.*Predominant negative symptoms of schizophrenia*- While the described symptoms (withdrawal, alogia, anhedonia, avolition) are **negative symptoms**, it is crucial to differentiate between primary negative symptoms and **secondary negative symptoms** caused by medication.- Given the long-term use of a **typical antipsychotic**, drug-induced parkinsonism mimicking negative symptoms (pseudonegative symptoms) is a more plausible explanation, especially with the onset after years of stability.*Comorbid depressive episode*- Although symptoms like **anhedonia** (loss of interest) and withdrawal can occur in depression, the overall clinical picture, particularly the **blunted affect** and **motor slowing** (implied by withdrawal and spending time in bed) on a **first-generation antipsychotic**, strongly points towards **drug-induced parkinsonism**.- There's no mention of core depressive symptoms like **depressed mood**, **guilt**, or **suicidal ideation**, which are typically present in a major depressive episode.*Development of dementia*- The patient's **cognitive examination** revealed **no significant deficits**, directly ruling out dementia as the cause of his current presentation.- At 35 years old, the development of dementia with these specific symptoms and without cognitive decline is highly improbable, making **antipsychotic side effects** a far more likely explanation.
Question 122: A 28-year-old woman with schizophrenia attends the community mental health team for review. She has been stable on risperidone 4mg daily for 2 years. She reports no active psychotic symptoms but mentions she has been feeling increasingly restless and has difficulty sitting still during the appointment. She paces around the room and frequently shifts her weight from one foot to the other. Her cognitive function is intact and she denies mood symptoms. Examination reveals no parkinsonian features or dystonia. What is the most appropriate immediate management?
A. Add propranolol (Correct Answer)
B. Reduce the dose of risperidone
C. Add procyclidine
D. Switch to a depot antipsychotic
E. Add diazepam
Explanation: ***Add propranolol***
- This patient's symptoms of subjective restlessness, difficulty sitting still, pacing, and shifting weight are classic presentations of **akathisia**, a common extrapyramidal side effect of **risperidone**.
- **Propranolol**, a lipophilic **beta-blocker**, is considered the **first-line pharmacological treatment** for akathisia due to its effectiveness in reducing both the subjective and objective motor restlessness.
*Reduce the dose of risperidone*
- The patient has been **stable on risperidone for 2 years**, indicating the current dose is effective for her schizophrenia. **Reducing the dose** carries a significant risk of **psychotic relapse**.
- While dose adjustment can be considered for side effects, in a clinically stable patient, managing the side effect with an additional agent is often preferred before risking efficacy.
*Add procyclidine*
- **Procyclidine** is an **anticholinergic medication** primarily used to treat other extrapyramidal symptoms such as **Parkinsonism** (e.g., tremor, rigidity) and **acute dystonia**.
- Anticholinergics are generally **ineffective for akathisia** and may even worsen the restlessness or cause other anticholinergic side effects.
*Switch to a depot antipsychotic*
- Switching to a **long-acting injectable (depot)** antipsychotic is typically indicated for issues with **medication adherence** or patient preference, neither of which is suggested in this case.
- A depot formulation would not inherently resolve the akathisia; the underlying propensity for the side effect with the medication would likely persist or recur.
*Add diazepam*
- **Benzodiazepines** like diazepam can be used as a **second-line option** to alleviate the distress and restlessness associated with akathisia, but they are not the first choice.
- They carry risks of **sedation, tolerance, and dependence**, making them less favorable for long-term or first-line management compared to propranolol.
Question 123: A 32-year-old woman with bipolar affective disorder type II experiences predominantly depressive episodes with occasional hypomanic episodes lasting 4-5 days. She has had three major depressive episodes in the past 2 years requiring time off work. She has tried lithium (caused tremor and polyuria) and quetiapine (excessive sedation). She is currently depressed with moderate severity. Which medication would be most appropriate as monotherapy for long-term management?
A. Lamotrigine (Correct Answer)
B. Sodium valproate
C. Carbamazepine
D. Olanzapine
E. Fluoxetine
Explanation: ***Lamotrigine***- **Lamotrigine** is highly effective for the **prevention of depressive episodes** in Bipolar II disorder, especially when depression is the predominant polarity.- It is generally **well-tolerated** with no weight gain, making it a suitable alternative for patients who cannot tolerate side effects of **Lithium** or **Quetiapine**.*Sodium valproate*- While used as a mood stabilizer, it is more effective at **preventing mania** than depression and is not first-line for bipolar depression monotherapy.- It is strictly **contraindicated** in women of childbearing potential due to high **teratogenic risk** (valproate pregnancy prevention program).*Carbamazepine*- Primarily used for **acute mania** or prophylaxis when other agents fail; it has very limited evidence for treating or preventing **bipolar depression**.- It is a potent **enzyme inducer**, leading to numerous drug interactions and a higher side-effect profile compared to lamotrigine.*Olanzapine*- Highly effective for **acute mania** and relapse prevention, but monotherapy is less effective for the depressive pole compared to combination therapy.- Associated with significant **metabolic side effects**, including substantial **weight gain** and increased risk of diabetes.*Fluoxetine*- **Antidepressant monotherapy** is generally avoided in bipolar disorder because it carries a risk of inducing **treatment-emergent mania** or rapid cycling.- If used for bipolar depression, it should typically be co-administered with a **mood stabilizer** or an antipsychotic to ensure mood stability.
Question 124: A 45-year-old woman with chronic paranoid schizophrenia has been on clozapine 600mg daily for 5 years with good symptom control. She presents to A&E with acute onset chest pain and shortness of breath. ECG shows: sinus tachycardia 115 bpm, PR interval 220 ms, QRS duration 95 ms, QTc 485 ms. Troponin is mildly elevated. Echocardiogram reveals left ventricular ejection fraction of 35% with global hypokinesia. She has no cardiac risk factors. What is the most likely diagnosis?
A. Acute coronary syndrome
B. Clozapine-induced cardiomyopathy (Correct Answer)
C. Pulmonary embolism
D. Acute pericarditis
E. QT prolongation with arrhythmia
Explanation: ***Clozapine-induced cardiomyopathy***
- **Clozapine** is known to cause **cardiomyopathy** and **myocarditis**, often presenting with **reduced ejection fraction** and **global hypokinesia**, along with symptoms like chest pain and shortness of breath.
- The patient's long-term **clozapine** use, lack of other **cardiac risk factors**, presence of **sinus tachycardia**, elevated **troponin**, and **severely reduced LVEF (35%)** strongly indicate this diagnosis.
*Acute coronary syndrome*
- While **mildly elevated troponin** and chest pain are present, the absence of typical **cardiac risk factors** and the finding of **global hypokinesia** rather than regional wall motion abnormalities make this less likely.
- The **ECG** lacks specific **ischemic changes** (e.g., ST-segment elevation or depression, T-wave inversions) that define acute coronary syndrome.
*Pulmonary embolism*
- **Pulmonary embolism** typically causes **right ventricular strain** or dysfunction on echocardiogram, not primary **left ventricular global hypokinesia** and severely reduced ejection fraction.
- Although tachycardia and shortness of breath are common, the elevated **troponin** and **echo findings** point more towards intrinsic myocardial damage.
*Acute pericarditis*
- **Acute pericarditis** usually presents with characteristic **widespread ST-segment elevation** and **PR-segment depression** on ECG, which were not observed here.
- Significant **left ventricular dysfunction** (LVEF 35%) and **global hypokinesia** are not typical features of isolated pericarditis.
*QT prolongation with arrhythmia*
- A **QTc of 485 ms** is prolonged and a known adverse effect of **clozapine**, increasing the risk of **Torsades de Pointes**.
- However, the primary clinical picture is dominated by structural **left ventricular dysfunction** (global hypokinesia, reduced LVEF), which is not directly explained by QT prolongation itself but rather by a broader cardiac insult like cardiomyopathy.
Question 125: A 38-year-old man with bipolar affective disorder type I has had three manic episodes over 7 years, each requiring hospitalization. He has been stable on lithium 1000mg daily for 18 months with therapeutic levels (0.8 mmol/L). He now presents with low mood, anhedonia, poor sleep, and suicidal ideation for 3 weeks. There are no psychotic features or mixed features. His lithium level remains therapeutic. What is the most appropriate pharmacological management?
A. Increase lithium dose to achieve level of 1.0-1.2 mmol/L
B. Add quetiapine to lithium (Correct Answer)
C. Switch lithium to lamotrigine
D. Add fluoxetine to lithium
E. Add sodium valproate to lithium
Explanation: ***Add quetiapine to lithium***
- This patient presents with a **severe depressive episode** with **suicidal ideation** despite therapeutic lithium levels for prophylaxis. **Quetiapine** is a first-line treatment for **bipolar depression**, especially when added to a mood stabilizer like lithium, and is **licensed** for this indication.
- It provides relatively **rapid symptom relief**, which is critical given the urgency of suicidal ideation, and helps stabilize mood without the risk of inducing mania often associated with antidepressants alone.
*Increase lithium dose to achieve level of 1.0-1.2 mmol/L*
- The patient's current lithium level (0.8 mmol/L) is already within the **therapeutic range** for maintenance. Higher levels (1.0-1.2 mmol/L) are typically targeted for **acute mania**, not for breakthrough depressive episodes.
- There is limited evidence that increasing lithium beyond the standard maintenance range effectively treats a **breakthrough depressive episode**, and it increases the risk of **adverse effects**.
*Switch lithium to lamotrigine*
- **Switching off lithium** in a patient with a history of recurrent severe manic episodes carries a significant risk of **manic relapse**, as lithium is highly effective in preventing mania.
- **Lamotrigine** is effective for preventing bipolar depression but requires a **slow upward titration** over several weeks to avoid **Stevens-Johnson syndrome**, making it unsuitable for acute management of severe depression with suicidal ideation.
*Add fluoxetine to lithium*
- While SSRIs can be used in bipolar depression, adding an antidepressant like **fluoxetine** to lithium carries a substantial risk of **inducing mania**, hypomania, or **rapid cycling** in a patient with a history of multiple manic episodes.
- Guidelines generally prefer atypical antipsychotics like **quetiapine** or **lurasidone** over antidepressants for the acute phase of bipolar depression due to a lower risk of mood destabilization.
*Add sodium valproate to lithium*
- **Sodium valproate** is primarily effective for managing and preventing **manic episodes** and can be used as an alternative or adjunct to lithium for manic prophylaxis.
- It has significantly **less evidence** for efficacy in treating the **acute depressive phase** of bipolar disorder compared to quetiapine, making it less appropriate for the patient's current presentation of depression with suicidal ideation.
Question 126: A 25-year-old man presents with his first episode of psychosis characterized by 8 weeks of auditory hallucinations, persecutory delusions, and social withdrawal. Drug screen is negative. Brain MRI is normal. He is commenced on risperidone with good initial response. According to current evidence and guidelines, what is the recommended minimum duration of antipsychotic treatment following complete remission of his first psychotic episode?
A. 6 months
B. 1 year
C. 2 years (Correct Answer)
D. 5 years
E. Lifelong treatment
Explanation: ***2 years***
- Major international guidelines, including **NICE** and **RANZCP**, recommend continuing antipsychotic treatment for **1 to 2 years** post-remission of a first psychotic episode to reduce the high risk of **relapse**.
- Maintaining treatment during this period reduces the **relapse rate** from approximately 80% (without medication) to 20%, ensuring long-term **functional recovery** and brain health.
*6 months*
- A 6-month period is considered insufficient for a **first-episode psychosis** because the risk of immediate **rebound psychosis** and symptom recurrence remains extremely high.
- This timeframe is typically reserved for brief psychotic disorders lasting less than a month, which is not the case for this patient's **8-week** presentation.
*1 year*
- While some older guidelines mentioned 1 year, the clinical consensus has shifted toward a minimum of **2 years** to better safeguard against **early relapse**.
- For a patient who has established symptoms for 8 weeks (meeting criteria for **schizophreniform disorder** or early schizophrenia), a 1-year duration is often deemed a minimum rather than the standard recommendation.
*5 years*
- **5 years** of maintenance therapy is generally indicated only after a **second episode** or a significant relapse following the first episode.
- Implementing a 5-year requirement for a first episode may lead to unnecessary **side effects** (like metabolic syndrome or tardive dyskinesia) and decreased **patient adherence**.
*Lifelong treatment*
- **Lifelong treatment** is usually reserved for patients with **multiple relapses**, chronic schizophrenia, or those who pose a significant **risk of harm** to themselves or others if untreated.
- For a **first-episode patient** who shows a good initial response, the goal is to assess for the lowest effective dose and eventual trial of discontinuation after a stable interval.
Question 127: A 34-year-old woman with paranoid schizophrenia has been stable on olanzapine 20mg daily for 4 years. She attends for routine monitoring. Her BMI has increased from 24 to 32 kg/m² over this period. Fasting blood tests show: glucose 6.8 mmol/L, HbA1c 44 mmol/mol, total cholesterol 6.2 mmol/L, LDL 4.1 mmol/L, triglycerides 2.8 mmol/L, HDL 0.9 mmol/L. She is reluctant to change antipsychotic due to previous relapses. What is the most appropriate management?
A. Switch to aripiprazole to improve metabolic profile
B. Add metformin and refer to dietitian (Correct Answer)
C. Start atorvastatin and lifestyle advice
D. Add orlistat for weight reduction
E. Reduce olanzapine to 10mg daily
Explanation: ***Add metformin and refer to dietitian***
- **Metformin** is evidence-based for managing **antipsychotic-induced weight gain** and preventing progression to type 2 diabetes in patients with **impaired fasting glucose** (6.1-6.9 mmol/L).
- Since the patient is reluctant to switch medication due to a high **risk of relapse**, pharmacological intervention for metabolic syndrome while maintaining psychiatric stability is the priority.
*Switch to aripiprazole to improve metabolic profile*
- While **aripiprazole** has a significantly lower risk of metabolic side effects, the patient's history of **previous relapses** makes switching risky.
- A switch might destabilize her **paranoid schizophrenia**, which has been stable on olanzapine for four years.
*Start atorvastatin and lifestyle advice*
- This addresses the **dyslipidemia** (low HDL, high LDL) but does not adequately manage the patient's **pre-diabetes** or significant weight gain.
- While statins are important for cardiovascular risk, they do not provide the weight reduction or glucose-sensitizing benefits found with **metformin**.
*Add orlistat for weight reduction*
- **Orlistat** has limited evidence and efficacy in patients with severe **antipsychotic-induced metabolic syndrome** compared to metformin.
- It only addresses fat absorption and does not target the **insulin resistance** or glucose abnormalities seen in this patient.
*Reduce olanzapine to 10mg daily*
- Reducing the dose is likely to trigger a **psychotic relapse** in a patient who has required 20mg daily for long-term stability.
- Even at a lower dose of 10mg, **olanzapine** continues to exert significant weight-gain and metabolic side effects through H1 and 5HT2C blockades.
Question 128: A 50-year-old man with bipolar affective disorder has been taking lithium carbonate 800mg daily for 6 years. He is admitted to hospital with pneumonia and treated with IV fluids and antibiotics. On day 3 of admission, he becomes confused, ataxic, and develops coarse tremor. Blood tests show: sodium 138 mmol/L, potassium 4.2 mmol/L, urea 8.5 mmol/L, creatinine 145 μmol/L (baseline 85), lithium level 1.8 mmol/L. What is the most appropriate immediate management?
A. Omit next dose and recheck lithium level in 12 hours
B. Stop lithium and give IV normal saline (Correct Answer)
C. Stop lithium and arrange hemodialysis
D. Reduce lithium dose to 400mg daily
E. Give activated charcoal
Explanation: ***Stop lithium and give IV normal saline***
- The patient presents with **lithium toxicity** (level 1.8 mmol/L) and acute kidney injury, necessitating immediate cessation of the drug and **aggressive hydration**.
- **IV normal saline** (0.9% NaCl) is the treatment of choice to increase sodium levels in the kidney, which promotes the **renal excretion** of lithium.
*Omit next dose and recheck lithium level in 12 hours*
- Simply omitting a single dose is insufficient for a patient showing significant **neurotoxicity** (confusion, ataxia) and a level above 1.5 mmol/L.
- Delaying intervention by 12 hours risks further clinical deterioration and permanent **neurological damage** in the setting of rising creatinine.
*Stop lithium and arrange hemodialysis*
- **Hemodialysis** is generally reserved for severe toxicity where levels exceed **2.0 mmol/L** with symptoms or **>3.5 mmol/L** regardless of symptoms.
- While the patient is symptomatic, hydration is the initial step for a level of 1.8 mmol/L unless there is a failure to respond or **refractory renal failure**.
*Reduce lithium dose to 400mg daily*
- Continuing lithium at any dose during an **acute toxic episode** is contraindicated and will worsen the patient's condition.
- Management requires complete **discontinuation** until levels return to the therapeutic range and renal function stabilizes.
*Give activated charcoal*
- **Activated charcoal** is ineffective because lithium is a small, monovalent cation that does not bind to charcoal.
- Gastric lavage or **whole bowel irrigation** might be considered in massive acute ingestions, but not for chronic toxicity associated with illness and dehydration.
Question 129: A 41-year-old woman with treatment-resistant schizophrenia has been on clozapine 400mg daily for 6 months with partial response. Her psychiatrist is considering increasing the dose. Clozapine level is checked at 12 hours post-dose and returns at 280 ng/mL. She smokes 20 cigarettes daily and takes no other medications. Her FBC, U&Es, LFTs, and ECG are normal. What is the most appropriate next step?
A. Increase clozapine to 500mg daily (Correct Answer)
B. Continue current dose as level is therapeutic
C. Check clozapine level again in 2 weeks
D. Add amisulpride to augment clozapine
E. Request smoking cessation and recheck level
Explanation: ***Increase clozapine to 500mg daily***
- The patient's clozapine level of **280 ng/mL** is below the generally accepted **therapeutic range** of 350-600 ng/mL, suggesting an opportunity to improve partial response by increasing the dose.
- Daily **smoking induces CYP1A2**, which significantly increases clozapine metabolism, requiring higher doses to achieve target plasma concentrations in smokers compared to non-smokers.
*Continue current dose as level is therapeutic*
- A clozapine level of **280 ng/mL** is considered **subtherapeutic**; the established therapeutic range for optimal response in treatment-resistant schizophrenia is typically 350-600 ng/mL.
- Given the patient's **partial response**, continuing the current dose would miss the chance to achieve better symptom control through dose optimization.
*Check clozapine level again in 2 weeks*
- The patient has been on clozapine for **6 months**, indicating that **steady-state** levels have already been reached, so rechecking the level without a dose change would not alter management.
- With a demonstrable **subtherapeutic level** and partial response, a dose adjustment is the appropriate next step rather than simply re-monitoring.
*Add amisulpride to augment clozapine*
- **Augmentation strategies** are generally reserved for patients who have failed an adequate trial of clozapine, which includes reaching **therapeutic serum levels** (350-600 ng/mL).
- Before resorting to **polypharmacy** with its increased risk of side effects, it is prudent to first optimize the clozapine dose to its full potential.
*Request smoking cessation and recheck level*
- While smoking cessation would increase clozapine levels, it is a significant lifestyle change that is often difficult to achieve and can lead to a dangerous **sudden increase in clozapine levels** if not carefully managed.
- Adjusting the **clozapine dose** to account for the patient's current smoking status is a more practical and safer immediate step than relying on an uncertain behavioral change.
Question 130: A 29-year-old man with bipolar affective disorder type I presents to A&E with a 4-day history of elevated mood, grandiose beliefs about being a prophet, pressured speech, and decreased need for sleep. He stopped taking his medication 2 weeks ago. He is agitated, intrusive with staff, and attempting to leave. Physical examination reveals: HR 110 bpm, BP 145/90 mmHg, temperature 37.2°C. He has no medical comorbidities. What is the most appropriate initial pharmacological management?
A. Oral lithium 400mg twice daily
B. Intramuscular haloperidol 5mg and lorazepam 2mg (Correct Answer)
C. Oral sodium valproate 500mg twice daily
D. Oral olanzapine 15mg stat
E. Oral lamotrigine 25mg daily
Explanation: ***Intramuscular haloperidol 5mg and lorazepam 2mg***- The patient presents with **acute mania**, **agitation**, and **intrusiveness**; intramuscular (IM) medication is indicated for **rapid tranquilization** when oral adherence is unlikely or risk is high.- Combining a **first-generation antipsychotic** (haloperidol) with a **benzodiazepine** (lorazepam) provides superior sedation and reduces the risk of **extrapyramidal side effects** compared to using an antipsychotic alone.*Oral lithium 400mg twice daily*- **Lithium** has a slow onset of action (requiring 5 to 7 days for therapeutic effect) and is therefore inappropriate for managing **acute behavioral agitation**.- It requires careful **serum level monitoring** and is typically used for long-term **maintenance therapy** rather than immediate crisis stabilization.*Oral sodium valproate 500mg twice daily*- While **sodium valproate** is an effective mood stabilizer, the **oral route** is not suitable for a patient who is currently agitated and attempting to leave the hospital, as adherence is unlikely.- Like lithium, it does not provide the **rapid sedation** necessary to manage the immediate safety risks posed by this patient's manic symptoms.*Oral olanzapine 15mg stat*- **Oral olanzapine** can be used as a first-line treatment for acute mania in patients who are **cooperative** with oral administration.- This patient's **agitation** and attempts to leave A&E suggest that **intramuscular therapy** is a safer and more reliable choice to ensure immediate clinical stability.*Oral lamotrigine 25mg daily*- **Lamotrigine** is primarily used for **bipolar depression prophylaxis** and has no role in the management of an **acute manic episode**.- Using this medication in an acute setting would be ineffective and fails to address the patient's **psychosis** and high-risk behaviors.
