A 35-year-old woman with bipolar affective disorder type II has experienced four depressive episodes in the past 12 months despite treatment with lithium and quetiapine. Each depressive episode lasts 6-8 weeks. She has had two hypomanic episodes in her lifetime, both lasting less than a week. Her current medications are lithium 800mg daily (level 0.8 mmol/L) and quetiapine 300mg at night. She is currently in a depressive episode. What term best describes her current course of illness?
Q142
A 46-year-old woman with treatment-resistant schizophrenia has been on clozapine 400mg daily for 6 months with good symptom control. She attends for routine monitoring. Her white cell count is 3.2 × 10⁹/L (4.0-11.0), neutrophil count 1.8 × 10⁹/L (2.0-7.5), haemoglobin 128 g/L, platelets 245 × 10⁹/L. She is clinically well with no symptoms of infection. Her previous white cell count 4 weeks ago was 4.5 × 10⁹/L with neutrophils 2.8 × 10⁹/L. What is the most appropriate immediate management according to clozapine monitoring guidelines?
Q143
A 32-year-old man with a first episode of psychosis was started on olanzapine 15mg daily 6 weeks ago. His positive symptoms have largely resolved. However, he now complains of excessive thirst, polyuria, and fatigue. Blood tests show: fasting glucose 14.2 mmol/L, HbA1c 58 mmol/mol (7.5%), total cholesterol 6.8 mmol/L, triglycerides 4.2 mmol/L. His BMI has increased from 24 to 28 kg/m². What is the most appropriate management of his antipsychotic medication?
Q144
A 29-year-old woman with bipolar affective disorder type I presents to the community mental health team reporting a 3-week history of low mood, anhedonia, increased sleep (12 hours daily), increased appetite with 5kg weight gain, and heavy feelings in her limbs. She describes feeling 'slowed down like moving through treacle.' She takes lithium 400mg twice daily with a recent level of 0.7 mmol/L. She has had three previous manic episodes but no previous depressive episodes. What is the most appropriate additional treatment?
Q145
A 44-year-old man with schizoaffective disorder has been treated with amisulpride 800mg daily for 18 months with good symptom control. He now presents with involuntary chewing movements, lip smacking, and darting tongue movements that persist throughout the consultation. He is unaware of these movements. His mental state examination is otherwise unremarkable. Physical examination shows no other abnormalities. What is the most likely diagnosis?
Q146
A 37-year-old woman with bipolar affective disorder has been stable on lithium carbonate 800mg twice daily for 4 years. She attends her routine monitoring appointment. Blood tests show: lithium level 0.9 mmol/L (therapeutic range 0.6-1.0), sodium 138 mmol/L, potassium 4.2 mmol/L, urea 8.2 mmol/L, creatinine 145 µmol/L (baseline 95 µmol/L 6 months ago), eGFR 38 ml/min/1.73m² (was 68 ml/min/1.73m² previously), TSH 5.8 mU/L. What is the most appropriate next step in management?
Q147
A 25-year-old woman presents to the emergency department with a 6-week history of bizarre behaviour. Her family reports she believes her thoughts are being broadcast on television and that she can control the weather. She has stopped washing and eating properly. She has no previous psychiatric history. On examination, she appears dishevelled with poor eye contact and exhibits thought blocking during the interview. What diagnostic category does the phenomenon of 'thought broadcasting' represent?
Q148
A 40-year-old man with chronic paranoid schizophrenia has been treated with various oral antipsychotics over 8 years with poor adherence. He has had four hospital admissions in the past 2 years. His care coordinator reports he forgets to take medications and becomes suspicious of tablets. He currently takes olanzapine 20mg daily but admits taking it only 2-3 times weekly. What is the most appropriate management strategy to improve adherence?
Q149
A 31-year-old woman with bipolar affective disorder type I is admitted to the psychiatric ward during her first trimester of pregnancy. She presents with pressured speech, grandiose delusions, reduced need for sleep, and irritability. She has been non-compliant with lithium for 3 months. She has no past history of violent behaviour. Her physical examination and routine blood tests are normal. What is the most appropriate acute pharmacological management?
Q150
A 34-year-old man with a 6-year history of paranoid schizophrenia is reviewed in the community mental health team. He has been stable on risperidone long-acting injection 50mg fortnightly for the past 2 years. He now wishes to start a family with his partner. On examination, he has mild gynaecomastia and reports reduced libido. Blood tests show a prolactin level of 2800 mU/L (normal range: 86-324 mU/L). His mental state remains stable with no active psychotic symptoms. What is the most appropriate next step in management?
Severe Mental Illness UK Medical PG Practice Questions and MCQs
Question 141: A 35-year-old woman with bipolar affective disorder type II has experienced four depressive episodes in the past 12 months despite treatment with lithium and quetiapine. Each depressive episode lasts 6-8 weeks. She has had two hypomanic episodes in her lifetime, both lasting less than a week. Her current medications are lithium 800mg daily (level 0.8 mmol/L) and quetiapine 300mg at night. She is currently in a depressive episode. What term best describes her current course of illness?
A. Refractory bipolar disorder
B. Rapid cycling bipolar disorder (Correct Answer)
C. Mixed affective state
D. Ultra-rapid cycling bipolar disorder
E. Chronic bipolar depression
Explanation: ***Rapid cycling bipolar disorder***
- **Rapid cycling** is defined by the occurrence of **four or more mood episodes** (depressive, manic, or hypomanic) within a **12-month period**.
- This patient meets the criteria with **four distinct depressive episodes** in the past year, a pattern frequently seen in **women** and individuals with **Bipolar II**.
*Refractory bipolar disorder*
- This term describes **treatment resistance** and is not a specific diagnostic pattern for the frequency of mood episodes.
- Although the patient is not responding optimally to treatment, it does not define the *course* of her illness as described by the frequency of episodes.
*Mixed affective state*
- A **mixed affective state** involves the co-occurrence of symptoms of **mania/hypomania** and **depression** simultaneously or in very rapid succession within a single episode.
- The patient's episodes are discrete, lasting **6-8 weeks** each, indicating distinct depressive phases rather than a mixed presentation.
*Ultra-rapid cycling bipolar disorder*
- This subtype refers to very frequent mood switches, occurring over **days or weeks**.
- The patient's depressive episodes lasting **6-8 weeks** are consistent with standard **rapid cycling** rather than the much shorter cycles of ultra-rapid cycling.
*Chronic bipolar depression*
- This diagnosis would imply a **persistent, non-remitting depressive state**, often lasting two years or more.
- The patient experiences distinct, episodic depressive periods, which resolves before another episode begins, characteristic of a **cycling course** rather than chronicity.
Question 142: A 46-year-old woman with treatment-resistant schizophrenia has been on clozapine 400mg daily for 6 months with good symptom control. She attends for routine monitoring. Her white cell count is 3.2 × 10⁹/L (4.0-11.0), neutrophil count 1.8 × 10⁹/L (2.0-7.5), haemoglobin 128 g/L, platelets 245 × 10⁹/L. She is clinically well with no symptoms of infection. Her previous white cell count 4 weeks ago was 4.5 × 10⁹/L with neutrophils 2.8 × 10⁹/L. What is the most appropriate immediate management according to clozapine monitoring guidelines?
A. Continue clozapine and repeat bloods in 1 week
B. Reduce clozapine dose to 300mg daily
C. Stop clozapine immediately and admit for assessment
D. Continue clozapine and repeat bloods in 3 days (Correct Answer)
E. Stop clozapine and switch to olanzapine
Explanation: ***Continue clozapine and repeat bloods in 3 days*** - The patient's **neutrophil count** of 1.8
× 10⁹/L, coupled with a **WCC** of 3.2
× 10⁹/L, places her in the **'Amber'** category according to clozapine monitoring guidelines (neutrophils 1.5-2.0
× 10⁹/L or WCC 3.0-3.5
× 10⁹/L). - For an 'Amber' result, the protocol requires continuing clozapine while increasing the frequency of **blood monitoring** to **twice weekly** (e.g., every 3 days) until counts return to the 'Green' range. *Continue clozapine and repeat bloods in 1 week* - Repeating blood counts only after **one week** is insufficient for an **'Amber' result**, as it does not meet the required **twice-weekly monitoring** frequency. - This delay could lead to a missed opportunity to detect a rapid progression to **severe neutropenia** or **agranulocytosis**. *Reduce clozapine dose to 300mg daily* - **Dose reduction** is not the standard management for **hematological changes** in clozapine monitoring; the risk of **agranulocytosis** is largely idiosyncratic and not strictly dose-dependent. - Decreasing the dose of clozapine in a patient with **treatment-resistant schizophrenia** risks **relapse of psychotic symptoms**, potentially undermining effective symptom control. *Stop clozapine immediately and admit for assessment* - Immediate cessation of clozapine is reserved for **'Red' results**, defined as a **neutrophil count <1.5
× 10⁹/L** or a **WCC <3.0
× 10⁹/L**. - The patient's current counts (neutrophils 1.8, WCC 3.2) do not meet these criteria, and she is **clinically well**, so immediate stopping and admission are not indicated. *Stop clozapine and switch to olanzapine* - Switching to an alternative antipsychotic like **olanzapine** is premature when the patient has **treatment-resistant schizophrenia** and is stable on clozapine, which is the gold standard for this condition. - Permanent discontinuation of clozapine is only considered for severe adverse events, typically **'Red' zone hematological results**, which are not present here.
Question 143: A 32-year-old man with a first episode of psychosis was started on olanzapine 15mg daily 6 weeks ago. His positive symptoms have largely resolved. However, he now complains of excessive thirst, polyuria, and fatigue. Blood tests show: fasting glucose 14.2 mmol/L, HbA1c 58 mmol/mol (7.5%), total cholesterol 6.8 mmol/L, triglycerides 4.2 mmol/L. His BMI has increased from 24 to 28 kg/m². What is the most appropriate management of his antipsychotic medication?
A. Continue olanzapine and add metformin
B. Switch to aripiprazole (Correct Answer)
C. Reduce olanzapine dose to 10mg daily
D. Switch to amisulpride
E. Continue olanzapine and add atorvastatin
Explanation: ***Switch to aripiprazole***- **Olanzapine** carries a very high risk of **metabolic side effects**, including significant **weight gain**, **hyperglycemia**, and **dyslipidemia**, which this patient has developed, indicating new-onset **diabetes mellitus**.- **Aripiprazole** is a **partial dopamine agonist** known for its low **metabolic side-effect profile**, making it a highly suitable choice to switch to while maintaining antipsychotic efficacy and addressing the severe metabolic complications. *Continue olanzapine and add metformin*- Continuing **olanzapine** means perpetuating the primary cause of the severe **metabolic syndrome** and **diabetes**, which is unlikely to be fully controlled by metformin alone.- While **metformin** would help with **glycemic control**, it does not reverse the weight gain or dyslipidemia and fails to address the iatrogenic origin of these problems. *Reduce olanzapine dose to 10mg daily*- Reducing the dose is unlikely to reverse established **diabetes mellitus**, significant **weight gain** (BMI from 24 to 28), or severe **dyslipidemia** once they have developed.- Lowering the dose could also risk a **relapse of psychotic symptoms** if 15mg was the optimal therapeutic dose for his resolved positive symptoms. *Switch to amisulpride*- While **amisulpride** has a better metabolic profile than olanzapine, it is not as metabolically benign as **aripiprazole** and still carries an intermediate risk for **weight gain**.- **Amisulpride** is also frequently associated with significant **prolactin elevation**, which can lead to other endocrine side effects such as sexual dysfunction and galactorrhea. *Continue olanzapine and add atorvastatin*- Adding **atorvastatin** would only address the **dyslipidemia** and would not manage the patient's new-onset **diabetes mellitus**, significant **weight gain**, or the ongoing metabolic insult from olanzapine.- Continuing the offending agent (olanzapine) maintains the primary risk factor for further metabolic deterioration and increased **cardiovascular morbidity** despite symptomatic treatment of one component.
Question 144: A 29-year-old woman with bipolar affective disorder type I presents to the community mental health team reporting a 3-week history of low mood, anhedonia, increased sleep (12 hours daily), increased appetite with 5kg weight gain, and heavy feelings in her limbs. She describes feeling 'slowed down like moving through treacle.' She takes lithium 400mg twice daily with a recent level of 0.7 mmol/L. She has had three previous manic episodes but no previous depressive episodes. What is the most appropriate additional treatment?
A. Increase lithium dose
B. Add fluoxetine
C. Add quetiapine (Correct Answer)
D. Add venlafaxine
E. Add lamotrigine
Explanation: ***Add quetiapine***
- **Quetiapine** is a first-line recommendation for **acute bipolar depression** due to its robust efficacy and its ability to provide relief without significant risk of **mood switching** to mania.
- It addresses **atypical features** like hypersomnia and leaden paralysis faster than medications requiring long titration periods.
*Increase lithium dose*
- The patient's **lithium level is 0.7 mmol/L**, which is within the therapeutic range (0.6–0.8 mmol/L) for maintenance, so increasing it is unlikely to resolve acute depression.
- Toxicity risk increases significantly at higher doses without guaranteed improvement in **depressive symptoms**.
*Add fluoxetine*
- Adding an **SSRI** like fluoxetine in bipolar I disorder carries a risk of inducing **mania/hypomania**, even when used alongside a mood stabilizer.
- Current guidelines generally prioritize **second-generation antipsychotics** (like quetiapine) or lamotrigine over antidepressants for acute bipolar depression.
*Add venlafaxine*
- **SNRIs** like venlafaxine have a higher risk of triggering **mood switching** to mania compared to SSRIs in bipolar patients.
- It should be avoided, especially in patients with a history of **multiple manic episodes**, as seen in this clinical presentation.
*Add lamotrigine*
- While effective for **bipolar depression prophylaxis**, lamotrigine requires a **slow titration** over 6–8 weeks to avoid severe rashes like Stevens-Johnson syndrome.
- Its slow onset of action makes it less suitable than quetiapine for the **acute management** of current distressing symptoms.
Question 145: A 44-year-old man with schizoaffective disorder has been treated with amisulpride 800mg daily for 18 months with good symptom control. He now presents with involuntary chewing movements, lip smacking, and darting tongue movements that persist throughout the consultation. He is unaware of these movements. His mental state examination is otherwise unremarkable. Physical examination shows no other abnormalities. What is the most likely diagnosis?
A. Acute dystonic reaction
B. Akathisia
C. Tardive dyskinesia (Correct Answer)
D. Parkinsonism
E. Neuroleptic malignant syndrome
Explanation: ***Tardive dyskinesia***
- This condition is a **late-onset extrapyramidal side effect** occurring after prolonged use of antipsychotics (e.g., 18 months), characterized by involuntary, repetitive movements such as **lip smacking**, **chewing movements**, and **darting tongue** movements.
- Patients are frequently **unaware** of these movements, and the symptoms can become **permanent** even if the offending medication is discontinued.
*Acute dystonic reaction*
- These reactions typically occur within **hours to days** of starting a dopamine antagonist or increasing the dose, rather than after long-term treatment.
- Characterized by **sustained muscle contractions** causing abnormal postures like **torticollis** or **oculogyric crisis**, which are not present here.
*Akathisia*
- Presents as a subjective feeling of **inner restlessness** and a physical inability to sit still, often manifesting as constant pacing or leg swinging.
- It does not involve the specific **oro-buccal-lingual dyskinesias** (lip smacking and tongue movements) described in this case.
*Parkinsonism*
- Drug-induced parkinsonism features a triad of **bradykinesia**, **rigidity**, and a **resting tremor** (pill-rolling).
- The movements in parkinsonism are not typically the darting or smacking dyskinetic movements seen in this patient.
*Neuroleptic malignant syndrome*
- A life-threatening emergency characterized by **autonomic instability**, **lead-pipe rigidity**, and **hyperpyrexia** (high fever).
- It is associated with **altered mental status** and high serum **creatine kinase**, which do not match this patient's unremarkable mental state and physical exam.
Question 146: A 37-year-old woman with bipolar affective disorder has been stable on lithium carbonate 800mg twice daily for 4 years. She attends her routine monitoring appointment. Blood tests show: lithium level 0.9 mmol/L (therapeutic range 0.6-1.0), sodium 138 mmol/L, potassium 4.2 mmol/L, urea 8.2 mmol/L, creatinine 145 µmol/L (baseline 95 µmol/L 6 months ago), eGFR 38 ml/min/1.73m² (was 68 ml/min/1.73m² previously), TSH 5.8 mU/L. What is the most appropriate next step in management?
A. Continue lithium and repeat bloods in 3 months
B. Reduce lithium dose to 600mg twice daily
C. Stop lithium and switch to sodium valproate
D. Refer to nephrology and consider switching to alternative mood stabiliser (Correct Answer)
E. Add levothyroxine and continue lithium
Explanation: ***Refer to nephrology and consider switching to alternative mood stabiliser***- The patient shows a significant **decline in eGFR** (from 68 to 38 ml/min) and a rising **creatinine**, indicating **Stage 3b Chronic Kidney Disease**, which requires specialist referral.- NICE guidelines suggest that if **eGFR** falls below 45 ml/min or shows a rapid decline, lithium should be reconsidered and potentially replaced with alternatives like **valproate** or **quetiapine** to prevent further nephrotoxicity.*Continue lithium and repeat bloods in 3 months*- Routine monitoring is inappropriate when there is evidence of **progressive renal impairment**, as waiting 3 months could lead to irreversible damage.- Lithium levels are currently within the therapeutic range, but the toxicity is **structural/interstitial**, meaning a "normal" level does not rule out ongoing renal damage.*Reduce lithium dose to 600mg twice daily*- While dose reduction may lower serum levels, it does not stop the progression of **lithium-induced interstitial nephritis** once significant impairment has occurred.- The drop in **eGFR** to below 40 ml/min is a critical threshold that mandates specialist expert review rather than simple titration.*Stop lithium and switch to sodium valproate*- Abruptly stopping lithium without **specialist psychiatric guidance** and **nephrology consultation** can cause a rebound relapse of bipolar symptoms.- While a switch is likely necessary, the management should be coordinated to balance **renal protection** with the risk of **mood destabilization**.*Add levothyroxine and continue lithium*- The mildly elevated **TSH (5.8 mU/L)** suggests **subclinical hypothyroidism**, which is a common side effect of lithium but not as urgent as the renal decline.- Starting levothyroxine addresses the endocrine issue but completely ignores the life-altering **progressive renal failure** demonstrated by the drop in eGFR.
Question 147: A 25-year-old woman presents to the emergency department with a 6-week history of bizarre behaviour. Her family reports she believes her thoughts are being broadcast on television and that she can control the weather. She has stopped washing and eating properly. She has no previous psychiatric history. On examination, she appears dishevelled with poor eye contact and exhibits thought blocking during the interview. What diagnostic category does the phenomenon of 'thought broadcasting' represent?
A. Delusion of reference
B. Passivity phenomenon (Correct Answer)
C. Thought disorder
D. Overvalued idea
E. Grandiose delusion
Explanation: ***Passivity phenomenon***
- **Thought broadcasting** is a Schneiderian **first-rank symptom** of schizophrenia, where a person believes their thoughts are being divulged to others.
- It falls under **passivity phenomena** (or disorders of thought possession), which signify a disturbance of **ego boundaries** where internal experiences are felt to be externally imposed or controlled.
*Delusion of reference*
- A **delusion of reference** involves the false belief that certain **neutral events or objects** in the environment carry specific, personal meaning or messages for the individual.
- While the patient's thoughts are 'broadcast on television', the core belief is about her thoughts being *known* or *sent out*, not merely interpreting an existing television program as referring to her.
*Thought disorder*
- This term refers to **disturbances in the form or stream of thought**, affecting how thoughts are expressed, such as **thought blocking**, loosening of associations, or tangentiality.
- Although the patient exhibits **thought blocking**, "thought broadcasting" is a **delusion** (a disturbance in content of thought) specifically categorized under passivity phenomena, not primarily a disorder of thought *form*.
*Overvalued idea*
- An **overvalued idea** is an understandable, albeit unreasonable, belief that is pursued with conviction but is not held with the same **absolute certainty** as a delusion and does not involve external imposition.
- Unlike thought broadcasting, overvalued ideas do not involve the perception of one's thoughts being **controlled or accessible** by external forces.
*Grandiose delusion*
- A **grandiose delusion** is a false belief in one's **exaggerated importance, power, or identity**, such as believing one can **control the weather**, which the patient also exhibits.
- While the patient has a grandiose delusion, this is a separate and distinct type of delusion from **thought broadcasting**, which specifically concerns the boundaries of one's mind and the privacy of thoughts.
Question 148: A 40-year-old man with chronic paranoid schizophrenia has been treated with various oral antipsychotics over 8 years with poor adherence. He has had four hospital admissions in the past 2 years. His care coordinator reports he forgets to take medications and becomes suspicious of tablets. He currently takes olanzapine 20mg daily but admits taking it only 2-3 times weekly. What is the most appropriate management strategy to improve adherence?
A. Increase olanzapine to 30mg daily
B. Change to paliperidone long-acting injection (Correct Answer)
C. Initiate clozapine treatment
D. Add lithium augmentation
E. Arrange supervised daily dispensing by pharmacy
Explanation: ***Change to paliperidone long-acting injection***
- **Long-acting injectable (LAI)** antipsychotics are the treatment of choice for patients with chronic schizophrenia who exhibit **poor adherence** and frequent hospital readmissions.
- This strategy ensures reliable delivery of medication and allows the clinical team to immediately identify **non-compliance** if the patient misses an injection appointment.
*Increase olanzapine to 30mg daily*
- Increasing the dose is ineffective when the primary issue is **medication non-adherence** rather than a lack of clinical response to the molecules.
- Higher doses may lead to increased **metabolic side effects**, which could further discourage the patient from taking the medication.
*Initiate clozapine treatment*
- **Clozapine** is indicated for **treatment-resistant schizophrenia**, defined as failure of two different antipsychotics despite adequate adherence.
- This patient's relapse is clearly linked to **poor compliance** rather than resistance, and clozapine requires strict adherence to blood monitoring and daily dosing.
*Add lithium augmentation*
- **Lithium augmentation** is typically used to manage mood symptoms or treatment-resistant cases, not as a primary strategy to manage **medication forgetfulness**.
- Adding more medications increases the **pill burden**, which likely worsens the patient's existing suspicion and poor adherence.
*Arrange supervised daily dispensing by pharmacy*
- While this ensures ingestion, it is more intrusive and burdensome than an **LAI**, requiring the patient to travel to a pharmacy every single day.
- For a patient with **suspiciousness** and a history of forgetting pills, a once-monthly or fortnightly injection provides a more sustainable and less stigmatizing long-term solution.
Question 149: A 31-year-old woman with bipolar affective disorder type I is admitted to the psychiatric ward during her first trimester of pregnancy. She presents with pressured speech, grandiose delusions, reduced need for sleep, and irritability. She has been non-compliant with lithium for 3 months. She has no past history of violent behaviour. Her physical examination and routine blood tests are normal. What is the most appropriate acute pharmacological management?
A. Restart lithium carbonate
B. Commence haloperidol (Correct Answer)
C. Commence sodium valproate
D. Commence lamotrigine
E. Commence carbamazepine
Explanation: ***Commence haloperidol***
- **Haloperidol** is a first-line agent for **acute mania** in pregnancy due to its established safety profile and extensive data regarding fetal safety, particularly in the **first trimester**.
- It effectively manages severe **psychotic symptoms** and irritability, making it a suitable choice for rapid control of acute manic episodes during pregnancy.
*Restart lithium carbonate*
- **Lithium** use during the **first trimester** is associated with an increased risk of **Ebstein's anomaly**, a congenital cardiac malformation.
- While it may be considered in later trimesters with careful monitoring, the immediate risks in early pregnancy make it an inappropriate acute management choice.
*Commence sodium valproate*
- **Sodium valproate** is strongly **contraindicated** in pregnancy, especially in the first trimester, due to a high risk of **neural tube defects** and long-term neurodevelopmental problems.
- Its teratogenicity makes it an unsuitable option for managing acute mania in a pregnant woman.
*Commence lamotrigine*
- **Lamotrigine** is primarily used for the management of **bipolar depression** or as maintenance therapy, rather than for the acute treatment of severe manic symptoms.
- Its slow **titration** schedule and limited efficacy for rapid mood stabilization make it inappropriate for an acute manic episode.
*Commence carbamazepine*
- **Carbamazepine** is a known **teratogen** associated with risks of **neural tube defects** and craniofacial anomalies when used in the first trimester of pregnancy.
- Given these risks and the availability of safer alternatives like haloperidol, it is not the appropriate acute pharmacological choice.
Question 150: A 34-year-old man with a 6-year history of paranoid schizophrenia is reviewed in the community mental health team. He has been stable on risperidone long-acting injection 50mg fortnightly for the past 2 years. He now wishes to start a family with his partner. On examination, he has mild gynaecomastia and reports reduced libido. Blood tests show a prolactin level of 2800 mU/L (normal range: 86-324 mU/L). His mental state remains stable with no active psychotic symptoms. What is the most appropriate next step in management?
A. Switch to aripiprazole long-acting injection (Correct Answer)
B. Add cabergoline to current medication
C. Switch to clozapine
D. Reduce risperidone dose to 25mg fortnightly
E. Continue current medication and reassure
Explanation: ***Switch to aripiprazole long-acting injection***- **Risperidone** is a potent **D2 antagonist** that frequently cause **hyperprolactinaemia**; switching to **aripiprazole**, a **partial dopamine agonist**, helps lower prolactin levels while maintaining antipsychotic control.- Using the **long-acting injection (LAI)** formulation ensures continued **medication adherence** and stability in a patient who has been well-managed on a depot.*Add cabergoline to current medication*- **Cabergoline** is a dopamine agonist used for prolactinomas but is generally avoided in **schizophrenia** as it can potentially **exacerbate psychotic symptoms**.- This approach introduces unnecessary **polypharmacy** rather than addressing the primary cause, which is the risperidone therapy.*Switch to clozapine*- **Clozapine** is typically reserved for cases of **treatment-resistant schizophrenia**, defined by failing two other antipsychotics, which does not apply to this stable patient.- It requires intensive **haematological monitoring** due to the risk of **agranulocytosis**, making it a disproportionate intervention for managing side effects.*Reduce risperidone dose to 25mg fortnightly*- A dose reduction carries a significant **risk of relapse** of psychotic symptoms in a patient who has been stable for two years.- Lowering the dose may not be sufficient to resolve **symptomatic hyperprolactinaemia** (gynaecomastia and reduced libido) if the D2 blockade remains high enough.*Continue current medication and reassure*- Clinical symptoms such as **gynaecomastia** and **reduced libido** are significant side effects that impair **quality of life** and the patient's desire to start a family.- **Hyperprolactinaemia** can have long-term health consequences, including **reduced bone mineral density** and osteoporosis, necessitating active management.
