Severe Mental Illness — MCQs

A 34-year-old man with paranoid schizophrenia presents to A&E with his family who report he has become increasingly restless over 24 hours. He is pacing continuously, reports feeling 'unable to sit still', and appears distressed. He started haloperidol 10mg daily 5 days ago. On examination, he has objective restlessness but no rigidity, normal temperature, and normal creatine kinase. What is the most likely diagnosis?

Q13

A 47-year-old man with bipolar affective disorder type I has had six mood episodes in the past 14 months, alternating between manic and depressive episodes. He is currently taking lithium carbonate 1200mg daily with therapeutic levels (0.8 mmol/L). What is the most appropriate additional treatment?

Q14

A 26-year-old man with schizophrenia has been taking clozapine 400mg daily for 6 months with good response. He now develops fever (38.5°C), sore throat, and malaise. His blood tests show: white cell count 2.8 × 10⁹/L, neutrophils 0.8 × 10⁹/L. What is the most appropriate immediate action?

Q15

A 52-year-old woman with a 25-year history of schizophrenia has been on clozapine 600mg daily for 8 years with good symptom control. Recent investigations show: white cell count 3.2 × 10⁹/L, neutrophils 1.8 × 10⁹/L, platelets 180 × 10⁹/L. She is asymptomatic with no signs of infection. What is the most appropriate management?

Q16

A 38-year-old man with schizoaffective disorder has been maintained on depot paliperidone 100mg monthly for 18 months. He now presents with new-onset diabetes mellitus (HbA1c 68 mmol/mol, fasting glucose 8.2 mmol/L). His mental state remains stable with no psychotic symptoms. His BMI is 32 kg/m². What is the most appropriate next step in management?

Q17

A 29-year-old woman with a first episode of psychosis has been treated with olanzapine 15mg daily for 4 months with complete resolution of symptoms. She asks about the duration of treatment required. According to current evidence and NICE guidance, what is the minimum recommended duration of antipsychotic treatment following a first episode of psychosis?

Q18

A 44-year-old woman with schizophrenia presents to her GP with a 6-week history of galactorrhoea and amenorrhoea. She has been taking risperidone 6mg daily for 8 months with good control of psychotic symptoms. Pregnancy test is negative. Prolactin level is 3200 mU/L (normal range 102-496). What is the most appropriate next step in management?

Q19

A 27-year-old man presents with a 5-month history of believing that MI5 is monitoring him through his mobile phone. He has become socially withdrawn, stopped attending work, and reports hearing occasional whispers but cannot make out what they say. His affect is blunted. There is no history of substance misuse or mood episodes. What is the most likely diagnosis?

Q20

A 31-year-old woman with bipolar affective disorder type I has been stable on quetiapine 400mg daily for 18 months following a manic episode. She now presents requesting to stop medication as she feels well and dislikes the weight gain. She has had two previous manic episodes requiring admission. What is the most appropriate management approach?

Severe Mental Illness UK Medical PG Practice Questions and MCQs

Question 11: A 24-year-old woman presents with amenorrhea, weight loss, and exercise intolerance. She has bradycardia and hypotension. Her BMI is 15 kg/m². What is the most serious immediate complication?

A. Osteoporosis
B. Cardiac arrhythmias (Correct Answer)
C. Renal failure
D. Liver dysfunction
E. Hypothermia

Explanation: ***Cardiac arrhythmias***- Severe malnutrition causes myocardial atrophy and significant electrolyte disturbances, particularly **hypokalemia** and **hypophosphatemia**, which prolong the **QT interval**.- These changes create an unstable electrical environment, leading to a high risk of lethal ventricular rhythms and **sudden cardiac death**, making it the most critical immediate complication.*Osteoporosis*- This is a chronic consequence of anorexia nervosa stemming from low **estrogen** levels, poor nutrition (calcium/vitamin D), and increased cortisol.- Osteoporosis significantly increases the risk of **pathological fractures** but is not an acute, life-threatening complication in the immediate term.*Renal failure*- Patients often develop **prerenal azotemia** due to dehydration and hypovolemia, but overt acute kidney injury is not the most common immediate primary cause of death.- Renal issues can be exacerbated later by **refeeding syndrome** or chronic diuretic/laxative abuse, but not typically the imminent threat.*Liver dysfunction*- Mild elevation of liver enzymes (**transaminitis**) is sometimes seen due to metabolic stress or fatty infiltration, but acute hepatic failure is uncommon.- This complication is generally less frequent and less immediately lethal than the severe disruption of cardiac function.*Hypothermia*- **Hypothermia** is a common sign of severe starvation resulting from loss of subcutaneous fat and a drastically reduced basal metabolic rate (**BMR**).- While dangerous, it is usually managed by warming measures; the immediate risk of **sudden death** is directly tied to the underlying cardiac instability.

Question 12: A 34-year-old man with paranoid schizophrenia presents to A&E with his family who report he has become increasingly restless over 24 hours. He is pacing continuously, reports feeling 'unable to sit still', and appears distressed. He started haloperidol 10mg daily 5 days ago. On examination, he has objective restlessness but no rigidity, normal temperature, and normal creatine kinase. What is the most likely diagnosis?

A. Akathisia (Correct Answer)
B. Neuroleptic malignant syndrome
C. Acute dystonia
D. Agitation due to psychosis
E. Tardive dyskinesia

Explanation: ***Akathisia***- Characterized by a subjective sense of **inner restlessness** and an objective inability to sit still, typically appearing within **days to weeks** of starting dopamine-blocking agents like **haloperidol**.- It is distinguished from other movement disorders by the clinical presentation of **pacing** and the patient’s significant distress regarding the physical need to move.*Neuroleptic malignant syndrome*- This is a life-threatening emergency characterized by **lead-pipe rigidity**, **hyperthermia**, and autonomic instability, which are absent in this patient.- Laboratory tests in this condition typically show significantly **elevated creatine kinase (CK)** and leukocytosis, neither of which are seen here.*Acute dystonia*- Presents as sudden, involuntary **sustained muscle contractions**, often resulting in abnormal postures such as **torticollis** or oculogyric crisis.- Typically occurs within the first **24 to 72 hours** of starting a high-potency antipsychotic, whereas this patient presents with pacing rather than muscle spasms.*Agitation due to psychosis*- While psychosis can cause hyperactivity, it lacks the specific **subjective sensation** of the physical inability to sit still described by the patient.- Psychotic agitation is usually driven by **delusions or hallucinations** rather than a primary motor urge localized to the limbs.*Tardive dyskinesia*- A late-onset side effect occurring after **months to years** of antipsychotic exposure, characterized by rhythmic, involuntary movements like **lip-smacking** or tongue protrusion.- Unlike akathisia, tardive dyskinesia is often **not perceived** or distressing to the patient and does not present as generalized pacing.

Question 13: A 47-year-old man with bipolar affective disorder type I has had six mood episodes in the past 14 months, alternating between manic and depressive episodes. He is currently taking lithium carbonate 1200mg daily with therapeutic levels (0.8 mmol/L). What is the most appropriate additional treatment?

A. Add sodium valproate for rapid-cycling bipolar disorder (Correct Answer)
B. Switch lithium to lamotrigine
C. Add quetiapine to the lithium regimen
D. Increase lithium dose to achieve higher therapeutic level
E. Add cognitive behavioural therapy for bipolar disorder

Explanation: ***Add sodium valproate for rapid-cycling bipolar disorder***- The patient's history of **six mood episodes in 14 months** clearly meets the diagnostic criteria for **rapid-cycling bipolar disorder**, defined as four or more mood episodes within a 12-month period.- When **lithium monotherapy** at therapeutic levels (0.8 mmol/L) is insufficient to control rapid cycling, adding **sodium valproate** is an evidence-based and highly effective strategy for stabilization.*Switch lithium to lamotrigine*- **Lamotrigine** is primarily indicated for preventing **depressive episodes** in bipolar disorder and has limited efficacy in preventing or treating **manic episodes**.- Switching away from lithium, which has established anti-manic properties, could potentially worsen the manic component of this patient's **Bipolar Type I** and rapid cycling.*Add quetiapine to the lithium regimen*- While **quetiapine** is an effective mood stabilizer for bipolar disorder, the combination of **lithium and sodium valproate** typically has stronger evidence for managing **rapid-cycling** that is refractory to lithium monotherapy.- Quetiapine might be considered if valproate is contraindicated or ineffective, but it is not the primary add-on recommendation for this specific **refractory rapid-cycling** pattern.*Increase lithium dose to achieve higher therapeutic level*- The patient is already at a **therapeutic lithium level of 0.8 mmol/L**; increasing the dose further would significantly elevate the risk of **lithium toxicity**.- Higher lithium levels (e.g., >1.0 mmol/L) are generally used for acute mania rather than for long-term maintenance in rapid-cycling, and the risk-benefit ratio would be unfavorable here.*Add cognitive behavioural therapy for bipolar disorder*- **Cognitive behavioral therapy (CBT)** is a valuable adjunctive treatment for bipolar disorder, aiding in symptom management and adherence, but it is not a primary intervention for acute or **rapid-cycling stabilization**.- For a patient experiencing **six mood episodes in 14 months** despite therapeutic medication, immediate and effective **pharmacological intervention** is paramount to stabilize the mood before psychological therapies can be fully beneficial.

Question 14: A 26-year-old man with schizophrenia has been taking clozapine 400mg daily for 6 months with good response. He now develops fever (38.5°C), sore throat, and malaise. His blood tests show: white cell count 2.8 × 10⁹/L, neutrophils 0.8 × 10⁹/L. What is the most appropriate immediate action?

A. Continue clozapine and treat symptomatically with paracetamol
B. Stop clozapine immediately, admit to hospital, and start broad-spectrum antibiotics (Correct Answer)
C. Reduce clozapine to 200mg daily and monitor closely
D. Stop clozapine temporarily until infection resolves then rechallenge
E. Continue clozapine and repeat blood tests in 24 hours

Explanation: ***Stop clozapine immediately, admit to hospital, and start broad-spectrum antibiotics*** - The patient's presentation with **fever**, **sore throat**, **malaise**, and a **neutrophil count of 0.8 × 10⁹/L** indicates **clozapine-induced agranulocytosis** (or severe neutropenia) with **neutropenic sepsis**. - This is a medical emergency requiring **immediate cessation of clozapine**, urgent **hospitalization**, and initiation of **broad-spectrum antibiotics** to prevent life-threatening infection. *Continue clozapine and treat symptomatically with paracetamol* - Continuing clozapine in the setting of severe **neutropenia** is extremely dangerous as it perpetuates the bone marrow suppression, leading to worsening agranulocytosis. - Symptomatic treatment with paracetamol alone does not address the underlying **life-threatening condition** caused by drug-induced bone marrow toxicity and increased infection risk. *Reduce clozapine to 200mg daily and monitor closely* - A **neutrophil count below 1.0 × 10⁹/L** (especially 0.8) while on clozapine mandates **immediate and permanent discontinuation**, not a dose reduction. - This reaction is often idiosyncratic and not dose-dependent; reducing the dose still leaves the patient at severe risk of **septic complications**. *Stop clozapine temporarily until infection resolves then rechallenge* - While stopping clozapine is correct, **rechallenge** after documented severe neutropenia or agranulocytosis is **absolutely contraindicated** due to the high risk of a rapid and severe recurrence. - Such a severe reaction necessitates permanent discontinuation of clozapine, and the patient should be registered in a national monitoring system. *Continue clozapine and repeat blood tests in 24 hours* - A **neutrophil count of 0.8 × 10⁹/L** combined with symptoms of infection (fever, sore throat) signifies an acute and severe adverse drug reaction requiring **immediate intervention**, not delayed monitoring. - Waiting 24 hours would dangerously prolong exposure to the drug and allow the **neutropenic sepsis** to progress, potentially leading to septic shock and death.

Question 15: A 52-year-old woman with a 25-year history of schizophrenia has been on clozapine 600mg daily for 8 years with good symptom control. Recent investigations show: white cell count 3.2 × 10⁹/L, neutrophils 1.8 × 10⁹/L, platelets 180 × 10⁹/L. She is asymptomatic with no signs of infection. What is the most appropriate management?

A. Continue clozapine and repeat blood tests in one week (Correct Answer)
B. Stop clozapine immediately and switch to olanzapine
C. Reduce clozapine dose to 400mg and repeat bloods in 3 days
D. Stop clozapine immediately and never rechallenge
E. Continue clozapine and repeat blood tests in 3 days

Explanation: ***Continue clozapine and repeat blood tests in one week*** - The patient's **neutrophil count (1.8 × 10⁹/L)** falls into the **'Amber' category** (1.5–2.0 × 10⁹/L), which requires increased monitoring rather than immediate drug cessation. - Guidelines suggest that for patients on stable long-term therapy, if results enter the amber range, treatment should continue with **increased frequency of blood monitoring** (twice weekly) until counts stabilize. *Stop clozapine immediately and switch to olanzapine* - Immediate cessation is only mandatory for **'Red' category** results, defined by an **absolute neutrophil count (ANC) < 1.5 × 10⁹/L** or WBC < 3.0 × 10⁹/L. - Switching to **olanzapine** is premature given that the patient has been stable for 8 years and does not meeting the threshold for **agranulocytosis** risk. *Reduce clozapine dose to 400mg and repeat bloods in 3 days* - **Dose reduction** is not a standard evidence-based response to hematological fluctuations in clozapine monitoring; the risk is the **idiosyncratic reaction**, not dose-dependent toxicity. - Management hinges on **monitoring frequency** rather than adjusting the dosage of the antipsychotic. *Stop clozapine immediately and never rechallenge* - A **'never rechallenge'** rule applies strictly to patients who experience confirmed **clozapine-induced agranulocytosis** (ANC < 0.5 × 10⁹/L). - The patient currently has a **mild neutropenia**, and stopping therapy would unnecessarily risk a relapse of her **schizophrenia** symptoms. *Continue clozapine and repeat blood tests in 3 days* - While continuing treatment is correct, the protocol for an **Amber result** specifically dictates **twice-weekly** testing until results improve. - This option is less precise than the requirement to ensure testing occurs twice every 7 days to closely monitor for a further **downward trend** in neutrophils.

Question 16: A 38-year-old man with schizoaffective disorder has been maintained on depot paliperidone 100mg monthly for 18 months. He now presents with new-onset diabetes mellitus (HbA1c 68 mmol/mol, fasting glucose 8.2 mmol/L). His mental state remains stable with no psychotic symptoms. His BMI is 32 kg/m². What is the most appropriate next step in management?

A. Continue paliperidone, commence metformin, and refer to diabetic services
B. Switch to amisulpride which has lower metabolic risk
C. Switch to lurasidone which has favourable metabolic profile
D. Continue paliperidone and manage diabetes with lifestyle modifications alone
E. Switch to aripiprazole depot which has lower diabetes risk (Correct Answer)

Explanation: ***Switch to aripiprazole depot which has lower diabetes risk*** - When a patient develops **metabolic complications** like new-onset diabetes while on an antipsychotic with known metabolic risk (like paliperidone), switching to a **metabolically safer** alternative is the most appropriate first-line intervention, especially when the mental state is stable. - **Aripiprazole** is an atypical antipsychotic with a **favorable metabolic profile** and is available as a **depot formulation**, which is crucial for maintaining **treatment adherence** and preventing relapse in patients with schizoaffective disorder. *Continue paliperidone, commence metformin, and refer to diabetic services* - While **metformin** and referral to diabetic services are important steps in managing diabetes, continuing the offending antipsychotic (paliperidone, known for moderate-to-high metabolic risk) without attempting a switch is not ideal given the patient's stable mental state and significant hyperglycemia. - The priority should be to minimize the **metabolic burden** by adjusting the psychotropic medication if a safer alternative is available and feasible. *Switch to amisulpride which has lower metabolic risk* - **Amisulpride** does have a better metabolic profile, but it is primarily available in **oral form**. Switching from a stable **depot regimen** to an oral medication significantly increases the risk of **non-adherence** and psychiatric relapse in patients with schizoaffective disorder. - Maintaining a **long-acting injectable** is crucial for this patient population to ensure consistent medication levels. *Switch to lurasidone which has favourable metabolic profile* - **Lurasidone** is known for its excellent **metabolic safety profile**, but like amisulpride, it is currently not available in a **depot (long-acting injectable)** formulation. - Transitioning to an oral-only medication could compromise **treatment adherence** in a patient with a chronic severe mental illness, potentially leading to symptom exacerbation. *Continue paliperidone and manage diabetes with lifestyle modifications alone* - The patient's **HbA1c of 68 mmol/mol** (8.4%) and **fasting glucose of 8.2 mmol/L** indicate established diabetes requiring pharmacological intervention, not just lifestyle modifications. - Relying solely on **lifestyle changes** while continuing a medication that contributes to metabolic dysfunction is insufficient and will likely result in poor glycemic control, increasing the risk of long-term diabetic complications.

Question 17: A 29-year-old woman with a first episode of psychosis has been treated with olanzapine 15mg daily for 4 months with complete resolution of symptoms. She asks about the duration of treatment required. According to current evidence and NICE guidance, what is the minimum recommended duration of antipsychotic treatment following a first episode of psychosis?

A. 6 months after symptom resolution
B. 1 year after symptom resolution
C. 2 years after symptom resolution (Correct Answer)
D. Until the patient feels ready to discontinue
E. Lifelong maintenance therapy

Explanation: ***2 years after symptom resolution*** - According to **NICE guidelines (CG178)**, antipsychotic treatment should be continued for a minimum of **1 to 2 years** following a first episode of psychosis to prevent relapse. - Evidence shows that maintaining medication for **2 years** significantly reduces the **relapse rate** compared to earlier discontinuation. *6 months after symptom resolution* - This duration is often recommended for a **first-episode depressive disorder**, but it is generally too short for preventing relapse in **psychosis**. - Stopping antipsychotic treatment this early carries a high risk of **recurrent psychotic symptoms** and functional deterioration. *1 year after symptom resolution* - While some guidelines historically considered **1 year** a minimum, current evidence and **NICE recommendations** now favor **2 years** for better long-term stability and reduced relapse risk. - One year might be considered for highly stable patients, but **2 years** is the more robust clinical standard for optimal outcomes. *Until the patient feels ready to discontinue* - Discontinuing antipsychotics solely based on **patient preference** without clinical guidance and a recommended duration risks **rebound psychosis** and poor prognosis. - The decision to stop must be a **shared clinical decision**, involving gradual tapering and close monitoring *after* the evidence-based treatment period. *Lifelong maintenance therapy* - **Lifelong antipsychotic treatment** is typically reserved for patients with **multiple relapses**, severe chronic symptoms, or an established diagnosis of a chronic psychotic disorder like **schizophrenia**. - For a **first episode of psychosis** with complete resolution, a supervised withdrawal after the two-year mark is generally attempted, not immediate lifelong therapy.

Question 18: A 44-year-old woman with schizophrenia presents to her GP with a 6-week history of galactorrhoea and amenorrhoea. She has been taking risperidone 6mg daily for 8 months with good control of psychotic symptoms. Pregnancy test is negative. Prolactin level is 3200 mU/L (normal range 102-496). What is the most appropriate next step in management?

A. Reduce risperidone dose to 4mg daily and reassess in 4 weeks
B. Switch to aripiprazole and monitor prolactin levels (Correct Answer)
C. Add cabergoline to reduce prolactin levels while continuing risperidone
D. Arrange urgent MRI pituitary to exclude prolactinoma
E. Switch to clozapine as it has lower risk of hyperprolactinaemia

Explanation: ***Switch to aripiprazole and monitor prolactin levels*** - **Risperidone** is a potent **D2 receptor antagonist** that frequently causes hyperprolactinaemia due to its strong blockade of dopamine receptors in the pituitary. - **Aripiprazole** acts as a **dopamine partial agonist**, which helps normalize prolactin levels while maintaining antipsychotic efficacy, making it a suitable switch. *Add cabergoline to reduce prolactin levels while continuing risperidone* - **Cabergoline** is a dopamine agonist that can potentially **exacerbate or trigger psychotic symptoms** by counteracting the antipsychotic effect of risperidone. - It is generally reserved for prolactinomas and is not the first-line management for **drug-induced hyperprolactinaemia**. *Reduce risperidone dose to 4mg daily and reassess in 4 weeks* - Lowering the dose may not be sufficient to resolve **symptomatic hyperprolactinaemia** like galactorrhoea and amenorrhoea at this significantly elevated level. - Reducing an effective antipsychotic dose risks **psychotic relapse**, which is a greater clinical concern given the patient's stable psychotic symptoms. *Arrange urgent MRI pituitary to exclude prolactinoma* - Drug-induced prolactin elevations (especially with risperidone) commonly range from **2000-4000 mU/L**, and the cause is clearly medication-related in this case. - An **MRI pituitary** is typically indicated for very high prolactin levels (>5000 mU/L) or if symptoms persist despite switching the offending drug. *Switch to clozapine as it has lower risk of hyperprolactinaemia* - **Clozapine** is reserved for **treatment-resistant schizophrenia** due to its significant side effect profile, including the risk of **agranulocytosis**, requiring intensive monitoring. - Since the patient’s psychotic symptoms are well-controlled on risperidone, switching to a high-risk medication like clozapine is not justified.

Question 19: A 27-year-old man presents with a 5-month history of believing that MI5 is monitoring him through his mobile phone. He has become socially withdrawn, stopped attending work, and reports hearing occasional whispers but cannot make out what they say. His affect is blunted. There is no history of substance misuse or mood episodes. What is the most likely diagnosis?

A. Paranoid schizophrenia (Correct Answer)
B. Delusional disorder - persecutory type
C. Schizotypal personality disorder
D. Schizoaffective disorder
E. Brief psychotic disorder

Explanation: ***Paranoid schizophrenia*** - The patient presents with classic features including **persecutory delusions** (MI5 monitoring), **auditory hallucinations** (occasional whispers), and **negative symptoms** (blunted affect, social withdrawal). - The duration of **5 months** and resulting **functional impairment** (stopped work), in the absence of mood episodes or substance misuse, strongly support a diagnosis of schizophrenia. *Delusional disorder - persecutory type* - This disorder is characterized by the presence of one or more delusions for at least one month **without other significant psychotic symptoms** like prominent hallucinations or marked negative symptoms. - The presence of **occasional whispers** (auditory hallucinations) and **blunted affect** in this patient makes a pure delusional disorder less likely than schizophrenia. *Schizotypal personality disorder* - This is a pervasive pattern of social and interpersonal deficits, with **cognitive or perceptual distortions** and eccentricities of behavior, but typically **lacks the intensity and persistence of frank delusions and hallucinations** seen here. - While individuals may have odd beliefs, it is a **personality disorder** and does not typically involve the acute onset and significant functional deterioration due to active psychotic symptoms as described. *Schizoaffective disorder* - This diagnosis requires that a **major mood episode** (depressive or manic) co-occur with symptoms of schizophrenia, and that delusions or hallucinations be present for at least two weeks **without a major mood episode**. - The history explicitly states there is **no history of substance misuse or mood episodes**, thereby ruling out schizoaffective disorder. *Brief psychotic disorder* - By definition, a brief psychotic disorder involves psychotic symptoms lasting **more than one day but less than one month**, followed by a full return to premorbid functioning. - The patient's symptoms have persisted for **five months**, which far exceeds the maximum duration for a brief psychotic disorder.

Question 20: A 31-year-old woman with bipolar affective disorder type I has been stable on quetiapine 400mg daily for 18 months following a manic episode. She now presents requesting to stop medication as she feels well and dislikes the weight gain. She has had two previous manic episodes requiring admission. What is the most appropriate management approach?

A. Support gradual medication reduction with close monitoring and psychoeducation about relapse risk
B. Advise continuation of current medication emphasising high relapse rates with discontinuation (Correct Answer)
C. Switch to lithium carbonate which has better long-term outcomes for relapse prevention
D. Reduce quetiapine to 200mg daily and review in 3 months
E. Stop quetiapine and commence cognitive behavioural therapy for bipolar disorder

Explanation: ***Advise continuation of current medication emphasising high relapse rates with discontinuation***- For a patient with **Bipolar I Disorder** and a history of **multiple severe manic episodes** requiring admission, long-term maintenance treatment is critically indicated to prevent further morbidity.- Discontinuation of mood stabilizers in such high-risk individuals is associated with a **relapse rate of 50-90%** within two years; clinician counseling must focus on these risks and strategies to manage **adverse effects** like weight gain.*Support gradual medication reduction with close monitoring and psychoeducation about relapse risk*- Given the patient's history of **three previous manic episodes** (one recent, two requiring admission), she is considered **high-risk for relapse**, making any medication reduction inappropriate at this stage.- While psychoeducation is essential, supporting medication reduction would significantly increase her risk of a **recurrent manic or depressive episode**, outweighing the benefit of addressing weight gain at this time.*Switch to lithium carbonate which has better long-term outcomes for relapse prevention*- The patient is currently **stable** on quetiapine, indicating its effectiveness for her. Switching stable medication without a compelling clinical reason (e.g., intolerance, ineffectiveness) is generally discouraged.- Switching to lithium would involve a **cross-titration process**, which can destabilize the patient and introduce new **side effects** or compliance challenges, despite lithium's established efficacy.*Reduce quetiapine to 200mg daily and review in 3 months*- Reducing the dose from 400mg daily, especially given her history of severe episodes, could render the medication **sub-therapeutic** for mood stabilization, significantly increasing relapse risk.- The 400mg dose has maintained stability for 18 months; lowering it primarily for weight gain without exploring other management strategies or a more gradual, justified approach is clinically unsound and might trigger a **manic episode**.*Stop quetiapine and commence cognitive behavioural therapy for bipolar disorder*- **Cognitive Behavioral Therapy (CBT)** is a valuable adjunctive treatment for bipolar disorder, but it is **not a substitute for pharmacotherapy**, especially in **Bipolar I Disorder** with a history of severe episodes.- Abruptly stopping quetiapine, a crucial mood stabilizer, would almost certainly precipitate a **manic or depressive episode**, as CBT alone is insufficient for mood stabilization in such cases.

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