Bipolar I Disorder — MRCPsych Paper B MCQ

Instant feedback + full explanation. One question, done properly.

ModerateMood DisordersBipolar I DisorderMRCPsych Paper B

A 30-year-old woman with bipolar I disorder develops a severe manic episode with psychotic features. She is not currently taking an antipsychotic or mood stabiliser. According to NICE CG185, which pharmacological treatment should be offered first?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Antipsychotic monotherapy

The correct answer is B. NICE CG185 recommends offering haloperidol, olanzapine, quetiapine or risperidone when an adult develops mania or hypomania and is not taking an antipsychotic or mood stabiliser. The choice should reflect clinical context, previous response, adverse-effect risks and patient preference. Psychotic features further support using an antipsychotic but do not require initial combination therapy. Lithium is not the first pharmacological step in this scenario: NICE advises trying an alternative listed antipsychotic if the first is ineffective or poorly tolerated, then considering lithium augmentation if the second is insufficient. Valproate is considered later if lithium is ineffective or unsuitable and is subject to stringent reproductive-safety restrictions. Carbamazepine and combined lithium–valproate treatment are not recommended first-line options for this untreated acute episode.

Reference: National Institute for Health and Care Excellence. Bipolar disorder: assessment and management (CG185), section 1.5, recommendations 1.5.3–1.5.6. Published 2014; updated 2025. https://www.nice.org.uk/guidance/cg185/chapter/Recommendations