Bipolar Depression — MRCPsych Paper B MCQ

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HardMood DisordersBipolar DepressionMRCPsych Paper B

A 38-year-old man with bipolar II disorder is assessed in secondary care with a moderate depressive episode. There are no mixed or psychotic features. He is not taking any medication for bipolar disorder, has no previous treatment response to guide the choice, and prefers monotherapy rather than combination treatment. According to current NICE CG185, which pharmacological treatment should be offered?

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Correct answer: B — Quetiapine

Quetiapine is correct. For moderate or severe bipolar depression in an adult who is not taking medication for bipolar disorder, NICE recommends offering either quetiapine monotherapy or fluoxetine combined with olanzapine, guided by preference and previous response. Because this patient prefers monotherapy, quetiapine is the treatment to offer. Fluoxetine alone is not the recommended regimen. Lamotrigine monotherapy and olanzapine monotherapy may be considered if the person prefers, but they are not framed as the primary treatments to offer. Lithium is the preferred long-term relapse-prevention treatment and is relevant to acute depression when the patient is already taking it, but it is not NICE's initial acute treatment here. Mirtazapine is not recommended for bipolar depression in this pathway.

Reference: National Institute for Health and Care Excellence. Bipolar disorder: assessment and management (CG185), section 1.6, recommendation 1.6.3. Updated 2025. https://www.nice.org.uk/guidance/cg185/chapter/Recommendations