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Dual Diagnosis — MRCPsych Paper B MCQ

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HardSubstance MisuseDual DiagnosisMRCPsych Paper B

A 55-year-old man with alcohol dependence has consumed alcohol heavily for 6 months. Depressive symptoms began after his drinking escalated. He has no history of depressive episodes, psychotic symptoms, suicidal intent or other indication for urgent independent psychiatric treatment. Assisted alcohol withdrawal is being planned. According to NICE guidance, what is the most appropriate approach to his depressive symptoms?

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Correct answer: E — Treat the alcohol misuse first; after 3–4 weeks of abstinence, reassess and treat persistent depression

Explanation lettering: D = shown as A · E = shown as B · A = shown as C · C = shown as D · B = shown as E

The correct answer is B. NICE CG115 recommends treating alcohol misuse first because associated depressive symptoms may improve substantially with abstinence. If depression continues after typically 3–4 weeks of abstinence, it should be reassessed and specific treatment or referral considered in line with the relevant NICE depression guideline. This is not an instruction to start an antidepressant automatically at 3–4 weeks; treatment depends on the subsequent assessment. Starting routinely during withdrawal (A) does not follow this sequencing where there is no urgent independent indication. Six months (C) is unnecessarily long. Persistent depression must not simply be dismissed as secondary to alcohol (D), and family history is neither necessary nor sufficient to determine treatment (E). Significant mental disorder or high suicide risk would require prompt psychiatric assessment rather than waiting.

Reference: National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (CG115), recommendation 1.3.8.1. 2011, updated 2014. https://www.nice.org.uk/guidance/cg115/chapter/Recommendations