Adjustment Disorder — MRCPsych Paper B MCQ

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ModerateLiaison PsychiatryAdjustment DisorderMRCPsych Paper B

A 65-year-old man with advanced cancer is referred to liaison psychiatry with adjustment disorder. Psychosocial assessment and supportive intervention have been initiated, but he continues to experience substantial affective distress accompanied by poor appetite and initial insomnia. If an antidepressant is considered following an individualised discussion of its potential benefits and harms, which option has the adverse-effect profile best suited to these associated symptoms?

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Correct answer: D — Mirtazapine

Mirtazapine is the best answer because its H1-antagonist activity commonly produces sedation, while increased appetite and weight gain are also very common adverse effects. These effects can make it a pragmatic antidepressant choice when clinically significant affective symptoms coexist with insomnia and poor appetite. Fluoxetine is relatively activating and may aggravate insomnia. Sertraline and citalopram are reasonable antidepressants but are less likely to improve appetite or sleep and may initially cause gastrointestinal symptoms. Venlafaxine can cause nausea, insomnia and dose-related hypertension. Psychological and supportive interventions remain central in adjustment disorder, for which evidence supporting routine antidepressant treatment is limited; medication should therefore follow individual assessment rather than be prescribed solely because adjustment disorder is present.

Reference: Electronic Medicines Compendium, Mirtazapine 30 mg tablets, Summary of Product Characteristics, sections 4.2, 4.8 and 5.1, 2025. https://www.medicines.org.uk/emc/product/100083/smpc