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Bipolar and Contraception — MRCPsych Paper B MCQ

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HardMood DisordersBipolar and ContraceptionMRCPsych Paper B

A 26-year-old woman with bipolar I disorder is stable on lithium. She wishes to start the combined oral contraceptive pill, partly because she has dysmenorrhoea. She reports taking over-the-counter ibuprofen for the first 2 days of each menstrual period. Which medication-related counselling point is most important?

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Reveal the answer and explanation

Correct answer: B — Over-the-counter ibuprofen may raise lithium concentrations and should not be used without clinical supervision

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

D is correct. The important interaction is with her as-required ibuprofen, not the combined pill. NSAIDs can reduce renal lithium clearance, increasing lithium concentrations and the risk of toxicity. NICE advises patients taking lithium not to use over-the-counter NSAIDs; if an NSAID is unavoidable, it should be prescribed regularly rather than as required, with enhanced lithium monitoring. The combined pill is not expected to lower lithium concentrations (A), and progestogen-only contraception is not known to increase them (B). C is incorrect because reliable contraception, pregnancy intentions and the potential fetal effects of lithium must be discussed. E is also incorrect: lithium does not mandate barrier-only contraception or generally contraindicate hormonal or intrauterine methods.

Reference: National Institute for Health and Care Excellence. Bipolar disorder: assessment and management (CG185), recommendation 1.10.18, updated 2025. https://www.nice.org.uk/guidance/cg185/chapter/Recommendations