Depression and Comorbidity — MRCPsych Paper B MCQ

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ModerateMood DisordersDepression and ComorbidityMRCPsych Paper B

A 45-year-old man has a moderate depressive episode and painful diabetic peripheral neuropathy. He would prefer, where possible, to use one medicine that may treat both conditions. His blood pressure is controlled, his eGFR is 75 mL/min/1.73 m², his liver function tests are normal, and he takes no interacting medication. Which antidepressant is most appropriate?

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Correct answer: C — Duloxetine

Duloxetine is the best answer. It is an SNRI licensed in UK adults for both major depressive disorder and diabetic peripheral neuropathic pain (eMC SmPC section 4.1), so a single medicine can address both conditions. NICE CG173 includes duloxetine among the four initial pharmacological options for neuropathic pain. The stem excludes the main barriers to initiation (hepatic impairment, significant renal impairment, uncontrolled hypertension, interacting drugs). Venlafaxine, the strongest distractor, shares SNRI pharmacology and has some neuropathic pain evidence, but it is neither licensed for diabetic neuropathic pain nor recommended by NICE for initiation in non-specialist settings. Fluoxetine, sertraline and mirtazapine are reasonable antidepressants but have no established role as initial treatment of diabetic neuropathic pain, so they would leave the pain untreated or require an additional agent.

Reference: Duloxetine Dr. Reddy's 30 mg Gastro-Resistant Capsules, Summary of Product Characteristics, section 4.1 (eMC, current). https://www.medicines.org.uk/emc/product/6946/smpc