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Bipolar Depression Treatment — MRCPsych Paper B MCQ

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HardMood DisordersBipolar Depression TreatmentMRCPsych Paper B

A 30-year-old woman with bipolar I disorder develops a moderate to severe depressive episode without manic or mixed features. She is adherent to lithium 800 mg daily. Her correctly timed plasma lithium level is 0.7 mmol/L, which is below her individually agreed target, and there are no clinical or biochemical contraindications to increasing the dose. Which pharmacological sequence most closely follows NICE CG185?

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Correct answer: B — Increase lithium to its target level; if further treatment is required at the maximum level, add quetiapine or fluoxetine combined with olanzapine

NICE recommends checking the plasma lithium level in moderate or severe bipolar depression occurring during lithium treatment. If the level is inadequate, lithium should first be increased. If it is at the maximum level and further treatment is required, either quetiapine or fluoxetine combined with olanzapine should be added. Depending on preference, olanzapine alone or lamotrigine added to lithium may be considered; lamotrigine is also an option after non-response to the principal add-on treatments. Fluoxetine without olanzapine and venlafaxine are not recommended NICE strategies here. Stopping lithium for lamotrigine monotherapy is unnecessary, and switching to valproate is not the recommended acute sequence—particularly in a 30-year-old woman given current reproductive-safety restrictions.

Reference: National Institute for Health and Care Excellence. Bipolar disorder: assessment and management (CG185), section 1.6, recommendation 1.6.4. Published 2014; last updated 2025. https://www.nice.org.uk/guidance/cg185/chapter/Recommendations