skip to main content

Breakthrough Mania on Lithium — MRCPsych Paper B MCQ

Instant feedback + full explanation. One question, done properly.

HardMood DisordersBreakthrough Mania on LithiumMRCPsych Paper B

A 33-year-old man with bipolar I disorder develops an acute manic episode despite confirmed adherence to lithium. His correctly timed 12-hour trough plasma lithium level is 0.8 mmol/L, renal and thyroid function are normal, and he is not taking an antidepressant or antipsychotic. According to current NICE guidance, which is the most appropriate pharmacological approach?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Continue lithium, check that its level is optimised, and consider adding an antipsychotic

The correct answer is D. NICE recommends checking the plasma lithium level to optimise treatment when mania or hypomania develops during lithium therapy, and considering addition of haloperidol, olanzapine, quetiapine or risperidone according to previous response, preference and clinical context. Although a relapse may justify maintaining lithium at 0.8–1.0 mmol/L for a trial period, routinely increasing it to 1.2 mmol/L is not the NICE recommendation and would increase toxicity risk. Lithium should not automatically be stopped in favour of valproate or carbamazepine. Valproate also carries substantial regulatory restrictions and is not the indicated first response here. Lamotrigine is used principally for bipolar depression and relapse prevention; NICE explicitly states that it should not be offered to treat acute mania.

Reference: National Institute for Health and Care Excellence. Bipolar disorder: assessment and management (CG185), sections 1.5.8, 1.5.12 and 1.10.16. Updated 2025. https://www.nice.org.uk/guidance/cg185/chapter/Recommendations