skip to main content

Mixed Affective Episode Treatment — MRCPsych Paper B MCQ

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

HardMood DisordersMixed Affective Episode TreatmentMRCPsych Paper B

A 38-year-old woman with bipolar I disorder is taking sertraline as monotherapy. Over 10 days she develops markedly reduced sleep, pressured speech, increased goal-directed activity and excessive spending, while continuing to experience pervasive low mood, guilt and suicidal thoughts. Substance-induced and organic causes have been excluded. Which pharmacological plan most closely follows NICE guidance for this mixed affective state?

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

Reveal the answer and explanation

Correct answer: B — Consider stopping sertraline and offering quetiapine

NICE recommends treating a mixed affective state according to its acute mania pathway while monitoring closely for emerging depression. When mania develops during antidepressant monotherapy, the antidepressant should be considered for discontinuation and an antipsychotic should be offered regardless of whether it is stopped. Quetiapine is one of the recommended options. Continuing sertraline is inappropriate despite the prominent depressive and suicidal symptoms because it may perpetuate the manic component. Lithium is not the recommended initial substitute before antipsychotic treatment has been tried. Valproate is neither the first-line step nor straightforwardly appropriate in a 38-year-old woman because of stringent reproductive-safety restrictions. Lorazepam may sometimes be used briefly for severe agitation but is not adequate monotherapy for the affective episode.

Reference: National Institute for Health and Care Excellence. Bipolar disorder: assessment and management (CG185), recommendations 1.5.2–1.5.11. Published 2014; updated 2025. https://www.nice.org.uk/guidance/cg185/chapter/Recommendations