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Bipolar and Substance Misuse — MRCPsych Paper B MCQ

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ModerateMood DisordersBipolar and Substance MisuseMRCPsych Paper B

A 25-year-old woman with established bipolar I disorder is admitted with an acute manic episode. She takes no regular psychotropic medication, uses cannabis daily and drinks alcohol heavily. Assessment finds no current intoxication, alcohol withdrawal or other medical emergency. Which approach to the coexisting substance misuse best accords with NICE guidance?

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Correct answer: E — Offer treatment for both conditions within a coordinated plan, tailoring the sequencing to severity and readiness for change

The correct answer is E. NICE CG185 recommends treating coexisting substance misuse in line with the relevant NICE guideline in addition to treating bipolar disorder. CG120 similarly advises evidence-based treatment for both conditions within a coordinated care plan. This does not require every intervention to begin at exactly the same moment: sequencing should reflect the relative severity of the mania and substance misuse, the clinical and social context, and readiness for change. Acute mania and any withdrawal risk require prompt management, but substance misuse should not simply be deferred until remission. Therefore A and C impose an inappropriate fixed sequence. D wrongly excludes substance misuse from psychiatric care, while E fragments care; specialist substance misuse input may be sought, but mental health services should retain coordination and use joint working where indicated.

Reference: NICE, Bipolar disorder: assessment and management (CG185), recommendation 1.1.2, updated 2025. https://www.nice.org.uk/guidance/cg185/chapter/recommendations