High-Dose Antipsychotic Monitoring — MRCPsych Paper B MCQ

Correct answer: E — Obtain an ECG and electrolytes at baseline, repeat the ECG during dose escalation and every few months, monitor adverse effects and metabolic health systematically, and review reduction to a conventional dose by 3 months

Explanation lettering: C = shown as A · E = shown as B · A = shown as C · B = shown as E

Option B is correct. High-dose antipsychotic prescribing should be treated as a defined, time-limited therapeutic trial rather than routine maintenance. Monitoring should include systematic assessment of response, movement and other dose-related adverse effects, physical and metabolic health, electrolytes and cardiac rhythm. RCPsych CR190 recommends ECG monitoring during initiation or dose escalation and subsequently every few months, with additional assessment during acute illness, after introducing interacting medicines or if arrhythmic symptoms occur. The dose should return to conventional levels after about 3 months unless clear benefit outweighs risk. Options A and E monitor too infrequently and lack an appropriate early endpoint. C omits routine cardiac surveillance, while D incorrectly makes enhanced ECG and electrolyte monitoring dependent solely on the individual SmPC.

Reference: Royal College of Psychiatrists. CR190: The risks and benefits of high-dose antipsychotic medication, executive summary, schizophrenia clinical implications, and cardiac side-effects sections. Revised January 2023. https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr190.pdf