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Antidepressant-Induced Mania — MRCPsych Paper B MCQ

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ModerateMood DisordersAntidepressant-Induced ManiaMRCPsych Paper B

A 29-year-old with a first recorded depressive episode starts sertraline. Three weeks later, they develop 4 days of persistently elevated mood, markedly reduced need for sleep, pressured speech and increased goal-directed activity. There is no fever, clonus, hyperreflexia, autonomic instability or substance use. Which interpretation and next step are most appropriate?

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Correct answer: B — Possible underlying bipolar disorder; consider stopping sertraline, reassess the diagnosis and treat the hypomania

This is a syndromal switch to hypomania, which raises suspicion that the original depression may represent bipolar depression rather than uncomplicated unipolar depression. NICE recommends considering stopping an antidepressant when mania or hypomania develops during antidepressant monotherapy and offering appropriate antimanic treatment. The longitudinal diagnosis should therefore be reassessed, including previous elevated episodes and family history. Serotonin syndrome would require compatible autonomic and neuromuscular findings, such as hyperthermia, clonus or hyperreflexia. Ordinary SSRI activation may cause anxiety, agitation or insomnia but does not account for sustained elevated mood, reduced need for sleep and increased goal-directed activity. There is no evidence of overdose. Personality disorder does not better explain a discrete, treatment-associated hypomanic syndrome.

Reference: National Institute for Health and Care Excellence. Bipolar disorder: assessment and management (CG185), recommendations 1.5.2–1.5.3. Published 2014; updated 2025. https://www.nice.org.uk/guidance/cg185/chapter/Recommendations