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Combination Mood Stabiliser Strategy — MRCPsych Paper B MCQ

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HardMood DisordersCombination Mood Stabiliser StrategyMRCPsych Paper B

A 60-year-old man with bipolar I disorder requires long-term pharmacological treatment to prevent further manic relapses. Lithium was ineffective despite good adherence and plasma concentrations within the target range. Two appropriate antipsychotics have subsequently been tried sequentially at adequate licensed doses but were ineffective. Reproductive risks, adverse effects and monitoring requirements have been discussed, and there are no contraindications to the available treatments. According to NICE, which of the following is an appropriate next pharmacological strategy?

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Correct answer: A — Add valproate to lithium

The correct answer is A. For long-term relapse prevention, NICE recommends lithium first line. If lithium is ineffective or unsuitable, an antipsychotic should be tried, followed by an alternative antipsychotic if necessary. Only when the alternative antipsychotic is ineffective should valproate be considered in combination with either lithium or an antipsychotic. Lamotrigine is more relevant to prevention of depressive episodes and is not the recommended next step in this sequence. Routine triple therapy with two antipsychotics is unsupported and increases adverse-effect burden. Antidepressant monotherapy is inappropriate in bipolar I disorder because it does not prevent mania and may precipitate mood elevation; fluoxetine has a role in bipolar depression only in specified regimens, notably with olanzapine. Current MHRA valproate reproductive-risk measures must be followed in both men and women.

Reference: NICE, Bipolar disorder: assessment and management (CG185), recommendations 1.7.7–1.7.10, updated 2025. https://www.nice.org.uk/guidance/cg185/chapter/Recommendations