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Bipolar Depression Pregnancy Decisions — MRCPsych Paper B MCQ

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HardPerinatal PsychiatryBipolar Depression Pregnancy DecisionsMRCPsych Paper B

A 30-year-old woman who is 10 weeks pregnant has bipolar I disorder and is experiencing a moderate-to-severe depressive episode. Abrupt withdrawal of maintenance medication during a previous pregnancy led to relapse and psychiatric admission. Concerned about fetal exposure, she now asks to stop all psychotropic medication immediately. Before selecting a specific intervention, which principle should govern treatment planning?

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Reveal the answer and explanation

Correct answer: C — Undertake an individualised shared decision with specialist perinatal input, balancing untreated illness and withdrawal risks against treatment risks, previous response and gestational stage

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

B is correct. Pregnancy changes the risk–benefit balance but does not create an absolute prohibition on psychotropic treatment. NICE recommends a shared, individualised assessment covering illness severity, previous treatment response, gestational stage, risks of untreated illness, and risks of starting, stopping or changing treatment, preferably with specialist perinatal advice. Her previous severe relapse after abrupt withdrawal is particularly relevant. A misinterprets the higher prescribing threshold as a requirement to stop treatment. C gives relapse risk automatic precedence over fetal risk rather than balancing both. D ignores prior efficacy and the destabilising effects of switching. Psychological treatment may be valuable, but E creates an unjustified delay and assumes it must precede medication regardless of severity or relapse history.

Reference: National Institute for Health and Care Excellence. Antenatal and postnatal mental health: clinical management and service guidance (CG192), recommendations 1.4.5–1.4.13 and 1.5.10. Published 2014; updated 2020; last reviewed 30 May 2025. https://www.nice.org.uk/guidance/cg192/chapter/Recommendations