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Antidepressant Monotherapy Bipolar Risk — MRCPsych Paper B MCQ

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ModerateMood DisordersAntidepressant Monotherapy Bipolar RiskMRCPsych Paper B

A 28-year-old woman with bipolar II disorder is taking sertraline monotherapy for a depressive episode. Three weeks after starting treatment, she develops a clear change from baseline with reduced need for sleep, increased talkativeness and increased goal-directed activity lasting 5 days. There is no marked functional impairment or psychosis. According to NICE CG185, which is the most appropriate medication response?

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Correct answer: A — Consider stopping sertraline and offer quetiapine

The symptoms represent hypomania emerging during antidepressant monotherapy. NICE CG185 recommends considering stopping the antidepressant and offering an antipsychotic—haloperidol, olanzapine, quetiapine or risperidone—regardless of whether the antidepressant is stopped. Therefore, B is the best answer. Continuing or increasing sertraline would leave a possible antidepressant-associated switch untreated. Lithium may be considered later if antipsychotic treatment is insufficient, but adding it while continuing sertraline is not NICE's recommended initial response in this scenario. Lamotrigine should not be offered to treat acute mania or hypomania. Lorazepam may sometimes help short-term agitation or insomnia, but it does not replace appropriate antimanic treatment.

Reference: NICE. Bipolar disorder: assessment and management (CG185), recommendations 1.5.2–1.5.3. Published 2014; last updated 2025. https://www.nice.org.uk/guidance/cg185/chapter/Recommendations