AD Monotherapy Bipolar Risk — MRCPsych Paper B MCQ
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Correct answer: A — Offer fluoxetine with olanzapine or quetiapine monotherapy rather than an antidepressant alone
Explanation lettering: B = shown as A · C = shown as B · D = shown as C · E = shown as D · A = shown as E
B is correct. NICE CG185 applies to both bipolar I and bipolar II disorder. For moderate or severe bipolar depression in a person taking no medication for bipolar disorder, NICE recommends fluoxetine combined with olanzapine or quetiapine monotherapy; olanzapine or lamotrigine monotherapy may also be considered. Antidepressant monotherapy is therefore not the recommended approach. If mania or hypomania develops during antidepressant monotherapy, NICE advises considering stopping the antidepressant and offering an antipsychotic. A is incorrect because bipolar II is not exempt. C and D wrongly describe particular antidepressant classes as switch-neutral. E reverses the clinical concern. The original explanation was too absolute: NICE does not say antidepressants must always be combined with a conventional mood stabiliser.
Reference: National Institute for Health and Care Excellence. Bipolar disorder: assessment and management (CG185), sections 1.5.2 and 1.6.3. Published 2014; updated 2025. https://www.nice.org.uk/guidance/cg185/chapter/recommendations