Bipolar Prophylaxis — MRCPsych Paper B MCQ

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EasyMood DisordersBipolar ProphylaxisMRCPsych Paper B

An adult with bipolar I disorder requires long-term pharmacological treatment to prevent relapse. They have no contraindications to the listed medicines and agree to the necessary physical-health and blood monitoring. According to NICE, which medication should be offered first-line?

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Correct answer: E — Lithium

Lithium is the correct answer. NICE describes lithium as the most effective long-term treatment for bipolar disorder and recommends offering it first-line to prevent relapse when it is suitable and the person accepts monitoring. Quetiapine is a possible long-term antipsychotic option if lithium is ineffective, poorly tolerated or unsuitable, rather than the routine first choice. Lamotrigine may have a role in bipolar depression but is not NICE's first-line general maintenance treatment. Valproate is not first-line and is subject to substantial MHRA reproductive-safety restrictions. Carbamazepine is also not recommended by NICE as first-line long-term pharmacological treatment. Treatment should still be individualised according to previous response, adverse effects, comorbidity and patient preference.

Reference: NICE. Bipolar disorder: assessment and management (CG185), section 1.7, recommendations 1.7.5–1.7.8. Updated 2025. https://www.nice.org.uk/guidance/cg185/chapter/Recommendations