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Acute mania during antidepressant monotherapy — MRCEM SBA MCQ

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HardMental health and behavioural emergenciesAcute mania during antidepressant monotherapyMRCEM SBA

A 36-year-old man attends the emergency department with his sister. Venlafaxine was started five weeks ago for depression; he takes no other regular medication. For the past six days he has slept about two hours a night without feeling tired, spoken rapidly, spent £18,000 on an implausible business venture and driven dangerously because he believes he has exceptional reflexes. He plans to drive again tonight. He is alert, afebrile and physiologically stable, with no evidence of intoxication or an acute physical illness. He agrees to remain for assessment and is willing to take oral medication. Which management and disposition plan is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Discuss stopping venlafaxine, offer olanzapine and arrange urgent specialist assessment.

Reduced need for sleep, sustained overactivity, grandiose beliefs and marked disinhibition indicate mania rather than uncomplicated antidepressant-related restlessness. The recent introduction of venlafaxine makes his antidepressant regimen an important part of the immediate review. NICE advises considering stopping an antidepressant taken as monotherapy when mania develops and offering an antipsychotic regardless of whether it is stopped. Olanzapine is one of the recommended options. His dangerous driving and impaired judgement also require an urgent specialist mental health and risk assessment before a disposition decision; physiological stability does not make routine follow-up sufficient. A includes an appropriate antimanic option but delays assessment despite an immediate safety concern. B is tempting because lithium treats bipolar disorder, but it is not the recommended first pharmacological step for this presentation in someone taking neither a mood stabiliser nor an antipsychotic. D offers a medicine that may help short-term agitation or sleep but does not replace antimanic treatment. E retains venlafaxine without addressing its potential contribution; although an antipsychotic should still be offered if the antidepressant is not stopped, discussing cessation is the better plan on the facts given. Specialist assessment should determine the safest subsequent care setting.

Reference: NICE CG185: Bipolar disorder: assessment and management — recommendations 1.2.2, 1.3.5 and 1.5.2–1.5.3 (Updated 2 September 2025) — https://www.nice.org.uk/guidance/cg185/chapter/recommendations