Depression and bipolar disorder flashcards
16 high-yield MRCP Part 1 cards from the Intellect Medicos Psychiatry course. Try to answer each question before you open it — then study them properly with spaced repetition, which brings each card back just before you would forget it.
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What is the first-line management of a new episode of less severe depression (PHQ-9 score below 16)?
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A low-intensity psychological intervention, e.g. guided self-help, group CBT, group behavioural activation or group exercise.
Why? NICE (NG222) groups subthreshold and mild depression as 'less severe'. Antidepressants are not routinely offered first line unless that is the person's preference.
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What is the most effective first-line treatment for a new episode of more severe depression (PHQ-9 16 or more)?
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An antidepressant (usually an SSRI such as sertraline) combined with individual high-intensity therapy such as CBT.
Why? NICE NG222 rates combined individual CBT plus an antidepressant as the most effective first-line option for moderate–severe depression.
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Severe depression is accompanied by nihilistic delusions and second-person derogatory voices. Which drug combination is first line?
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An antidepressant plus an antipsychotic (e.g. an SSRI with olanzapine or quetiapine).
Why? Psychotic depression responds poorly to an antidepressant alone; adding an antipsychotic treats the psychotic features.
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A man with bipolar disorder presents with acute mania and is on no regular medication. Which class of drug is first line?
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An antipsychotic: haloperidol, olanzapine, quetiapine or risperidone.
Why? Antipsychotics work quickly in acute mania. If the first fails, try a second; if that fails, consider adding lithium, then valproate.
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What is first-line treatment for moderate–severe bipolar depression in a patient not already on bipolar medication?
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Fluoxetine combined with olanzapine, or quetiapine alone.
Why? An antidepressant alone risks switching the patient into mania, so it is paired with an antipsychotic.
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Which drug is first line for long-term mood stabilisation in bipolar disorder?
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Lithium.
Why? Lithium has the strongest evidence for preventing relapse of both mania and depression, and also reduces suicide risk.
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A woman with known bipolar disorder is 6 days post-partum. She has not slept for 3 nights, is overactive and tells the midwife her baby is evil. What is the most appropriate immediate management?
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Emergency psychiatric assessment and admission, ideally to a mother-and-baby unit.
Why? This is post-partum psychosis, a psychiatric emergency with high risk of suicide and infanticide. NICE CG192 asks for assessment by a specialist perinatal service within 4 hours of referral. Treatment is with antipsychotics, mood stabilisers (often lithium) and ECT if severe.
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A breastfeeding mother has moderate post-natal depression and needs an antidepressant. Which SSRI is usually preferred?
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Sertraline.
Why? Very little sertraline passes into breast milk, so it is a common choice when breastfeeding.
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To diagnose a manic episode, symptoms must last at least ______; a hypomanic episode needs at least 4 days.
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7 days
Why? Mania also causes marked functional impairment and may need admission; hypomania does not.
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To diagnose a manic episode, symptoms must last at least 7 days; a hypomanic episode needs at least ______.
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4 days
Why? Mania also causes marked functional impairment and may need admission; hypomania does not.
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Which pattern of mood episodes defines bipolar II disorder?
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At least one hypomanic episode and at least one depressive episode, with no manic episode ever.
Why? Bipolar I needs at least one manic episode; a depressive episode is not required for bipolar I.
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Which two screening questions should be asked when depression is suspected?
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During the last month, have you often been bothered by feeling down, depressed or hopeless? Have you often been bothered by little interest or pleasure in doing things?
Why? A 'yes' to either question should prompt a full assessment, with a severity scale such as the PHQ-9.
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For how many consecutive years must a seasonal pattern of depression occur to diagnose seasonal affective disorder?
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At least 2 consecutive years.
Why? Episodes typically start in autumn or winter and remit in spring or summer. Atypical features are common: hypersomnia, increased appetite and carbohydrate craving.
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What is the strongest single risk factor for suicide?
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A previous suicide attempt (previous self-harm).
Why? Other major factors: current suicidal ideation with a plan, psychiatric illness, substance misuse, hopelessness, social isolation, recent major loss and male sex.
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Which class of antidepressant should usually be avoided in older people with depression, and why?
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Tricyclic antidepressants: anticholinergic effects, postural hypotension and falls, confusion, and cardiotoxicity.
Why? An SSRI such as sertraline is preferred in older people, with a sodium check because of the risk of SIADH.
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Under the 2024 MHRA rules, what is required before valproate can be started in a new patient (male or female) under 55?
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Two specialists must independently consider and document that there is no other effective or tolerated treatment, or that there are compelling reasons the reproductive risks do not apply.
Why? Valproate in pregnancy causes major malformations and neurodevelopmental disorders, and there is a possible risk to children of men taking it around conception.