Consultant Psychiatry oral assessment prep

Knowledge: This is postpartum psychosis until proven otherwise: abrupt onset within the first two weeks, a fluctuating confusional or perplexed quality, mood elevation with lability, and delusions with infant-related content, in this case a delusional misidentification of the baby, which is a particularly high-risk symptom.

Management: I would assess her at the bedside without delay, take a collateral history from the husband and midwives, and explicitly ask about thoughts of harming herself or the baby, altruistic ideas of taking the baby with her, and command phenomena. Investigations include full blood count, CRP, cultures if febrile, urea and electrolytes, calcium, magnesium, liver and renal function, thyroid function, glucose, blood pressure and urinalysis for pre-eclampsia, and neuroimaging if there are focal signs, seizures or persistent confusion.

Ethics and communication: Infant safety creates a genuine tension with maternal autonomy and confidentiality, and I would be transparent with her that I am obliged to consider the baby's welfare and will involve her husband and the paediatric or child protection team; concealing that would damage trust more than stating it.

Reference: NICE CG192 Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance (2014, updated 2020); Royal College of Psychiatrists CR232 Perinatal Mental Health Services (2021); Maudsley Prescribing Guidelines in Psychiatry, 14th edition (2021)

Knowledge: This is severe lithium toxicity, with a level of 2.8 mmol per litre and neurological signs, which is a life-threatening emergency. The mechanism is straightforward and I would explain it explicitly: lithium is renally excreted and handled like sodium in the proximal tubule, so volume depletion from vomiting and diarrhoea, a thiazide diuretic and an NSAID have each independently reduced clearance and stacked on top of one another. Her acute kidney injury both results from and worsens the toxicity.

Management: Immediate steps are to stop lithium, the thiazide and the NSAID, secure the airway and protect against aspiration given her drowsiness, and begin intravenous isotonic saline to restore volume and promote renal clearance while monitoring for fluid overload. I would take urea and electrolytes, creatinine, calcium, thyroid function, full blood count, glucose and repeat lithium levels every four to six hours until they fall consistently, and obtain an ECG looking for T wave flattening, QT changes and arrhythmia, with cardiac monitoring.

Ethics and communication: This event is largely preventable, so I would look honestly at the system that allowed it: whether she had a lithium alert card and written sick-day rules, whether the prescriber of the thiazide knew about the lithium, and whether her routine monitoring had actually been performed.

Reference: Maudsley Prescribing Guidelines in Psychiatry, 14th edition (2021); Decker BS et al., Extracorporeal Treatment for Lithium Poisoning: EXTRIP Workgroup Systematic Review and Recommendations, Clinical Journal of the American Society of Nephrology (2015); NICE CG185 Bipolar Disorder (2014, updated 2023)

Knowledge: My first concern is the timing of induction. Buprenorphine is a high-affinity partial mu agonist that will displace full agonists from the receptor, so induction before the patient is in sufficient objective withdrawal precipitates a severe and distressing withdrawal that destroys engagement.

Management: I would take a full substance, medical and psychiatric history, examine injection sites, check for cellulitis and endocarditis, and arrange urine toxicology including fentanyl where available, blood-borne virus screening for HIV, hepatitis B and C, liver function, full blood count, pregnancy test if applicable and an ECG, since tramadol and any methadone exposure raise QTc and seizure concerns.

Ethics and communication: Refusing an unsafe request is a clinical judgement, not a punishment, and I would say so explicitly, name my reasons, and offer real alternatives so that he does not experience the refusal as rejection or as moral judgement about drug users. Stigma is a major driver of disengagement, so my language matters, and I would avoid terms such as clean and dirty urine.

Reference: ASAM National Practice Guideline for the Treatment of Opioid Use Disorder, 2020 Focused Update; NICE CG52 Drug Misuse in Over 16s: Opioid Detoxification (2007); WHO Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence (2009)

Knowledge: Valproate is the drug I am most concerned about, because in utero exposure carries roughly a ten per cent risk of major congenital malformation, particularly neural tube defects, and approximately a thirty to forty per cent risk of neurodevelopmental disorder including reduced IQ and autism spectrum disorder.

Management: I would arrange a dedicated preconception appointment with her and, if she wishes, her husband, with adequate time and an interpreter if needed, and I would not make a decision in a five-minute review. I would review her illness history in detail, because two severe manic episodes and a three-year period of stability argue strongly for maintaining prophylaxis.

Ethics and communication: This is a shared decision, not a prescription: my role is to give her accurate absolute risks in numbers she can use, present the options including the option of no medication with its consequences, and support the decision she reaches.

Reference: NICE CG192 Antenatal and Postnatal Mental Health (2014, updated 2020); MHRA Drug Safety Update: Valproate Pregnancy Prevention Programme (2018, updated 2024); Maudsley Prescribing Guidelines in Psychiatry, 14th edition (2021)