Psych CASC / OSCE · General adult psychiatry — bipolar and related disorders
Explain bipolar diagnosis and lithium — CASC communication station
MRCPsych/FRANZCP-style communication station: explain bipolar I in plain language, outline lithium benefits including relapse and suicide-risk evidence framing, discuss blood monitoring and side-effects, address cannabis, and check understanding.
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Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the psychiatry registrar on the ward step-down clinic. [1]
Candidate instructions. Explain the diagnosis of bipolar I disorder after a first manic episode, why lithium is being recommended, what monitoring involves, common side-effects and toxicity warning signs, and realistic prognosis. Address cannabis if raised. Check understanding. The examiner plays the partner. [1]
Candidate scenario
Your patient had a first manic episode requiring admission, is now settling on lithium plus a short course of olanzapine, and plans discharge this week. Partner asks: "Does this mean he is manic-depressive forever? Will lithium damage his kidneys? Can he drink on weekends? Should he stop lithium when he feels normal?" [1]
Marking domains
- Empathy and structure
- Accurate plain-language explanation of mania/bipolar I
- Balanced lithium benefit–risk including blood tests
- Toxicity red flags the partner can recognise
- Relapse prevention (sleep, cannabis, early warning signs)
- Checks understanding; avoids jargon dumps [1][2]
Reveal assessor key
Open and agenda-set. Thank them; name the time; ask their main worries first. [1]
Explain diagnosis. Bipolar I means he has had a period of abnormally high energy and mood or irritability lasting days, with reduced need for sleep and impaired judgement — not just stress. Many people also get depressive episodes later. It is a recurrent vulnerability, but treatment and lifestyle sharply change the course. Avoid fatalism and avoid minimising. [1]
Explain lithium. Lithium is one of the best-proven long-term treatments to prevent further mood episodes; research comparing lithium and valproate found lithium particularly effective for staying well.[1] It is also associated with lower risk of suicidal behaviour in mood disorders compared with many alternatives.[2] We aim for a blood level taken 12 hours after the dose. Kidneys and thyroid need periodic checks because long-term effects can occur — that is why monitoring exists, not because harm is inevitable.[3]
Practical safety. Maintain fluid intake; care with dehydration, heavy NSAID use, and some blood-pressure tablets; seek urgent help for severe tremor, vomiting, unsteady walking, or confusion. Alcohol can disrupt sleep and adherence — safer to minimise. Do not stop lithium abruptly when he feels well without a medical plan. [3]
Cannabis and sleep. Cannabis can trigger further episodes; regular sleep is protective. Agree early warning signs and a crisis contact. [1]
Close. Summarise, invite questions, offer written information and clinic follow-up dates for levels. [1]
References
- [1]BALANCE investigators and collaborators, Geddes JR, Goodwin GM, et al. Lithium plus valproate combination therapy versus monotherapy for relapse prevention in bipolar I disorder (BALANCE): a randomised open-label trial Lancet, 2010.PMID 20092882
- [2]Cipriani A, Hawton K, Stockton S, et al. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis BMJ, 2013.PMID 23814104
- [3]McKnight RF, Adida M, Budge K, et al. Lithium toxicity profile: a systematic review and meta-analysis Lancet, 2012.PMID 22265699