Explaining psychotropic choices in CKD and cirrhosis (CASC)

Station instructions (candidate)

You have 7 minutes. Explain in plain language why lithium needs kidney monitoring and why anti-inflammatory painkillers can raise lithium levels; why standard sleeping tablets (benzodiazepines) are risky with her liver disease; and how decisions about antidepressants in kidney disease are individualised — including that a major trial (CAST) found sertraline no better than placebo for depression symptoms in non-dialysis CKD, so expectations and non-drug options matter. Do not terrify her into stopping lithium without a plan. Do not promise cure. Check understanding and safety (suicide risk, who to call if confused or very unsteady).[1][2][3][5]

Marking domains

Empathy and agenda setting; accurate lithium–kidney and NSAID counselling; HE-aware benzodiazepine advice; CAST-informed shared decision without therapeutic nihilism; collaborative monitoring plan; safety-netting for toxicity and mood risk.[1][2][3][4]

Model communication map

1. Open: thank her; name the three worries (painkiller, sleep tablets, antidepressant); check mood and safety.[5]
2. Lithium and kidneys: lithium is cleared by the kidneys; we watch blood levels and kidney tests because levels can creep up when kidneys work less well or when dehydrated.[2][4]
3. Ibuprofen: anti-inflammatory painkillers can push lithium higher — that is why GP stopped them; prefer agreed alternatives and always ask before new pharmacy medicines.[2]
4. Sleep tablets: with liver disease, strong sedatives can tip people into confusion (encephalopathy); we avoid routine benzodiazepines and use safer sleep strategies first; if a medicine is ever essential it would be a carefully chosen short course at low dose.[3][6]
5. Low mood / sertraline: depression is common and treatable with support; CAST showed sertraline was not better than placebo for symptoms in people with kidney disease not on dialysis and had more stomach side-effects — so we decide together, may still trial a medicine carefully, and always include talking therapies and safety planning.[1][5]
6. Close: written sick-day rules, next blood test date, crisis contacts, symptoms needing urgent review (coarse tremor, confusion, severe unsteadiness, yellowing of eyes).[2]

Common fails

• Ordering her off lithium without explaining benefit and monitoring.[4]
• Agreeing to regular diazepam for cirrhosis insomnia.[3]
• Claiming “sertraline always works in CKD” contrary to CAST teaching.[1]
• Omitting suicide/safety assessment for new depression.[5]
• Using jargon (EXTRIP, free fraction) without plain-language translation.[2]