Late-Life Depression — MCQs
Among which of the following conditions is suicide risk highest?
What is the possible cause of irreversible dementia?
The disability adjusted life years (DALYs) lost due to neuropsychiatric disorders are highest in -
Which of the following disorders is characterized by intense nihilism, somatization and agitation in old age?
A patient presents with symptoms of major depressive disorder. Which medication should be prescribed for treatment?
Cyclothymia is classified as which type of mood disorder?
Indications for ECT are all except?
Intense nihilism, somatization and agitation in old age are the hallmark symptoms of -
Dementia of Alzheimer's type is not associated with one of the following
A patient complains of sadness of mood, increased lethargy, early morning awakening, loss of interest and reports no will to live and hears voices asking her to kill self. What is the diagnosis?
Late-Life Depression Indian Medical PG Practice Questions and MCQs
Question 1: Among which of the following conditions is suicide risk highest?
- A. Depression (Correct Answer)
- B. Alcohol dependence
- C. Dementia
- D. Schizophrenia
Explanation: ***Depression*** - **Major depressive disorder** is the psychiatric condition most frequently associated with **suicide**, accounting for a large percentage of completed suicides. - The presence of severe depression, especially with features like **hopelessness**, **agitation**, and **prior suicide attempts**, significantly elevate the risk. *Alcohol dependence* - While **alcohol dependence** is a significant risk factor for suicide, it often co-occurs with mood disorders like depression; alcohol can exacerbate suicidal ideation and impulsivity. - It is an important comorbidity, but **major depression** alone has a higher prevalence in suicide statistics than alcohol dependence as a primary factor. *Dementia* - **Dementia** generally poses a lower risk of completed suicide compared to mood disorders, as cognitive decline can impair the ability to plan and execute such acts. - Early stages of dementia, particularly when insight into cognitive decline is preserved, may carry some risk, but it is not the highest risk condition overall. *Schizophrenia* - Individuals with **schizophrenia** have a significantly elevated risk of suicide compared to the general population, often due to factors like **command hallucinations**, hopelessness, and adverse effects of medication. - However, **depression** remains the leading psychiatric diagnosis associated with suicide completions.
Question 2: What is the possible cause of irreversible dementia?
- A. Vitamin B12 deficiency
- B. NPH
- C. Hypothyroid
- D. Lewy body (Correct Answer)
Explanation: ***Lewy body*** - **Lewy body dementia** is a progressive, irreversible neurodegenerative disorder characterized by the abnormal accumulation of **alpha-synuclein proteins** within neurons [1]. - It presents with fluctuating cognition, recurrent visual hallucinations, and spontaneous **parkinsonism**, eventually leading to severe and irreversible cognitive decline [1]. *Vitamin B12 deficiency* - **Vitamin B12 deficiency** can cause cognitive impairment and dementia-like symptoms, but these are often **reversible** with appropriate B12 supplementation [2]. - Symptoms include **anemia**, peripheral neuropathy, and psychiatric changes, which can improve with treatment. *NPH* - **Normal Pressure Hydrocephalus (NPH)** presents with a classic triad of gait disturbance, urinary incontinence, and dementia [2]. - While it causes dementia, it is often **reversible** with surgical placement of a **ventriculoperitoneal shunt** to drain excess CSF [2]. *Hypothyroid* - **Hypothyroidism** can lead to cognitive slowing, memory impairment, and confusion, resembling dementia. - These symptoms are typically **reversible** and improve significantly with **thyroid hormone replacement therapy**.
Question 3: The disability adjusted life years (DALYs) lost due to neuropsychiatric disorders are highest in -
- A. Panic disorders
- B. Obsessive compulsive disorder
- C. Bipolar affective disorders
- D. Unipolar depressive disorders (Correct Answer)
Explanation: ***Unipolar depressive disorders*** - **Unipolar depressive disorders** are the leading cause of DALYs lost among neuropsychiatric conditions globally. - This is due to their **high prevalence**, **early age of onset**, and significant impact on **functional capacity** and quality of life. *Panic disorders* - While panic disorders significantly impair an individual's quality of life, their **prevalence** and **disability burden** are generally lower than that of unipolar depressive disorders. - They tend to cause episodic, intense distress rather than chronic, pervasive functional impairment to the same extent as severe depression. *Obsessive compulsive disorder* - **OCD** can be severely disabling, but its **prevalence** is lower than that of unipolar depressive disorders. - The impact on DALYs, while substantial for affected individuals, does not reach the global burden attributed to depression. *Bipolar affective disorders* - **Bipolar affective disorders** contribute significantly to DALYs due to their chronic nature and severe episodes of mood disturbance. - However, their **prevalence** is lower compared to unipolar depressive disorders, resulting in a lower overall DALY burden globally.
Question 4: Which of the following disorders is characterized by intense nihilism, somatization and agitation in old age?
- A. Atypical depression
- B. Bipolar depression
- C. Involutional melancholia (Correct Answer)
- D. Somatized depression
Explanation: ***Involutional melancholia*** - This term refers to a severe depressive disorder in **late adulthood** characterized by profound **nihilism** (belief in the meaninglessness of existence), **somatization** (physical symptoms without a physical cause), and **agitation**. - It often involves prominent **psychotic features** like delusional guilt, nihilistic delusions (e.g., believing one's organs are rotting), and severe anxiety, distinguishing it from other forms of depression in older adults. - **Note**: This is a **historical diagnostic term** no longer used in DSM-5/ICD-11. The condition is now classified as **Major Depressive Disorder with melancholic features** or **with psychotic features** (when delusions are present). *Atypical depression* - Characterized by mood reactivity (mood improves in response to positive events), **increased appetite**, **hypersomnia**, leaden paralysis, and interpersonal rejection sensitivity. - This presentation is largely opposite to the **agitation** and severe **nihilism** seen in the described disorder. *Bipolar depression* - Occurs as part of **bipolar disorder**, involving episodes of both depression and mania/hypomania. - While it can be severe, the specific constellation of **intense nihilism**, prominent **somatization**, and persistent **agitation** in old age is more characteristic of what was historically termed involutional melancholia. *Somatized depression* - Refers to depression where **physical symptoms** are prominent. While somatization is present in the question, the defining features of **intense nihilism** and **agitation** are not specific to somatized depression. - This term usually emphasizes the physical presentation, whereas involutional melancholia describes a broader, severe depressive syndrome typical of later life.
Question 5: A patient presents with symptoms of major depressive disorder. Which medication should be prescribed for treatment?
- A. Haloperidol
- B. Olanzapine
- C. Alprazolam
- D. Sertraline (Correct Answer)
Explanation: ***Sertraline*** - **Sertraline** is a **selective serotonin reuptake inhibitor (SSRI)**, which are first-line agents for treating major depressive disorder due to their efficacy and generally favorable side effect profile. - SSRIs work by increasing the availability of **serotonin** in the brain, helping to improve mood and reduce symptoms of depression. *Haloperidol* - **Haloperidol** is a **first-generation antipsychotic** primarily used to treat psychotic disorders like **schizophrenia** and severe agitation, not major depressive disorder. - It works by blocking **dopamine D2 receptors**, and its side effects can include **extrapyramidal symptoms**. *Alprazolam* - **Alprazolam** is a **benzodiazepine** used to treat anxiety disorders and panic attacks due to its *rapid onset of action* in reducing anxiety symptoms. - While it can alleviate anxiety that co-occurs with depression, it is not an antidepressant and does not treat the underlying depressive disorder; it also carries a risk of **dependence and withdrawal**. *Olanzapine* - **Olanzapine** is a **second-generation antipsychotic** used for conditions such as **schizophrenia** and **bipolar disorder**. - While it can be used as an **adjunctive treatment** in some cases of treatment-resistant depression, it is not a first-line monotherapy for major depressive disorder.
Question 6: Cyclothymia is classified as which type of mood disorder?
- A. Major depression
- B. Dysthymia
- C. Persistent mood disorder
- D. Bipolar mood disorder (Correct Answer)
Explanation: ***Bipolar mood disorder*** - **Cyclothymia (Cyclothymic Disorder)** is classified under **Bipolar and Related Disorders** in both DSM-5 and ICD-11, making it part of the bipolar spectrum. - It is characterized by **chronic, fluctuating mood disturbances** lasting at least 2 years (1 year in children/adolescents) with numerous periods of hypomanic and depressive symptoms that do not meet full criteria for hypomanic or major depressive episodes. - The alternating, less severe mood swings share the fundamental **bipolar pattern** of mood elevation and depression, hence its classification under bipolar mood disorders. *Major depression* - **Major depressive disorder** is a unipolar mood disorder involving persistent feelings of sadness, loss of interest, and other depressive symptoms that significantly impair daily functioning, **without any episodes of mania or hypomania**. - Cyclothymia involves **mood instability with both elevated and depressed periods**, which distinguishes it from unipolar major depression. *Dysthymia* - **Dysthymia** (now termed **Persistent Depressive Disorder** in DSM-5) is characterized by chronic, low-grade depressive symptoms lasting at least 2 years, **without manic or hypomanic episodes**. - While both involve sub-threshold symptoms, cyclothymia includes periods of **hypomanic symptoms** (elevated mood, increased energy), which are absent in dysthymia. *Persistent mood disorder* - This is a broad, non-specific descriptive term rather than a formal diagnostic category in DSM-5 or ICD-11. - While cyclothymia is indeed a persistent condition, it is **specifically categorized under Bipolar and Related Disorders** due to the presence of both elevated (hypomanic) and depressed mood states.
Question 7: Indications for ECT are all except?
- A. Severe psychosis
- B. Catatonic schizophrenia
- C. Severe manic attack (Correct Answer)
- D. Severe depression with suicidal risk
Explanation: ***Severe manic attack*** - While **severe mania IS a recognized indication for ECT**, it is generally considered **less commonly used as first-line therapy** compared to the other options listed. - In clinical practice, **acute severe mania** is typically managed initially with **antipsychotics and mood stabilizers** (lithium, valproate), with ECT reserved for **treatment-resistant cases** or when rapid response is critical. - ECT is highly effective for severe mania, particularly with **psychotic features** or **medication intolerance**, but is not the **most typical first-choice indication** compared to severe depression or catatonia. - This question reflects the **relative clinical priority** of ECT indications rather than absolute contraindication. *Severe depression with suicidal risk* - This is the **most common and well-established indication for ECT**. - ECT provides **rapid antidepressant effect** (often within 1-2 weeks) and is particularly indicated when there is **imminent suicide risk**, **psychotic depression**, or **treatment-resistant depression**. - Response rates exceed 70-90% in severe depression, making it a primary indication. *Catatonic schizophrenia* - **Catatonia is one of the strongest indications for ECT**, regardless of underlying etiology (schizophrenia, mood disorders, or medical conditions). - ECT rapidly resolves **catatonic symptoms** including mutism, stupor, posturing, and waxy flexibility. - Often considered **first-line treatment** for severe or malignant catatonia due to life-threatening complications. *Severe psychosis* - ECT is indicated for **severe psychotic disorders** that are **treatment-resistant** or when patients cannot tolerate antipsychotic medications. - Particularly effective in **acute psychotic agitation**, **treatment-refractory schizophrenia**, and psychosis with high risk of harm. - Provides rapid symptom control when pharmacotherapy has failed or is contraindicated.
Question 8: Intense nihilism, somatization and agitation in old age are the hallmark symptoms of -
- A. Depressive stupor
- B. Atypical depression
- C. Involutional melancholia (Correct Answer)
- D. Somatized depression
Explanation: ***Involutional melancholia*** - This **historical term** (now obsolete in DSM-5 and ICD-11) described a severe depressive episode occurring in late life, characterized by **intense nihilism**, **somatization**, and **agitation**. - In modern psychiatry, this presentation would be diagnosed as **Major Depressive Disorder with melancholic features** or **with psychotic features** (if nihilistic delusions are present). - Though no longer used as a formal diagnosis, this term may still appear in older psychiatric literature and some textbook references, particularly describing the classical triad in elderly patients. - Key features included: severe guilt, nihilistic themes, marked psychomotor agitation (not retardation), and somatic preoccupations in older adults. *Depressive stupor* - This is a rare and severe form of depression characterized by extreme **psychomotor retardation**, where the individual is almost entirely unresponsive, withdrawn, and has minimal or no movement or speech. - The key differentiating feature is **marked retardation** rather than **agitation** - these are opposite psychomotor presentations. - While it involves severe depression, the primary features of **agitation** and active **somatization** as described in the question are not characteristic of depressive stupor. *Atypical depression* - This type of depression is characterized by **mood reactivity** (mood improves in response to positive events), increased appetite or weight gain, hypersomnia, leaden paralysis, and interpersonal rejection sensitivity. - Features **reversed neurovegetative symptoms** (hypersomnia and hyperphagia rather than insomnia and anorexia). - The symptoms of **nihilism**, **somatization**, and **agitation** are not typical features; atypical depression often involves anergic features and is more common in younger patients. *Somatized depression* - This refers to depression where psychological distress is primarily expressed through **physical symptoms** such as pain, fatigue, or gastrointestinal issues, often leading to medical consultations. - While **somatization** is the predominant feature, it lacks the specific constellation of **intense nihilism** and severe **agitation in elderly patients** that characterizes the classical involutional presentation. - More commonly seen in cultures where psychological expression of distress is stigmatized.
Question 9: Dementia of Alzheimer's type is not associated with one of the following
- A. Delusions
- B. Apraxia and aphasia
- C. Cerebral infarcts (Correct Answer)
- D. Depressive symptoms
Explanation: ***Cerebral infarcts*** - **Cerebral infarcts** are characteristic of **vascular dementia**, where brain damage is caused by reduced blood flow due to stroke or transient ischemic attacks. - While an individual with Alzheimer's could coincidentally have a stroke, **cerebral infarcts** are not a primary neuropathological feature or an expected clinical association inherent to the progression of Alzheimer's disease itself. *Delusions* - **Delusions**, particularly paranoid delusions (e.g., believing caregivers are stealing from them), are relatively common **psychotic symptoms** that can occur in later stages of Alzheimer's disease. - They are considered a behavioral and psychological symptom of dementia (BPSD) and can significantly impact the patient's and caregiver's quality of life. *Apraxia and aphasia* - **Apraxia** (difficulty with motor tasks despite intact motor function) and **aphasia** (language difficulties) are core **cognitive symptoms** that define Alzheimer's dementia. - These are progressive deficits in executive function, language, and motor skills that lead to functional impairment. *Depressive symptoms* - **Depressive symptoms**, including apathy, anhedonia, and low mood, are highly prevalent in individuals with Alzheimer's disease, particularly in the earlier stages. - They can be a reaction to the cognitive decline and loss of independence, or a direct result of the neurodegenerative process affecting mood-regulating brain regions.
Question 10: A patient complains of sadness of mood, increased lethargy, early morning awakening, loss of interest and reports no will to live and hears voices asking her to kill self. What is the diagnosis?
- A. Schizophrenia
- B. Major depressive disorder plus psychosis (Correct Answer)
- C. Schizoaffective disorder
- D. Schizotypal personality disorder
Explanation: ***Major depressive disorder plus psychosis*** - The patient presents with classic symptoms of **major depressive disorder**, including persistent sadness, **anhedonia (loss of interest)**, **lethargy**, and **early morning awakening**. - The presence of **auditory hallucinations** (hearing voices asking her to kill herself) indicates **psychotic features** accompanying the severe depression, leading to the diagnosis of major depressive disorder with psychotic features. *Schizophrenia* - While schizophrenia involves psychosis, the primary presentation here is a prominent **depressive syndrome** rather than the typical **positive symptoms (delusions, hallucinations)**, **negative symptoms (alogia, avolition)**, and **disorganized thought** processes characteristic of schizophrenia. - The depressive symptoms are too pervasive and central to the clinical picture to be solely schizophrenia. *Schizoaffective disorder* - This disorder requires a period of **at least two weeks of psychotic symptoms** (hallucinations or delusions) **without prominent mood symptoms**, which is not described. - In this case, the **psychotic symptoms are congruent with the depressed mood** (e.g., voices urging self-harm, reflecting hopelessness), rather than independent. *Schizotypal personality disorder* - This is a pervasive pattern of **social and interpersonal deficits** marked by acute discomfort with, and reduced capacity for, close relationships, as well as by **cognitive or perceptual distortions** and eccentricities of behavior. - It does not involve persistent, severe depressive episodes with overt psychotic symptoms as described, nor significant functional impairment to the extent seen here.
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