Mood Disorders Practice Questions

Q: A 42-year-old male with a past history of a manic episode presents with an illness of 1 month duration characterized by depressed mood, anhedonia, and profound psychomotor retardation. What is the most appropriate initial management strategy?

Antidepressants and mood stabilizers. **Explanation:** The patient presents with a current depressive episode and a documented past history of mania. This clinical profile confirms a diagnosis of **Bipolar I Disorder, Current Episode Depressed.** **1. Why Option B is Correct:** In Bipolar Depression, the primary risk of using antidepressant monotherapy (SSRIs/TCAs) is the **"manic switch"**—precipitating a transition from depression into mania or a mixed state. Therefore, antidepressants must always be co-administered with a **Mood Stabilizer** (e.g., Lithium, Valproate, or Lamotrigine). The mood stabilizer acts as a "safety net" to prevent this switch while treating the depressive symptoms. **2. Why Other Options are Incorrect:** * **Option A:** Antipsychotics are primarily used for psychotic symptoms or acute mania. Using them with antidepressants without a mood stabilizer does not provide the standard long-term prophylaxis required for Bipolar Disorder. * **Option C:** While some atypical antipsychotics (like Quetiapine or Lurasidone) have antidepressant properties, the combination of an antipsychotic and mood stabilizer is typically the treatment of choice for *acute mania*, not primarily for non-psychotic bipolar depression. * **Option D:** Benzodiazepines are used for anxiety or insomnia but have no efficacy in treating the core symptoms of depression or preventing manic relapses. **Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC) for Bipolar Depression:** Quetiapine, Lurasidone, or the combination of Olanzapine + Fluoxetine (OFC). * **The "Switch" Risk:** TCAs have a higher risk of inducing a manic switch compared to SSRIs or Bupropion. * **Profound Psychomotor Retardation:** This is a classic "atypical" feature often seen in bipolar depression compared to unipolar depression. * **Lithium:** Remains the gold standard for long-term prophylaxis and reducing suicide risk in Bipolar Disorder.

Q: Which of the following is NOT a feature of depression?

Hyperactivity. ### Explanation **Core Concept:** Depression (Major Depressive Disorder) is characterized by a "slowing down" of physical and mental processes, known as **psychomotor retardation**. In contrast, **hyperactivity** is a hallmark feature of **Mania** or ADHD, not depression. While some patients may experience "agitated depression," the classic clinical presentation involves a significant decrease in energy and activity levels. **Analysis of Options:** * **C. Hyperactivity (Correct Answer):** This is the "odd one out." Depressed patients typically exhibit psychomotor retardation (slowed speech, movement, and thought). Hyperactivity, increased energy, and pressure of speech are diagnostic criteria for a Manic Episode. * **A. Depressed mood:** This is one of the two core "gateway" symptoms of depression (the other being Anhedonia). According to ICD-11 and DSM-5, a persistent low mood for at least two weeks is essential for diagnosis. * **B. Loss of appetite:** Somatic or vegetative symptoms are common in depression. Most patients experience anorexia and weight loss, though "atypical depression" can present with increased appetite (hyperphagia). * **D. Suicidal ideas:** Depression is the most common psychiatric condition associated with suicide. Feelings of hopelessness, worthlessness, and helplessness often lead to suicidal ideation. **High-Yield Clinical Pearls for NEET-PG:** * **Beck’s Cognitive Triad:** Negative views about the **Self, World, and Future**. * **Biological Markers:** Increased cortisol levels (failure of Dexamethasone Suppression Test) and reduced REM latency on sleep studies (entering REM sleep faster). * **Atypical Depression:** Characterized by mood reactivity, leaden paralysis, hypersomnia, and **increased appetite** (reversed vegetative symptoms). * **First-line Treatment:** SSRIs (Selective Serotonin Reuptake Inhibitors) are the drugs of choice due to their safety profile.

Q: What is the antidepressant agent most likely to cause persistent erections (priapism) in a 40-year-old male patient?

Trazodone. **Explanation:** The correct answer is **Trazodone**. **Mechanism and Rationale:** Trazodone is a Serotonin Antagonist and Reuptake Inhibitor (SARI). The occurrence of priapism (a prolonged, painful erection lasting >4 hours) is a classic, high-yield side effect associated with Trazodone, often colloquially referred to by the mnemonic **"Trazodone stays up all night."** The underlying medical concept involves its potent **alpha-1 adrenergic receptor antagonism**. By blocking alpha-1 receptors, Trazodone prevents the sympathetic nervous system from mediating detumescence (the return of the penis to a flaccid state), leading to venous congestion and persistent erection. This is considered a medical emergency as it can lead to permanent erectile dysfunction if not treated promptly. **Analysis of Incorrect Options:** * **A. Venlafaxine:** An SNRI that typically causes sexual dysfunction in the form of decreased libido or delayed ejaculation, rather than priapism. * **B. Tranylcypromine:** A non-selective MAO inhibitor. While it has many side effects (like hypertensive crisis with tyramine), priapism is not a characteristic feature. * **C. Doxepin:** A Tricyclic Antidepressant (TCA). While TCAs have anticholinergic effects, they are rarely associated with priapism compared to Trazodone. **High-Yield Clinical Pearls for NEET-PG:** * **Trazodone** is frequently used off-label for **insomnia** due to its sedative properties (H1 blockade). * **Management of Priapism:** Initial treatment often involves intracavernosal injection of an alpha-agonist (e.g., **Phenylephrine**). * Other drugs causing priapism: Antipsychotics (especially Chlorpromazine), Sildenafil, and Alprostadil. * In the context of antidepressants and sexual side effects, **Bupropion** is the drug of choice for patients wishing to *avoid* sexual dysfunction.

Q: Which of the following is most characteristic of sleep in a 45-year-old woman with major depressive disorder?

Waking up too early in the morning. **Explanation:** Sleep disturbances are a hallmark of Major Depressive Disorder (MDD), affecting approximately 90% of patients. The most characteristic finding in "melancholic" or typical depression is **Terminal Insomnia**, also known as **Early Morning Awakening (EMA)**. **1. Why Option C is Correct:** In MDD, there is a significant disruption of the circadian rhythm. Patients typically wake up 2 to 3 hours before their usual time and are unable to fall back asleep. This is often associated with "diurnal variation," where depressive symptoms (low mood, hopelessness) are most severe in the morning and slightly improve as the day progresses. Polysomnography (PSG) in these patients typically shows decreased REM latency (entering REM sleep faster), increased REM density, and a reduction in deep sleep (Stage N3/Slow Wave Sleep). **2. Analysis of Incorrect Options:** * **Option A (Hypersomnia):** While "sleeping too much" occurs in **Atypical Depression**, it is less common than insomnia in the classic 45-year-old MDD presentation. * **Option B (Sudden sleep onset):** This describes **Narcolepsy** (sleep attacks), not depression. * **Option D (Sleep Drunkenness):** This refers to **Confusional Arousal**, often seen in sleep apnea, idiopathic hypersomnia, or certain sedative uses, but it is not a diagnostic feature of MDD. **Clinical Pearls for NEET-PG:** * **Most common sleep disturbance in MDD:** Middle insomnia (waking up during the night). * **Most characteristic/specific sleep disturbance in MDD:** Terminal insomnia (Early morning awakening). * **Gold Standard PSG finding:** **Shortened REM Latency** (REM sleep starts <60 minutes after sleep onset). This is a high-yield biological marker for depression.

Q: Which of the following is NOT a cause of depression?

Metformin. **Explanation:** The correct answer is **Metformin**. This question tests your knowledge of **Secondary Depression**, which refers to depressive symptoms caused by underlying medical conditions or pharmacological agents. **Why Metformin is the correct answer:** Metformin is a biguanide used as the first-line treatment for Type 2 Diabetes Mellitus. It is **not** associated with causing depression. In fact, emerging research suggests that by improving insulin sensitivity and reducing systemic inflammation, Metformin may have potential neuroprotective and antidepressant-like effects. **Analysis of incorrect options (Drugs that DO cause depression):** * **Clonazepam (Benzodiazepines):** Long-term use of benzodiazepines is a well-known cause of "depressant" effects on the CNS, often leading to lethargy, emotional blunting, and clinical depression. * **Methyldopa:** This centrally acting alpha-2 agonist (used in pregnancy-induced hypertension) depletes central biogenic amines (dopamine, norepinephrine, and serotonin), which is a classic pharmacological trigger for depressive episodes. * **Corticosteroids:** Steroid-induced mood disorders are common. While they can cause euphoria or psychosis acutely, chronic use or withdrawal frequently leads to severe depression. **High-Yield Clinical Pearls for NEET-PG:** * **Other common drugs causing depression:** Reserpine (classic example), Interferon-alpha, Isotretinoin (Accutane), Propranolol (Beta-blockers), and Oral Contraceptive Pills (OCPs). * **Medical causes of depression:** Hypothyroidism (most common endocrine cause), Cushing’s syndrome, Vitamin B12 deficiency, and Pancreatic carcinoma. * **Mnemonic for Methyldopa/Reserpine:** These drugs "deplete the tank" of neurotransmitters, leading to the "Biogenic Amine Hypothesis" of depression.

Q: All of the following medications have mood-stabilizing action EXCEPT:

Paroxetine. **Explanation:** The core concept in managing Bipolar Affective Disorder (BPAD) is the use of **Mood Stabilizers**. These are medications that treat at least one phase of the illness (mania or depression) without increasing the frequency or severity of the opposite phase. **Why Paroxetine is the correct answer:** Paroxetine is a **Selective Serotonin Reuptake Inhibitor (SSRI)**, which is an antidepressant. While it treats the depressive phase of BPAD, it is not a mood stabilizer because it carries a risk of inducing **"treatment-emergent affective switch"** (triggering a manic episode) and does not prevent future relapses when used alone. **Analysis of Incorrect Options:** * **Lithium (Option C):** The "Gold Standard" mood stabilizer. It is effective in treating acute mania, bipolar depression, and is the most effective agent for preventing suicide in psychiatric patients. * **Carbamazepine (Option A):** An anticonvulsant used as a second-line mood stabilizer, particularly effective in rapid cycling bipolar disorder and acute mania. * **Lamotrigine (Option B):** An anticonvulsant mood stabilizer specifically effective for the **maintenance/prevention of bipolar depression**. It is not effective for acute mania. **High-Yield Clinical Pearls for NEET-PG:** 1. **Valproate** is often the first-line treatment for acute mania (especially mixed episodes). 2. **Lithium Toxicity:** Occurs at levels >1.5 mEq/L; characterized by coarse tremors, ataxia, and vomiting. 3. **Lamotrigine Warning:** Must be titrated slowly to avoid **Stevens-Johnson Syndrome (SJS)**. 4. **Drug of Choice (DOC):** Lithium is the DOC for prophylaxis of BPAD.

Q: A 30-year-old pregnant woman presents with decreased sleep, increased appetite, and hyperactivity for the past two weeks. A diagnosis of mania is made. Further probing reveals four episodes of major depression in the past two years. What medication would you prescribe for this patient?

Haloperidol. ### **Explanation** **1. Why Haloperidol is the Correct Choice:** The patient is presenting with an acute manic episode during pregnancy. In the management of acute mania in pregnancy, **First-Generation Antipsychotics (FGAs)** like **Haloperidol** are considered the first-line treatment. Haloperidol has a long-standing safety record in pregnancy; it is not associated with significant teratogenic risks (unlike mood stabilizers) and effectively controls hyperactivity and behavioral disturbances rapidly. **2. Why Other Options are Incorrect:** * **Lithium (Option B):** While Lithium is a gold-standard mood stabilizer, it is generally avoided in the first trimester due to the risk of **Ebstein’s Anomaly** (tricuspid valve malformation). Even in later stages, it requires intensive monitoring of fetal echoes and maternal serum levels. * **Promethazine (Option C):** This is an antihistamine with sedative properties. While it may help with sleep, it is not an antimanic agent and cannot treat the underlying core symptoms of mania. * **Clonazepam (Option D):** Benzodiazepines are used as adjuncts for sedation in mania but are not primary treatments. There is also a potential risk of "floppy infant syndrome" if used near term. **3. Clinical Pearls for NEET-PG:** * **Rapid Cycling:** This patient has had four episodes of depression in two years, meeting the criteria for **Rapid Cycling Bipolar Disorder** (≥4 episodes of mood disturbance in 12 months). * **Teratogenicity High-Yields:** * **Valproate:** Highest risk; causes Neural Tube Defects (NTDs). **Strictly contraindicated** in pregnancy. * **Carbamazepine:** Also causes NTDs and craniofacial defects. * **Treatment of Choice (TOC):** * Acute Mania in Pregnancy: Haloperidol. * Bipolar Depression in Pregnancy: Quetiapine or Lurasidone. * Severe/Refractory Mania in Pregnancy: Electroconvulsive Therapy (ECT) is considered safe and highly effective.

Q: What is the drug of choice in Manic Depressive Psychosis (MDP)?

Lithium. **Explanation:** **Manic Depressive Psychosis (MDP)**, now clinically referred to as **Bipolar Affective Disorder (BPAD)**, is characterized by cyclic episodes of mania and depression. **Why Lithium is the Correct Answer:** Lithium remains the **gold standard** and the drug of choice for both the treatment of acute mania and the long-term prophylaxis of MDP. It is a mood stabilizer that acts by modulating neurotransmitters (inhibiting dopamine and glutamate while enhancing GABA) and inhibiting the inositol monophosphatase pathway. Crucially, Lithium is one of the few drugs in psychiatry proven to **reduce the risk of suicide** in patients with mood disorders. **Analysis of Incorrect Options:** * **B. Amphetamine:** This is a CNS stimulant that increases synaptic dopamine. It can actually **precipitate** a manic episode and is contraindicated in MDP. * **C. Diazepam & D. Alprazolam:** These are Benzodiazepines. While they may be used as adjuncts to manage acute agitation or insomnia in a manic patient, they have **no mood-stabilizing properties** and do not treat the underlying pathology of MDP. **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic Index:** Lithium has a narrow therapeutic index. Target serum levels are **0.8–1.2 mEq/L** for acute mania and **0.6–1.0 mEq/L** for maintenance. * **Side Effects:** Common side effects include fine tremors, polyuria (nephrogenic diabetes insipidus), and hypothyroidism. * **Teratogenicity:** Use in pregnancy is associated with **Ebstein’s Anomaly** (atrialization of the right ventricle). * **Alternative:** If Lithium is contraindicated (e.g., renal failure), **Sodium Valproate** is the preferred alternative for acute mania.

Q: Which of the following is not an indicator of a good prognosis for major depressive disorder?

A history of more than one previous depressive episode. **Explanation:** In Major Depressive Disorder (MDD), prognosis is determined by clinical history, social support, and the nature of the episodes. **Why Option C is the correct answer:** A history of **recurrent episodes** is one of the strongest indicators of a **poor prognosis**. Statistically, the risk of recurrence increases with each subsequent episode: after one episode, the risk of a second is 50%; after two, it is 70%; and after three, it rises to 90%. Frequent episodes often lead to a more chronic course, shorter periods of remission, and increased treatment resistance. **Analysis of Incorrect Options (Good Prognostic Factors):** * **Option A (Stable family functioning):** Strong social support and a stable home environment are significant protective factors that correlate with better treatment adherence and faster recovery. * **Option B (No more than one previous hospitalization):** Fewer hospitalizations suggest a less severe illness trajectory and better community-based management. * **Option D (Advanced age of onset):** While late-life depression has its own challenges (like vascular causes), a **late age of onset** in adulthood is generally considered a good prognostic factor compared to early-onset MDD (childhood/adolescence), which is often associated with higher genetic loading and personality pathology. **High-Yield Clinical Pearls for NEET-PG:** * **Good Prognostic Factors:** Acute onset, absence of psychotic symptoms, short duration of the index episode, and solid friendships/social support. * **Poor Prognostic Factors:** Co-morbid anxiety or personality disorders, male gender, substance abuse, and a history of more than two previous episodes. * **Most common age of onset:** Approximately 40 years (though it can occur at any age). * **Gender ratio:** Twice as common in females (2:1).

Question 1

A 42-year-old male with a past history of a manic episode presents with an illness of 1 month duration characterized by depressed mood, anhedonia, and profound psychomotor retardation. What is the most appropriate initial management strategy?

Accepted Answer

Antidepressants and mood stabilizers

Answer

Antipsychotics and antidepressants

Answer

Antipsychotics and mood stabilizers

Answer

Antidepressants and benzodiazepines

Question 2

Which of the following is NOT a feature of depression?

Accepted Answer

Hyperactivity

Answer

Depressed mood

Answer

Loss of appetite

Answer

Suicidal ideas

Question 3

What is the antidepressant agent most likely to cause persistent erections (priapism) in a 40-year-old male patient?

Accepted Answer

Trazodone

Answer

Venlafaxine

Answer

Tranylcypromine

Answer

Doxepin

Question 4

Which of the following is most characteristic of sleep in a 45-year-old woman with major depressive disorder?

Accepted Answer

Waking up too early in the morning

Answer

Sleeping too many hours at night

Answer

Falling asleep suddenly during the daytime

Answer

Having difficulty coming fully awake after sleep

Question 5

A patient presents with non-stop talking, singing, uncontrollable behavior, and an apparent loss of contact with reality, diagnosed as acute mania. Which of the following is the most suitable drug for rapid control of his symptoms?

Accepted Answer

Haloperidol

Answer

Lithium carbonate

Answer

Phenobarbitone

Answer

Valproic acid

Question 6

Which of the following is NOT a cause of depression?

Accepted Answer

Metformin

Answer

Clonazepam

Answer

Methyldopa

Answer

Corticosteroid

Question 7

All of the following medications have mood-stabilizing action EXCEPT:

Accepted Answer

Paroxetine

Answer

Carbamazepine

Answer

Lamotrigine

Answer

Lithium

Question 8

A 30-year-old pregnant woman presents with decreased sleep, increased appetite, and hyperactivity for the past two weeks. A diagnosis of mania is made. Further probing reveals four episodes of major depression in the past two years. What medication would you prescribe for this patient?

Accepted Answer

Haloperidol

Answer

Lithium

Answer

Promethazine

Answer

Clonazepam

Question 9

What is the drug of choice in Manic Depressive Psychosis (MDP)?

Accepted Answer

Lithium

Answer

Amphetamine

Answer

Diazepam

Answer

Alprazolam

Question 10

Which of the following is not an indicator of a good prognosis for major depressive disorder?

Accepted Answer

A history of more than one previous depressive episode

Answer

Stable family functioning

Answer

No more than one previous hospitalization

Answer

Advanced age of onset

Mood Disorders — MCQs

Mood Disorders — MCQs

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