Mood Disorders — MCQs

A patient with major depressive disorder is brought in by her mother, complaining that the patient attempted suicide by hanging. She has a history of multiple suicide attempts and frequently talks about death. Electroconvulsive therapy (ECT) is suggested. Which of the following is an absolute contraindication to ECT?

Q285Easy

Which of the following is NOT a risk factor for suicide in patients with depression?

Q286Medium

Which drug is primarily used to decrease suicidal tendencies in manic bipolar disorder?

Q287Medium

What is the treatment for depression with suicidal tendencies?

Q288Medium

Neurotic depression may be characterized by all of the following except?

Q289Medium

In developing countries, which of the following features is most prominently shown by patients with depression?

Q290Easy

Suicide is most common in which of the following conditions?

Mood Disorders Indian Medical PG Practice Questions and MCQs

Question 281: Delusion of nihilism and early morning insomnia are characteristic features of which psychiatric condition?

A. Mania
B. Major depression (Correct Answer)
C. Personality disorder
D. Schizophrenia

Explanation: **Explanation:** The correct answer is **Major Depression**, specifically depression with **melancholic or psychotic features**. 1. **Why Major Depression is correct:** * **Delusion of Nihilism (Cotard’s Syndrome):** This is a specific type of delusion where the patient believes they are dead, non-existent, or that their internal organs/the world have ceased to exist. It is a hallmark of severe psychotic depression. * **Early Morning Insomnia (Terminal Insomnia):** This refers to waking up at least 2 hours before the scheduled time and being unable to fall back asleep. It is a "biological marker" for endogenous or melancholic depression, reflecting a disturbance in the circadian rhythm. 2. **Why other options are incorrect:** * **Mania:** Characterized by a *decreased need for sleep* (feeling refreshed after only 3 hours) rather than insomnia, and delusions are typically **grandiose** (inflated self-worth) rather than nihilistic. * **Personality Disorder:** These are enduring patterns of behavior/inner experience. While they can co-occur with depression, nihilistic delusions and specific sleep architecture changes are symptoms of Axis I clinical disorders, not personality traits. * **Schizophrenia:** While delusions are common (usually persecutory or bizarre), early morning awakening is not a diagnostic feature. Nihilism is specifically tied to the profound "low mood" of depression. **Clinical Pearls for NEET-PG:** * **Beck’s Cognitive Triad:** Hopelessness, Helplessness, and Worthlessness (common in depression). * **Sleep Changes in Depression:** Decreased REM latency (REM sleep starts sooner), increased REM density, and decreased slow-wave (Stage 3 & 4) sleep. * **Cotard’s Syndrome:** Often associated with atrophy in the nondominant cerebral hemisphere or severe depressive states.

Question 282: Which type of delusion is typically mood-congruent in depression?

A. Delusion of grandeur
B. Delusion of nihilism (Correct Answer)
C. Delusional parasitosis
D. Delusion of reference

Explanation: **Explanation:** In psychiatry, delusions in mood disorders are categorized as **mood-congruent** (consistent with the patient's emotional state) or **mood-incongruent**. **1. Why Delusion of Nihilism is correct:** In severe depression (Melancholic or Psychotic depression), the patient’s mood is characterized by extreme hopelessness, guilt, and despair. **Nihilistic delusions** (also known as **Cotard delusion**) involve the belief that oneself, a body part, or the world has ceased to exist or is "dead." This profound sense of loss and non-existence perfectly mirrors the "empty" and "low" emotional state of depression, making it a classic mood-congruent feature. **2. Analysis of Incorrect Options:** * **A. Delusion of Grandeur:** This is a belief in one's own inflated importance, power, or identity. It is **mood-congruent to Mania**, not depression. * **C. Delusional Parasitosis (Ekbom Syndrome):** This is a monosymptomatic hypochondriacal psychosis where patients believe they are infested with insects. It is generally considered mood-neutral. * **D. Delusion of Reference:** The belief that neutral environmental cues (e.g., a news anchor’s comments) are directed specifically at the patient. While it can occur in depression, it is more characteristic of Schizophrenia and is considered **mood-incongruent** in the context of a primary mood disorder. **Clinical Pearls for NEET-PG:** * **Cotard Syndrome:** Often associated with the "Walking Corpse" syndrome; it is a severe form of nihilistic delusion seen in elderly depressed patients. * **Mood-Congruent Delusions in Depression:** Include delusions of guilt, poverty, nihilism, and somatic ruin. * **Prognostic Significance:** The presence of mood-incongruent delusions in a mood disorder usually indicates a poorer prognosis and a higher risk of transitioning to Schizoaffective disorder.

Question 283: Which of the following neurotransmitters is most consistently associated with an increased risk of suicide?

A. Noradrenaline
B. Serotonin (Correct Answer)
C. GABA
D. Dopamine

Explanation: **Explanation:** The correct answer is **Serotonin (5-HT)**. Low levels of serotonin and its primary metabolite, **5-HIAA (5-hydroxyindoleacetic acid)**, in the cerebrospinal fluid (CSF) are the most consistent biological markers associated with impulsive aggression and completed suicide across various psychiatric diagnoses. **Why Serotonin is Correct:** Neurobiological studies have shown that decreased serotonergic activity in the **ventromedial prefrontal cortex** leads to a failure in "top-down" inhibition of aggressive impulses. Post-mortem studies of suicide victims frequently reveal reduced serotonin transporter binding and altered 5-HT receptor density in the brain. **Why Other Options are Incorrect:** * **Noradrenaline (A):** While dysregulation of the noradrenergic system (specifically overactivity) is linked to anxiety and the "stress response," it is not as specific or consistent a predictor of suicidal behavior as serotonin. * **GABA (C):** GABA is the primary inhibitory neurotransmitter. While it plays a role in anxiety and impulsivity, it is not the primary neurotransmitter implicated in the pathophysiology of suicide. * **Dopamine (D):** Dopamine is primarily associated with the reward system and motor control. While low dopamine may contribute to the anhedonia seen in depression, it lacks the strong, consistent correlation with suicide found with serotonin. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Marker:** Low **CSF 5-HIAA** is the most frequently cited biochemical finding in suicidal patients. * **Impulsivity:** The link between serotonin and suicide is strongest for **impulsive** or violent suicide attempts rather than planned ones. * **Genetics:** Polymorphisms in the **Tryptophan Hydroxylase (TPH)** gene, the rate-limiting enzyme for serotonin synthesis, are also linked to increased suicide risk. * **Antidepressants:** While SSRIs increase serotonin, patients must be monitored closely during the first 2 weeks of treatment as an increase in physical energy may precede the improvement in mood, potentially providing the "energy" to act on suicidal ideation.

Question 284: A patient with major depressive disorder is brought in by her mother, complaining that the patient attempted suicide by hanging. She has a history of multiple suicide attempts and frequently talks about death. Electroconvulsive therapy (ECT) is suggested. Which of the following is an absolute contraindication to ECT?

A. Brain tumor
B. Myocardial disease
C. Aortic aneurysm
D. No absolute contraindication (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. No absolute contraindication.** In modern psychiatry, **Electroconvulsive Therapy (ECT)** is considered one of the safest procedures performed under general anesthesia. While several conditions significantly increase the risk of complications, current medical consensus (including guidelines from the APA) maintains that there are **no absolute medical contraindications** to ECT. If the psychiatric condition (e.g., severe suicidal intent or catatonia) is life-threatening, ECT can be performed even in high-risk patients, provided they are stabilized and monitored by a multidisciplinary team. **Analysis of Incorrect Options:** * **A. Brain tumor:** Previously considered an absolute contraindication due to the risk of increased intracranial pressure (ICP) and herniation. It is now a **relative contraindication**; with the use of steroids and antihypertensives, ECT can be safely administered. * **B. Myocardial disease:** Recent myocardial infarction (within 3 months) is a major **relative contraindication** due to the transient tachycardia and hypertension during the seizure. However, it is not absolute if the cardiac status is optimized. * **C. Aortic aneurysm:** This is a **relative contraindication** because the surge in blood pressure during the convulsion could lead to rupture. It is managed with beta-blockers and careful pressure control. **High-Yield Clinical Pearls for NEET-PG:** * **Most common side effect:** Retrograde amnesia (usually resolves within 6 months). * **Most common cause of death:** Cardiovascular complications (arrhythmias/MI). * **Drug of choice for anesthesia:** Methohexital (Gold standard); Thiopentone is also used. * **Muscle relaxant of choice:** Succinylcholine. * **Indications:** Severe depression with suicidal risk (fastest response), Catatonia, and Treatment-resistant Schizophrenia.

Question 285: Which of the following is NOT a risk factor for suicide in patients with depression?

A. Female gender (Correct Answer)
B. Male gender over 45 years of age
C. Childhood conduct disorder
D. Family history of suicide

Explanation: **Explanation:** The assessment of suicide risk is a critical competency in Psychiatry for NEET-PG. To answer this correctly, one must distinguish between the **frequency of attempts** and the **rate of completion**. **Why Option A is correct:** While women are **3 times more likely to attempt** suicide (parasuicide), men are **4 times more likely to complete** suicide. Therefore, being female is statistically associated with a lower risk of completed suicide compared to being male. In the context of risk stratification for mortality, female gender is considered a lower risk factor than male gender. **Analysis of Incorrect Options:** * **B. Male gender over 45 years:** Risk increases with age for men. Males over 45 (and especially those over 65) have the highest rates of completed suicide due to the use of more lethal methods and higher intent. * **C. Childhood conduct disorder:** A history of impulsive behavior, aggression, or conduct disorder is a significant predictor of future suicidal behavior. Impulsivity is a core psychological component of suicide risk. * **D. Family history of suicide:** Genetics and shared environment play a role. A positive family history (especially in a first-degree relative) significantly increases the risk, often independent of the underlying psychiatric diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **SAD PERSONS Scale:** A useful mnemonic for risk factors (Sex: Male, Age: <19 or >45, Depression, Previous attempt, Ethanol/Substance use, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness). * **Single Best Predictor:** The strongest predictor of a future completed suicide is a **previous suicide attempt**. * **Marital Status:** Marriage (especially with children) is protective; being divorced, widowed, or single increases risk. * **Profession:** Doctors (specifically Anesthesiologists, Psychiatrists, and Surgeons) have higher rates of completed suicide compared to the general population.

Question 286: Which drug is primarily used to decrease suicidal tendencies in manic bipolar disorder?

A. Fluoxetine
B. Lithium (Correct Answer)
C. Carbamazepine
D. Risperidone

Explanation: **Explanation:** **Lithium** is the gold standard treatment for Bipolar Disorder and is uniquely recognized for its **anti-suicidal properties**. While many medications treat the symptoms of mania or depression, Lithium is one of the few drugs in psychiatry (along with Clozapine) proven to significantly reduce the risk of completed suicide and suicidal attempts. It achieves this independently of its mood-stabilizing effect, likely by reducing impulsivity and aggression. **Analysis of Incorrect Options:** * **Fluoxetine (A):** An SSRI used for depression. In Bipolar Disorder, antidepressants can actually worsen the condition by inducing "mood switching" into mania and may potentially increase suicidal ideation in younger patients. * **Carbamazepine (C):** An anticonvulsant used as a second-line mood stabilizer. While effective for rapid cycling or acute mania, it does not possess the specific evidence-based anti-suicidal benefits that Lithium offers. * **Risperidone (D):** An atypical antipsychotic used to control acute psychotic symptoms in mania. While it stabilizes the acute phase, it is not the primary drug indicated for long-term suicide prevention. **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 **0.6–0.8 mEq/L** for maintenance. * **Monitoring:** Before starting Lithium, always check **Thyroid Function Tests (TFT)** and **Renal Function Tests (RFT)**, as it can cause hypothyroidism and nephrogenic diabetes insipidus. * **Teratogenicity:** Use in pregnancy is associated with **Ebstein’s Anomaly** (tricuspid valve malformation). * **Drug of Choice:** Lithium remains the first-line treatment for classic "euphoric" mania.

Question 287: What is the treatment for depression with suicidal tendencies?

A. Clozapine
B. Mirtazapine
C. ECT (Correct Answer)
D. Olanzapine

Explanation: **Explanation:** **1. Why ECT is the Correct Answer:** Electroconvulsive Therapy (ECT) is the gold-standard treatment for severe depression with **active suicidal ideation**. While antidepressants take 2–4 weeks to show clinical effects, ECT provides a **rapid therapeutic response**, making it life-saving in emergency psychiatric situations. It is the treatment of choice when a quick reduction in suicidal risk or depressive stupor is required. **2. Analysis of Incorrect Options:** * **Clozapine (A):** This is an atypical antipsychotic used for treatment-resistant schizophrenia. While it is the only drug FDA-approved specifically to reduce suicidal behavior in **schizophrenia**, it is not the primary treatment for suicidal depression. * **Mirtazapine (B):** An antidepressant (NaSSA) often used for depression with insomnia or weight loss. However, like all oral antidepressants, its onset of action is too slow for an acute suicidal crisis. * **Olanzapine (D):** An atypical antipsychotic used in bipolar disorder or as an adjunct in depression, but it does not have a primary role in the acute management of suicidal tendencies. **3. High-Yield Clinical Pearls for NEET-PG:** * **Indications for ECT:** Severe depression with suicide risk (Top priority), Catatonia, Depressive Stupor, and Treatment-resistant Depression. * **Most common side effect of ECT:** Retrograde amnesia (usually transient). * **Absolute Contraindication:** There are no absolute contraindications, but **Increased Intracranial Pressure (ICP)** is the most significant relative contraindication. * **Lithium:** Along with Clozapine, Lithium is one of the few pharmacological agents proven to reduce the long-term risk of suicide (specifically in Bipolar Disorder).

Question 288: Neurotic depression may be characterized by all of the following except?

A. Ravenous appetite (Correct Answer)
B. Hypersomnia
C. Increased libido
D. Weight gain

Explanation: This question focuses on the clinical presentation of **Neurotic Depression**, often referred to in modern psychiatry as **Atypical Depression** (a subtype of Major Depressive Disorder or Dysthymia). ### **Understanding the Concept** While "typical" melancholic depression is characterized by insomnia, anorexia, and weight loss, **Atypical (Neurotic) Depression** presents with "reversed" vegetative symptoms. The hallmark features include: 1. **Mood Reactivity:** The ability to feel better in response to positive events. 2. **Hyperphagia:** Increased appetite (often leading to weight gain). 3. **Hypersomnia:** Sleeping more than usual. 4. **Leaden Paralysis:** A heavy feeling in the limbs. ### **Analysis of Options** * **A. Ravenous appetite (Correct Answer):** While patients experience *increased* appetite (hyperphagia), the term "Ravenous appetite" (Polyphagia/Bulimia) is classically associated with eating disorders or specific endocrine pathologies rather than the diagnostic criteria for neurotic depression. In the context of this specific MCQ, it is considered the "odd one out" compared to the standard triad of hypersomnia, weight gain, and increased food intake. * **B. Hypersomnia:** This is a classic feature of atypical/neurotic depression. Patients often sleep >10 hours a day. * **C. Increased libido:** While depression usually decreases libido, neurotic/atypical depression can occasionally present with increased libido or "nymphomania" as a form of emotional seeking, though it is less common than weight/sleep changes. * **D. Weight gain:** This is a direct consequence of the hyperphagia seen in these patients and is a core diagnostic feature. ### **NEET-PG High-Yield Pearls** * **Drug of Choice:** While SSRIs are first-line, **MAO Inhibitors (MAOIs)** are historically considered more effective specifically for Atypical Depression. * **Key Distinction:** Always look for **Mood Reactivity**; if the patient cannot cheer up even briefly, it is likely Melancholic, not Atypical. * **Leaden Paralysis:** This is a high-yield buzzword specifically linked to this condition in exams.

Question 289: In developing countries, which of the following features is most prominently shown by patients with depression?

A. Low mood
B. Sleep disturbance
C. Vague body aches (Correct Answer)
D. Suicidal tendency

Explanation: ### Explanation **Correct Answer: C. Vague body aches** In developing countries and non-Western cultures, depression often presents through **Somatization**. This is a clinical phenomenon where psychological distress is manifested as physical symptoms. Patients in these regions frequently present to primary care with "vague body aches," chronic pain, fatigue, or gastrointestinal disturbances rather than reporting emotional symptoms. **Why it is the correct answer:** Cultural factors play a significant role in symptom expression. In many developing nations, there is a high social stigma associated with mental illness, and patients may lack the psychological vocabulary to describe emotional states. Consequently, they "somatize" their depression. Vague, ill-defined physical complaints (like "body aches" or "heaviness") are more culturally acceptable reasons to seek medical help than feelings of sadness. **Analysis of Incorrect Options:** * **A. Low mood:** While "depressed mood" is a core criterion for MDD in ICD and DSM classifications, it is often denied or underreported by patients in developing countries (sometimes referred to as "masked depression"). * **B. Sleep disturbance:** This is a common vegetative symptom of depression globally, but it is not as specific or "prominently" characteristic of the cultural presentation in developing regions as somatization is. * **D. Suicidal tendency:** This is a severe feature of depression but is less frequent as a presenting complaint compared to physical symptoms in a primary care setting. **Clinical Pearls for NEET-PG:** * **Somatization:** The most common presentation of depression in primary care settings worldwide, but especially prominent in India and other developing nations. * **Masked Depression:** A term used when the patient denies depressive mood but presents with somatic symptoms (aches, pains, sleep issues). * **Core Symptoms (ICD-10):** Depressed mood, loss of interest (anhedonia), and decreased energy (fatigability). * **Cultural Syndrome:** In the Indian context, "Dhat syndrome" or "Shen-kuei" are examples of how psychological distress manifests through somatic concerns.

Question 290: Suicide is most common in which of the following conditions?

A. Depression (Correct Answer)
B. Alcohol dependence
C. Dementia
D. Schizophrenia

Explanation: **Explanation:** **1. Why Depression is Correct:** Depression (Major Depressive Disorder) is the psychiatric condition most strongly associated with completed suicide. Statistically, approximately **15% of patients** with severe depression eventually die by suicide. The core symptoms of hopelessness, worthlessness, and psychomotor retardation (or agitation) create a high-risk profile. Hopelessness, in particular, is considered the strongest psychological predictor of suicidal intent. **2. Analysis of Incorrect Options:** * **Alcohol Dependence:** While substance abuse significantly increases impulsivity and is the second most common psychiatric diagnosis associated with suicide, the lifetime risk (approx. 7%) is lower than that of primary mood disorders. * **Dementia:** Patients with dementia may experience depression or confusion, but they have a lower overall rate of completed suicide compared to functional psychiatric disorders, often due to cognitive and physical limitations. * **Schizophrenia:** There is a significant risk in schizophrenia (approx. 5-10% lifetime risk), particularly in young patients with high premorbid functioning who have "insight" into their deteriorating condition (post-psychotic depression). However, it remains statistically lower than Major Depression. **3. High-Yield Clinical Pearls for NEET-PG:** * **Single most important risk factor:** A previous history of suicide attempts. * **Strongest predictor of suicide:** Hopelessness (Beck’s Hopelessness Scale). * **Demographics:** Men "commit" suicide more often (higher lethality), while women "attempt" suicide more frequently. * **Protective Factor:** Pregnancy and strong social/family support are significant protective factors. * **Bipolar Disorder:** The risk of suicide is actually higher during the **depressive phase** or **mixed episodes** than in pure mania.

Practice by Chapter

Major Depressive Disorder

Practice Questions

Bipolar Disorder: Manic Episodes

Practice Questions

Bipolar Disorder: Depressive and Mixed Episodes

Practice Questions

Persistent Depressive Disorder (Dysthymia)

Practice Questions

Cyclothymic Disorder

Practice Questions

Seasonal Affective Disorder

Practice Questions

Suicide and Suicidal Behavior

Practice Questions

Pharmacotherapy of Mood Disorders

Practice Questions

Psychotherapy for Mood Disorders

Practice Questions

Brain Stimulation Therapies

Practice Questions

Treatment-Resistant Depression

Practice Questions

Mood Disorders in Special Populations

Practice Questions

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