Mood Disorders — MCQs

A 40-year-old female patient presents with a history of depressed mood, loss of appetite, insomnia, and lack of interest in her surroundings for the past year. These symptoms followed soon after a business loss one year back. Which of the following statements is true regarding the management of this patient?

Q36Easy

Which of the following is not a part of Beck's triad?

Q37Medium

A 28-year-old lady was admitted to the psychiatric ward after she ran out of the house removing her clothes. She complained of feeling depressed but was speaking very fast. She did not let the resident doctor complete his questions. She was hyperactive, distractible, and often confronted people on the ward. She complained about not being able to sleep and was low in mood despite being on an antidepressant. Which of the following is the most appropriate treatment for her condition?

Q38Easy

Which of the following is associated with neurotic depression?

Q39Easy

What is the drug of choice in acute mania?

Q40Medium

What is the treatment of choice for prophylaxis in patients with repeated episodes of bipolar illness?

Mood Disorders Indian Medical PG Practice Questions and MCQs

Question 31: Which medication is DOC for rapid cycling Bipolar Affective Disorder?

A. Lithium
B. Valproate (Correct Answer)
C. Calcium channel blocker
D. Carbamazepine

Explanation: **Explanation:** **Rapid Cycling Bipolar Affective Disorder (BPAD)** is defined by the occurrence of **four or more mood episodes** (manic, hypomanic, or depressive) within a 12-month period. 1. **Why Valproate is Correct:** While Lithium remains the gold standard for classic BPAD, **Sodium Valproate** is the **Drug of Choice (DOC)** for rapid cycling and mixed episodes. Valproate has shown superior efficacy in stabilizing mood fluctuations in patients who do not respond well to Lithium. Its mechanism involves enhancing GABAergic transmission and modulating glutamate and voltage-gated sodium channels, which provides a broader spectrum of anti-cycling activity. 2. **Why Other Options are Incorrect:** * **Lithium:** Although the first-line treatment for prophylaxis and acute mania, it is notoriously **less effective** in rapid cycling variants. * **Carbamazepine:** This is considered a second-line mood stabilizer. It is used when patients are intolerant to Valproate or Lithium but is generally not the first choice for rapid cycling. * **Calcium Channel Blockers (e.g., Verapamil):** These have very limited evidence in mood stabilization and are never used as first-line monotherapy for rapid cycling. **High-Yield Clinical Pearls for NEET-PG:** * **DOC for Acute Mania:** Lithium (if mild/moderate); Valproate or Antipsychotics (if severe). * **DOC for BPAD in Pregnancy:** Second-generation antipsychotics (e.g., Quetiapine). Avoid Lithium (Ebstein’s anomaly) and Valproate (Neural tube defects) in the first trimester. * **Therapeutic Range for Lithium:** 0.8–1.2 mEq/L (Acute); 0.6–1.0 mEq/L (Maintenance). * **Antidepressant-Induced Cycling:** Always rule out antidepressant use as a cause for rapid cycling before intensifying mood stabilizer therapy.

Question 32: A patient presents with depressed mood, loss of sleep, loss of hope, feeling of worthlessness, and diminished concentration for the past month. Which of the following is the drug of choice in this patient?

A. SSRIs (Selective Serotonin Reuptake Inhibitors) (Correct Answer)
B. Atypical antidepressants
C. Lithium
D. Tricyclic antidepressants

Explanation: ### Explanation **1. Why SSRIs are the Correct Choice:** The patient presents with classic symptoms of **Major Depressive Disorder (MDD)**: depressed mood, insomnia, hopelessness, worthlessness, and poor concentration, lasting for more than two weeks. According to current clinical guidelines (APA and NICE), **Selective Serotonin Reuptake Inhibitors (SSRIs)** are the **first-line treatment** for MDD. They are preferred because of their favorable safety profile, better tolerability, and lower risk of toxicity in overdose compared to older antidepressants. **2. Analysis of Incorrect Options:** * **B. Atypical Antidepressants:** While effective (e.g., Bupropion, Mirtazapine), these are generally considered second-line or used in specific scenarios (e.g., Bupropion if sexual dysfunction is a concern). * **C. Lithium:** This is the drug of choice for **Bipolar Affective Disorder (BPAD)** prophylaxis and acute mania. While it can augment antidepressants in treatment-resistant depression, it is not the initial drug of choice for unipolar depression. * **D. Tricyclic Antidepressants (TCAs):** Though equally effective as SSRIs, TCAs are no longer first-line due to significant side effects (anticholinergic, antihistaminic, anti-alpha-1) and high **cardiotoxicity** in overdose (prolonged QTc). **3. NEET-PG High-Yield Pearls:** * **Most common side effect of SSRIs:** Gastrointestinal upset (nausea/diarrhea). * **Most common long-term side effect:** Sexual dysfunction. * **Fluoxetine:** Has the longest half-life (ideal for patients who forget doses). * **Fluvoxamine:** Specifically indicated for Obsessive-Compulsive Disorder (OCD). * **Sertraline:** Considered the safest SSRI post-Myocardial Infarction (MI). * **Escitalopram:** Known for having the highest specificity for the serotonin transporter.

Question 33: All of the following are true about mania except?

A. Elevated mood
B. Flight of ideas
C. Delusions of grandeur
D. Word salad (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Word salad**. In psychiatry, **Word Salad** (schizophasia) is a severe form of thought form disorder characterized by a random jumble of words that lack any logical or grammatical connection. It is a hallmark feature of **Schizophrenia** (specifically disorganized type) rather than Mania. **Analysis of Options:** * **A. Elevated mood:** This is the core emotional feature of Mania. The mood is typically described as euphoric, expansive, or irritable, lasting for at least one week. * **B. Flight of ideas:** This is the classic **thought form disorder** seen in Mania. It involves a rapid succession of thoughts where ideas are connected by chance associations (e.g., clanging or punning), but a thin thread of logic usually remains, unlike word salad. * **C. Delusions of grandeur:** These are common **thought content disorders** in Mania. Patients have inflated self-esteem and believe they possess special powers, wealth, or a unique relationship with a deity or famous person. **Clinical Pearls for NEET-PG:** 1. **DIGFAST Mnemonic for Mania:** **D**istractibility, **I**ndiscretion (excessive involvement in pleasurable activities), **G**randiosity, **F**light of ideas, **A**ctivity increase, **S**leep deficit (decreased need for sleep), **T**alkativeness (pressured speech). 2. **Pressure of Speech:** In Mania, speech is rapid, loud, and difficult to interrupt. 3. **Distinction:** While "Flight of Ideas" is characteristic of **Mania**, "Loosening of Associations" and "Word Salad" are more characteristic of **Schizophrenia**. 4. **Hypomania vs. Mania:** Hypomania lasts ≥4 days, does not require hospitalization, and lacks psychotic features. Mania lasts ≥1 week or requires hospitalization.

Question 34: What is paradoxical suicide?

A. Suicide observed in caretakers of individuals with depression.
B. Suicide observed in children of individuals with depression.
C. Suicide observed in parents of individuals with depression.
D. Suicide observed after the initiation of treatment. (Correct Answer)

Explanation: ### Explanation **Paradoxical suicide** refers to a phenomenon where a patient with severe depression commits suicide shortly after starting treatment (pharmacotherapy or psychotherapy) or during the early stages of recovery. **Why Option D is Correct:** In severe depression, patients often suffer from **psychomotor retardation**—a state where they lack the physical energy and motivation to carry out a suicide plan, despite having suicidal ideation. When treatment (like SSRIs) begins, physical energy and motivation often improve **before** the depressive mood and hopelessness lift. This "energy gap" creates a window where the patient now has the physical drive to act on their pre-existing suicidal thoughts. This is why the risk of suicide paradoxically increases in the first few weeks of antidepressant therapy. **Why Other Options are Incorrect:** * **Options A, B, and C:** While family members and caregivers of depressed patients are at a higher risk for depression and "caregiver burnout," their suicidal behavior is not termed "paradoxical suicide." These would be categorized under the genetic or environmental transmission of mental illness. **High-Yield Clinical Pearls for NEET-PG:** * **The "Danger Zone":** The highest risk for paradoxical suicide is typically within the first **10 to 14 days** of starting antidepressants. * **Black Box Warning:** The FDA has a black box warning for SSRIs regarding increased suicidal thoughts and behaviors in children, adolescents, and young adults (up to age 24). * **Clinical Management:** Always monitor patients closely during the initial phase of treatment. If a patient suddenly appears "energetic" but still expresses hopelessness, it is a major red flag. * **ECT:** Electroconvulsive Therapy (ECT) is often preferred in actively suicidal patients because it works faster than drugs to bridge this dangerous gap.

Question 35: A 40-year-old female patient presents with a history of depressed mood, loss of appetite, insomnia, and lack of interest in her surroundings for the past year. These symptoms followed soon after a business loss one year back. Which of the following statements is true regarding the management of this patient?

A. No treatment is necessary as the symptoms are due to business loss.
B. SSRI is the most efficacious of the available antidepressant drugs.
C. Antidepressant treatment selection is primarily based on the side effect profile of the drug. (Correct Answer)
D. Combination therapy of two antidepressants should be administered.

Explanation: ### Explanation **1. Why Option C is Correct:** The patient presents with symptoms suggestive of **Major Depressive Disorder (MDD)** (depressed mood, anhedonia, neurovegetative symptoms) lasting for one year. In clinical practice, all major classes of antidepressants (SSRIs, SNRIs, TCAs, and Atypical antidepressants) have roughly **equal efficacy** for the treatment of MDD. Therefore, the choice of drug is not based on superior effectiveness, but on the **side effect profile**, patient comorbidities, cost, and previous response to treatment. For example, a patient with insomnia might benefit from a sedating antidepressant like Mirtazapine. **2. Why the Other Options are Incorrect:** * **Option A:** While the symptoms were triggered by a "business loss," the duration (one year) and severity indicate a clinical depression rather than a transient grief reaction. Treatment is necessary to restore functioning. * **Option B:** While SSRIs are the **first-line** treatment due to their safety and tolerability, they are **not more efficacious** than other classes like TCAs or SNRIs. * **Option D:** Monotherapy is the standard of care for initial treatment. Combination therapy is reserved for treatment-resistant depression and is not a first-line approach. **3. Clinical Pearls for NEET-PG:** * **Duration Criteria:** For MDD diagnosis (DSM-5), symptoms must be present for at least **2 weeks**. * **First-line:** SSRIs are preferred due to low toxicity in overdose and better patient compliance. * **Lag Period:** Antidepressants typically take **2–4 weeks** to show clinical improvement; patients should be counseled about this delay. * **Common Side Effects:** SSRIs (GI upset, sexual dysfunction); TCAs (Anticholinergic effects, cardiotoxicity); Mirtazapine (Weight gain, sedation).

Question 36: Which of the following is not a part of Beck's triad?

A. Hopelessness
B. Worthlessness
C. Helplessness
D. Sleeplessness (Correct Answer)

Explanation: **Explanation:** **Beck’s Cognitive Triad** is a core concept in the cognitive theory of depression developed by Aaron Beck. It describes three specific patterns of negative thinking that maintain depressive symptoms. The triad consists of negative views about: 1. **The Self (Worthlessness):** The individual perceives themselves as defective, inadequate, or lacking the necessary requirements for happiness. 2. **The World/Environment (Helplessness):** The individual interprets ongoing experiences in a negative way, believing the world makes exorbitant demands or presents insuperable obstacles. 3. **The Future (Hopelessness):** The individual anticipates that current difficulties or suffering will continue indefinitely. **Why Sleeplessness is the correct answer:** Sleeplessness (Insomnia) is a **somatic (physical) symptom** of depression, not a cognitive one. While it is a common diagnostic criterion for Major Depressive Disorder (MDD) in the DSM-5, it is not part of Beck’s psychological model of cognitive distortions. **Analysis of Incorrect Options:** * **Hopelessness:** Represents the negative view of the **future**. It is a strong predictor of suicidal intent. * **Worthlessness:** Represents the negative view of the **self**. * **Helplessness:** Represents the negative view of the **world/current situation**, where the individual feels they have no control over their environment. **High-Yield Clinical Pearls for NEET-PG:** * **Cognitive Behavioral Therapy (CBT):** Aimed at identifying and restructuring these three negative schemas. * **Learned Helplessness:** A related but distinct concept developed by **Martin Seligman** (based on animal models). * **Suicide Risk:** Among the triad, **Hopelessness** is the most significant indicator of long-term suicidal risk.

Question 37: A 28-year-old lady was admitted to the psychiatric ward after she ran out of the house removing her clothes. She complained of feeling depressed but was speaking very fast. She did not let the resident doctor complete his questions. She was hyperactive, distractible, and often confronted people on the ward. She complained about not being able to sleep and was low in mood despite being on an antidepressant. Which of the following is the most appropriate treatment for her condition?

A. Stop antidepressant and start Methylphenidate
B. Stop antidepressant and start Mood Stabiliser (Correct Answer)
C. Use antidepressant and Mood Stabiliser
D. Use antidepressant and Typical Antipsychotic

Explanation: ### **Explanation** The clinical presentation describes a **Mixed Episode (Mixed Features)** of Bipolar Disorder. The patient exhibits a combination of depressive symptoms (low mood) and manic symptoms (pressured speech/logorrhea, hyperactivity, distractibility, disinhibition, and decreased need for sleep). **1. Why Option B is Correct:** The patient is currently on an antidepressant, which is a known trigger for **treatment-emergent affective switch (TEAS)**—flipping a patient from depression into mania or a mixed state. In Bipolar Disorder, antidepressants should never be used as monotherapy. The first step in managing a mixed episode or antidepressant-induced mania is to **stop the antidepressant** and initiate a **Mood Stabilizer** (e.g., Lithium or Valproate) or an Atypical Antipsychotic to stabilize the mood from "above." **2. Why Other Options are Incorrect:** * **Option A:** Methylphenidate is a stimulant used for ADHD. It would worsen tachycardia, insomnia, and agitation in a manic/mixed state. * **Option C:** Continuing the antidepressant while adding a mood stabilizer is risky during an active mixed/manic state, as the antidepressant continues to fuel the "switch" and cycle acceleration. * **Option D:** While antipsychotics are used in mania, the priority is to remove the offending agent (antidepressant) and stabilize the mood. Typical antipsychotics are generally second-line to atypical ones due to the risk of extrapyramidal side effects. ### **Clinical Pearls for NEET-PG:** * **Mixed Features (DSM-5):** Defined as the presence of at least three symptoms of the opposite polarity during a mood episode. * **Antidepressant-Induced Mania:** Always suspect Bipolar Disorder in a patient who "switches" or becomes agitated shortly after starting SSRIs/TCAs. * **Drug of Choice:** **Valproate** is often preferred over Lithium for **Mixed Episodes** and Rapid Cycling Bipolar Disorder. * **Safety Note:** In a patient with "pressured speech" and "disinhibition" (removing clothes), immediate safety and stabilization are paramount.

Question 38: Which of the following is associated with neurotic depression?

A. Usually associated with anxiety (Correct Answer)
B. Treated by ECT
C. Endogenous depression
D. Usually bipolar

Explanation: **Explanation:** In psychiatry, **Neurotic Depression** (also known as Dysthymia or Persistent Depressive Disorder in modern terminology) is characterized by a chronic, low-grade depressive state that is often triggered by external stressors or personality factors. **1. Why Option A is Correct:** Neurotic depression is frequently characterized by a "mixed" clinical picture. Unlike psychotic or endogenous depression, it is **usually associated with anxiety**, irritability, and somatic complaints. Patients often remain in touch with reality but struggle with chronic dissatisfaction and emotional instability. **2. Why the other options are incorrect:** * **Option B (ECT):** Electroconvulsive Therapy (ECT) is indicated for severe, biological, or "melancholic" depression, especially when there is a high suicide risk or catatonia. It is rarely, if ever, used for neurotic depression, which responds better to psychotherapy and SSRIs. * **Option C (Endogenous depression):** This is the opposite of neurotic depression. Endogenous depression arises from internal biological factors (not external stressors), presents with "vegetative" symptoms (weight loss, early morning awakening), and is often more severe. * **Option D (Bipolar):** Neurotic depression is typically unipolar. Bipolar disorder involves distinct episodes of mania or hypomania, which are absent in neurotic/dysthymic patterns. **High-Yield Clinical Pearls for NEET-PG:** * **Neurotic vs. Psychotic Depression:** In neurotic depression, reality testing is intact, and there are no delusions or hallucinations. * **Diurnal Variation:** In endogenous depression, symptoms are worse in the morning; in neurotic depression, symptoms often worsen as the day progresses (**evening worsening**). * **Treatment:** The mainstay for neurotic depression is a combination of **Cognitive Behavioral Therapy (CBT)** and Pharmacotherapy (SSRIs).

Question 39: What is the drug of choice in acute mania?

A. Lithium
B. Chlorpromazine
C. Valproic acid
D. Risperidone (Correct Answer)

Explanation: **Explanation:** In the management of **acute mania**, the primary goal is rapid symptom control. While multiple drug classes are effective, **Atypical Antipsychotics (Second-Generation Antipsychotics)** are currently considered the first-line treatment of choice due to their rapid onset of action compared to mood stabilizers. **Why Risperidone is Correct:** Risperidone is a potent atypical antipsychotic that provides rapid sedation and control of manic symptoms (agitation, flight of ideas, and psychosis). In acute clinical settings, antipsychotics work faster (within hours to days) than Lithium or Valproate, which may take 5–10 days to reach therapeutic levels and show clinical efficacy. **Analysis of Incorrect Options:** * **Lithium (A):** Traditionally the "gold standard" for long-term maintenance and prophylaxis of Bipolar Disorder. However, in acute mania, its slow onset and narrow therapeutic index make it a second-line choice for immediate stabilization compared to antipsychotics. * **Chlorpromazine (B):** A typical (first-generation) antipsychotic. While effective, it is no longer the drug of choice due to a higher side-effect profile, including extrapyramidal symptoms (EPS) and significant sedation. * **Valproic acid (C):** An excellent mood stabilizer, especially for "mixed episodes" or "rapid cycling." Like Lithium, it has a slower onset of action than Risperidone in an acute crisis. **High-Yield Clinical Pearls for NEET-PG:** * **First-line for Acute Mania:** Atypical Antipsychotics (Risperidone, Olanzapine, Haloperidol). * **Best for Maintenance/Suicide Prevention:** Lithium. * **Best for Mixed Episodes/Rapid Cycling:** Valproate. * **Pregnancy:** Avoid Lithium (Ebstein’s anomaly) and Valproate (Neural tube defects). Antipsychotics or ECT are preferred. * **Severe Mania:** Combination therapy (Lithium/Valproate + an Antipsychotic) is often superior to monotherapy.

Question 40: What is the treatment of choice for prophylaxis in patients with repeated episodes of bipolar illness?

A. Lithium
B. Valproate
C. Lithium and Valproate (Correct Answer)
D. None of the above

Explanation: **Explanation:** The management of Bipolar Affective Disorder (BPAD) often requires long-term prophylaxis to prevent relapses of both mania and depression. **Why Option C is Correct:** While Lithium and Valproate are both first-line agents individually, clinical evidence (notably the **BALANCE trial**) and various treatment guidelines (such as CANMAT) indicate that **combination therapy with Lithium and Valproate** is more effective than monotherapy for preventing relapse in patients with repeated episodes. This synergistic approach provides superior stabilization of mood, especially in patients who have failed monotherapy or those with high-frequency cycling. **Why Other Options are Incorrect:** * **Option A (Lithium):** Historically the "gold standard" for prophylaxis and excellent for preventing manic relapses and reducing suicide risk. However, as monotherapy, it may not be sufficient for patients with "repeated episodes" or rapid cycling compared to the combination. * **Option B (Valproate):** An effective first-line mood stabilizer, particularly for mixed episodes and rapid cycling. However, like Lithium, its efficacy in preventing all-cause relapse is statistically lower when used alone compared to the combination. **High-Yield Clinical Pearls for NEET-PG:** * **Therapeutic Index:** Lithium has a narrow therapeutic index. Prophylactic blood levels should be maintained between **0.6 – 0.8 mEq/L**. * **Drug of Choice (DOC):** * Acute Mania: Lithium (or Valproate). * Rapid Cycling BPAD: Valproate. * BPAD in Pregnancy: Second-generation antipsychotics (avoid Lithium/Valproate due to teratogenicity like Ebstein’s anomaly and Neural Tube Defects). * **Suicide Prevention:** Lithium is the only mood stabilizer proven to reduce the risk of completed suicide in BPAD patients.

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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