Pharmacotherapy of Mood Disorders — MCQs
A 72 year old lady is severely depressed. For the past 2 days she has suicidal thoughts with an actual intent to die. Which of the following is best suitable to alleviate the symptoms?
A 45-year-old patient with a history of depression was initially being treated with sertraline, but his symptoms were not adequately controlled. His medication regimen was changed to include an MAO inhibitor and amitriptyline. Shortly after the change in medication, the patient developed agitation, seizures, hyperreflexia, and tremor. Which of the following is the most appropriate treatment for this patient?
Electroconvulsive therapy is not useful in which of the following conditions?
Which of the following is a tricyclic antidepressant?
A patient presents with symptoms of major depressive disorder. Which medication should be prescribed for treatment?
Which drug is not considered a mood stabilizer?
A patient on SSRI sertraline was also prescribed amitriptyline and subsequently developed serotonin toxicity. What is the likely treatment for serotonin toxicity?
Double depression is seen in:
What deficiency may contribute to relapse in a patient who has experienced remission with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs)?
A 30-year-old male was brought for evaluation, with a history of his 3-year-old son's death, 5 months prior, following a car accident. At the time of the accident, the patient was a witness. Since then, he has experienced symptoms of sadness, crying spells, feelings of hopelessness, poor sleep, and poor appetite. He has had suicidal thoughts on two occasions, but has not acted on them. He has not been attending work for the past 5 months. What is the likely diagnosis?
Pharmacotherapy of Mood Disorders Indian Medical PG Practice Questions and MCQs
Question 1: A 72 year old lady is severely depressed. For the past 2 days she has suicidal thoughts with an actual intent to die. Which of the following is best suitable to alleviate the symptoms?
- A. ECT (Correct Answer)
- B. Selegiline
- C. Haloperidol + Chlorpromazine
- D. Amitriptyline
Explanation: ***ECT (Electroconvulsive Therapy)*** - **ECT** is the most effective and rapid treatment for severe depression, especially when associated with active **suicidal ideation** and intent. - Its quick onset of action (often within days) makes it vital in situations requiring urgent symptom alleviation to ensure patient safety. - **First-line treatment** for geriatric depression with suicidal risk and when rapid response is needed. *Selegiline* - **Selegiline** is a monoamine oxidase inhibitor (MAOI) used for depression and Parkinson's disease, but its antidepressant effects are not immediate. - It would not sufficiently address the patient's acute suicidal intent due to its slower therapeutic onset (several weeks). *Haloperidol + Chlorpromazine* - This combination consists of **antipsychotics**, primarily used for conditions with psychotic features or severe agitation but not as a primary treatment for severe depression with suicidal ideation. - While they might provide some sedation, they do not treat the underlying depressive disorder effectively and rapidly enough to resolve acute suicidal intent. *Amitriptyline* - **Amitriptyline** is a tricyclic antidepressant (TCA) that can be effective for depression but has a delayed onset of action (2-4 weeks). - **Highly contraindicated in suicidal patients** due to its extreme lethality in overdose (cardiotoxic effects). - Its slow therapeutic effect would not be appropriate for an urgent situation involving active suicidal thoughts with intent.
Question 2: A 45-year-old patient with a history of depression was initially being treated with sertraline, but his symptoms were not adequately controlled. His medication regimen was changed to include an MAO inhibitor and amitriptyline. Shortly after the change in medication, the patient developed agitation, seizures, hyperreflexia, and tremor. Which of the following is the most appropriate treatment for this patient?
- A. Cyproheptadine (Correct Answer)
- B. Lorazepam
- C. L-carnitine
- D. Leucovorin
- E. Dantrolene
Explanation: ***Cyproheptadine*** - This patient exhibits symptoms of **serotonin syndrome** (agitation, seizures, hyperreflexia, tremor) due to the combination of an **MAO inhibitor** and **amitriptyline**. - **Cyproheptadine** is a **serotonin antagonist** and is the most appropriate treatment for reversing the effects of serotonin syndrome. - Treatment also includes discontinuing offending agents and supportive care. *Lorazepam* - **Lorazepam** is a **benzodiazepine** that can help manage agitation and seizures, but it does not address the underlying serotonin overstimulation. - It would be used as an adjunct for symptom control, not as the primary treatment for serotonin syndrome. *Dantrolene* - **Dantrolene** is a **muscle relaxant** used for **neuroleptic malignant syndrome (NMS)** and **malignant hyperthermia**. - While NMS and serotonin syndrome can have overlapping features (hyperthermia, rigidity), dantrolene is not indicated for serotonin syndrome. - Cyproheptadine is the specific serotonin antagonist needed for this condition. *L-carnitine* - **L-carnitine** is a supplement often used for conditions like **carnitine deficiency** or certain **metabolic disorders**. - It has no role in the treatment of serotonin syndrome. *Leucovorin* - **Leucovorin** (folinic acid) is used to **rescue bone marrow** from the toxic effects of **methotrexate** or to enhance the effects of **fluorouracil**. - It is not indicated for the treatment of serotonin syndrome.
Question 3: Electroconvulsive therapy is not useful in which of the following conditions?
- A. Panic attacks (Correct Answer)
- B. Depression
- C. Seizures
- D. Delirium
Explanation: ***Panic attacks*** - ECT has **no established role** in the treatment of panic disorder or panic attacks. - **First-line treatments** include SSRIs, benzodiazepines, and cognitive behavioral therapy (CBT). - ECT is not indicated for **anxiety-predominant disorders** and there is no evidence supporting its use in panic attacks. *Depression* - ECT is a **highly effective** treatment for **severe major depression**, particularly: - **Treatment-resistant depression** (failed multiple antidepressant trials) - **Psychotic depression** (depression with psychotic features) - **Severe melancholic or catatonic depression** - Depression with **high suicide risk** requiring rapid response - ECT is considered one of the most effective treatments in psychiatry for severe depression. *Seizures* - ECT **induces controlled therapeutic seizures** to achieve psychiatric benefits, but it is **not a treatment for epilepsy** or seizure disorders. - The therapeutic effect in psychiatric conditions is mediated through the induced seizure and its neurobiological effects. - ECT does **not treat or prevent epileptic seizures**; patients with epilepsy can safely receive ECT with appropriate precautions. *Delirium* - ECT can be used in **highly selected cases** of refractory delirium, particularly: - Delirium with **severe agitation** unresponsive to medical management - Delirium in the context of **catatonia** - While not a first-line treatment, ECT **has documented efficacy** in specific refractory cases of delirium when conventional treatments have failed.
Question 4: Which of the following is a tricyclic antidepressant?
- A. Fluoxetine
- B. Citalopram
- C. Doxepin (Correct Answer)
- D. Venlafaxine
Explanation: ***Doxepin*** - **Doxepin** is a **tricyclic antidepressant (TCA)** that inhibits the reuptake of **serotonin** and **norepinephrine**, and also has significant **histaminergic** and **cholinergic** blocking effects. - TCAs, including doxepin, are commonly used for treating **depression**, **anxiety**, and certain pain conditions. *Venlafaxine* - **Venlafaxine** is a **serotonin-norepinephrine reuptake inhibitor (SNRI)**, not a tricyclic antidepressant. - SNRIs selectively block the reuptake of both **serotonin** and **norepinephrine**, but lack the broad receptor affinity of TCAs. *Fluoxetine* - **Fluoxetine** is a **selective serotonin reuptake inhibitor (SSRI)**, which specifically targets serotonin reuptake. - SSRIs are generally considered a first-line treatment for depression due to a more favorable side effect profile compared to TCAs. *Citalopram* - **Citalopram** is also a **selective serotonin reuptake inhibitor (SSRI)**, much like fluoxetine. - It works by increasing the levels of **serotonin** in the brain by blocking its reuptake, differentiating it from tricyclic antidepressants.
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: Which drug is not considered a mood stabilizer?
- A. Lithium
- B. Lamotrigine
- C. Imipramine (Correct Answer)
- D. Carbamazepine
Explanation: ***Imipramine*** - Imipramine is a **tricyclic antidepressant (TCA)**, primarily used to treat depression, not to stabilize mood in bipolar disorder. - TCAs can sometimes induce **mania** or hypomania in individuals with bipolar disorder, thus they are generally not used as monotherapy for mood stabilization. *Lithium* - **Lithium** is considered the gold standard and one of the oldest and most effective **mood stabilizers** for bipolar disorder. - It works by modulating **neurotransmitter systems** and second messenger pathways in the brain. *Lamotrigine* - **Lamotrigine** is an **anticonvulsant** medication that is also recognized as an effective **mood stabilizer**, particularly for preventing depressive episodes in bipolar disorder. - Its mechanism involves stabilizing neuronal membranes by blocking **voltage-gated sodium channels**. *Carbamazepine* - **Carbamazepine** is an **anticonvulsant** medication often used as a **mood stabilizer** for the treatment of acute manic and mixed episodes in bipolar disorder. - It works by reducing the excitability of nerve impulses through blocking **voltage-sensitive sodium channels**.
Question 7: A patient on SSRI sertraline was also prescribed amitriptyline and subsequently developed serotonin toxicity. What is the likely treatment for serotonin toxicity?
- A. Flumazenil
- B. Cyproheptadine (Correct Answer)
- C. L-Carnitine
- D. Leucovorin
- E. Naloxone
Explanation: ***Cyproheptadine*** - **Cyproheptadine** is a serotonin antagonist that can help reverse the effects of excessive serotonin in the central nervous system. - It works by blocking **serotonin 5-HT2A receptors**, which are implicated in the pathophysiology of serotonin toxicity. *Flumazenil* - **Flumazenil** is a benzodiazepine receptor antagonist used to reverse the effects of benzodiazepine overdose. - It has no role in the treatment of **serotonin toxicity**, as it does not affect serotonin pathways. *L-Carnitine* - **L-Carnitine** is a mitochondrial co-factor used in fatty acid metabolism, sometimes supplemented for certain metabolic disorders or muscle pain. - It does not have any direct action on **serotonin receptors** or the serotonin system, making it ineffective for serotonin toxicity. *Leucovorin* - **Leucovorin** (folinic acid) is used to counteract the effects of methotrexate toxicity or to enhance the effects of fluorouracil in chemotherapy. - It is not involved in modulating **neurotransmitter levels** or reversing the symptoms of serotonin toxicity. *Naloxone* - **Naloxone** is an opioid receptor antagonist used to reverse opioid overdose. - It has no effect on **serotonin receptors** or serotonergic pathways, making it ineffective for treating serotonin toxicity.
Question 8: Double depression is seen in:
- A. Depression with dysthymia (Correct Answer)
- B. Depression with anxiety attack
- C. Major depression with OCD
- D. Major depressive disorder from 2 years
Explanation: ***Depression with dysthymia*** - **Double depression** is a specific mood disorder characterized by the co-occurrence of a **major depressive episode** on top of a pre-existing **dysthymic disorder** (persistent depressive disorder). - This means an individual experiences the chronic, milder symptoms of dysthymia, which are then worsened by the more severe symptoms of a major depressive episode. *Depression with anxiety attack* - While depression and anxiety attacks can co-occur, this specific combination is not referred to as **double depression**. - **Anxiety attacks** are acute episodes of intense fear and discomfort, often associated with panic disorder, and are distinct from chronic low-grade depressive symptoms. *Major depression with OCD* - **Obsessive-compulsive disorder (OCD)** is a distinct anxiety disorder characterized by obsessions and compulsions, which can co-occur with major depression. - However, the term **double depression** specifically refers to the combination of major depression and dysthymia, not other psychiatric comorbidities. *Major depressive disorder from 2 years* - Experiencing **major depressive disorder for 2 years** implies a chronic course of major depression. - If the symptoms meet the criteria for major depressive disorder continuously for at least two years, it might be termed **chronic major depressive disorder**, but not double depression, unless there was an underlying dysthymia.
Question 9: What deficiency may contribute to relapse in a patient who has experienced remission with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs)?
- A. Pyridoxine
- B. Cobalamin
- C. Ascorbate
- D. Folate (Correct Answer)
Explanation: ***Folate*** - **Folate (vitamin B9) deficiency** is strongly linked to depression and is a well-established cause of relapse in patients treated with antidepressants. - Folate plays a crucial role in the **one-carbon metabolism pathway**, which is essential for the synthesis of monoamine neurotransmitters including **serotonin, norepinephrine, and dopamine**. - Studies show that **low folate levels** are associated with poor response to SSRIs and TCAs, and folate supplementation can improve antidepressant efficacy. - Approximately **30% of depressed patients** have folate deficiency, making it a clinically significant factor in treatment resistance and relapse. *Cobalamin* - **Cobalamin (vitamin B12)** deficiency can cause neuropsychiatric symptoms including depression and cognitive impairment. - While B12 is important for myelin formation and neurotransmitter synthesis, it is less specifically implicated in antidepressant relapse compared to folate. - B12 deficiency more commonly presents with **cognitive and neurological symptoms** rather than pure mood symptoms. *Pyridoxine* - **Pyridoxine (vitamin B6)** is a cofactor in neurotransmitter synthesis, including serotonin and dopamine. - While B6 deficiency can contribute to mood disturbances, it is not commonly implicated as a primary cause of relapse in antidepressant-treated depression. *Ascorbate* - **Ascorbate (vitamin C)** is an antioxidant with some role in neurotransmitter metabolism. - Severe vitamin C deficiency (scurvy) can have psychiatric manifestations, but it is not typically associated with relapse in patients treated with SSRIs or TCAs.
Question 10: A 30-year-old male was brought for evaluation, with a history of his 3-year-old son's death, 5 months prior, following a car accident. At the time of the accident, the patient was a witness. Since then, he has experienced symptoms of sadness, crying spells, feelings of hopelessness, poor sleep, and poor appetite. He has had suicidal thoughts on two occasions, but has not acted on them. He has not been attending work for the past 5 months. What is the likely diagnosis?
- A. Post-traumatic stress disorder (PTSD)
- B. Normal grief reaction
- C. Adjustment disorder with depressed mood
- D. Major depressive disorder (Correct Answer)
Explanation: ***Major depressive disorder*** - The duration of symptoms (5 months) and severity, including **suicidal ideation** and significant occupational impairment, exceed what is typically expected for **normal grief** or **adjustment disorder**. - Symptoms like **sadness**, crying spells, feelings of hopelessness, **poor sleep**, and poor appetite are classic for **major depressive disorder**, especially when persistent and functionally debilitating. *Post-traumatic stress disorder (PTSD)* - While experiencing a traumatic event (witnessing his son's death) is a prerequisite for PTSD, the patient's primary symptoms are **depressive** rather than the characteristic re-experiencing, avoidance, negative alterations in cognitions and mood, or hyperarousal associated with PTSD. - There is no mention of **flashbacks**, nightmares, or significant **avoidance behaviors** directly linked to the trauma beyond general withdrawal. *Normal grief reaction* - While grief is expected after the death of a child, the severity (suicidal ideation) and significant functional impairment (not attending work for 5 months) suggest a reaction beyond **normal grief**. - **Normal grief** typically doesn't involve persistent, severe functional impairment or recurrent suicidal thoughts over such a prolonged period without additional significant depressive symptoms. *Adjustment disorder with depressed mood* - **Adjustment disorder** usually resolves within 6 months of the stressor or its consequences ceasing, and symptoms are generally less severe than those seen in major depression. - The presence of **suicidal ideation** and profound, persistent functional impairment for 5 months makes **major depressive disorder** a more fitting diagnosis.
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