Treatment Algorithms and Guidelines — 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?
According to DSM-IV criteria, the minimum duration of symptoms required for diagnosing major depressive disorder is:
A young patient with schizophrenia is resistant to treatment with conventional antipsychotic medications. Which drug is most preferred?
What is the treatment of choice for acute panic attacks?
Which of the following treatments cannot be used for management of Obsessive Compulsive Disorder (OCD)?
First agent shown to be effective in manic phase of Bipolar Disorder -
Provision of the Mental Health Act 2017, based on WHO guidelines, includes all, except:
In obsessive-compulsive disorder, which medication is NOT used for treatment?
A patient was diagnosed to have single skin lesion of Leprosy without any AFB positive bacteria from the scrapings. What should be the treatment of this patient according to latest guidelines?
The patient with leprosy had slightly erythematous, anesthetic plaques on the trunk and upper limbs. He was treated with paucibacillary multidrug therapy (PB-MDT) for 6 months. At the end of 6 months, he had persistent erythema and induration in the plaque. According to the World Health Organization (WHO) guidelines, what is the next recommended step of action for this patient?
Treatment Algorithms and Guidelines 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: According to DSM-IV criteria, the minimum duration of symptoms required for diagnosing major depressive disorder is:
- A. 1 week
- B. 2 weeks (Correct Answer)
- C. 3 weeks
- D. 4 weeks
Explanation: ***2 weeks*** - The **DSM-IV (and DSM-5)** criteria for **major depressive disorder** require that a person experience a **depressed mood** or **loss of interest or pleasure (anhedonia)**, along with at least four additional symptoms (e.g., changes in appetite or sleep, fatigue, feelings of worthlessness or guilt, difficulty concentrating, suicidal ideation) for a continuous period of at least **two weeks**. - This **duration criterion** helps differentiate a major depressive episode from transient sad moods or normal grief reactions. *1 week* - A duration of **1 week** is a criterion for some mood disorders, such as a **manic episode** in bipolar disorder, but it is too short for a diagnosis of major depressive disorder. - Brief periods of sadness or low mood lasting only a week would typically not meet the diagnostic threshold for a full major depressive episode. *3 weeks* - While 3 weeks of symptoms would certainly meet the **minimum duration** for major depressive disorder, it is not the *minimum required* time set forth by the DSM criteria. - Waiting for 3 weeks of symptoms might delay diagnosis and treatment if the criteria are already met at 2 weeks. *4 weeks* - Similar to 3 weeks, a 4-week duration of symptoms is longer than the **minimum required** for diagnosing major depressive disorder according to DSM criteria. - This duration would be more appropriate for chronic mood disturbances like **persistent depressive disorder (dysthymia)**, which requires at least two years of symptoms, or to observe the response to treatment.
Question 3: A young patient with schizophrenia is resistant to treatment with conventional antipsychotic medications. Which drug is most preferred?
- A. Haloperidol
- B. Olanzapine
- C. Clozapine (Correct Answer)
- D. Risperidone
Explanation: ***Clozapine*** - **Clozapine** is the drug of choice for **treatment-resistant schizophrenia** or patients who are **intolerant to conventional antipsychotics**. - Its unique efficacy often comes with a risk of **agranulocytosis**, requiring regular **blood monitoring**. *Olanzapine* - While an effective **atypical antipsychotic**, it is not specifically indicated for **treatment-resistant cases** in the same way as clozapine. - It carries a risk of significant **metabolic side effects**, such as weight gain and dyslipidemia. *Haloperidol* - This is a **first-generation (conventional) antipsychotic** and would be unsuitable for a patient described as **intolerant to conventional antipsychotics**. - It is associated with a high incidence of **extrapyramidal symptoms (EPS)** and **tardive dyskinesia**. *Risperidone* - As an **atypical antipsychotic**, it is a good first-line option but is not typically reserved for **treatment-resistant schizophrenia** or those with conventional antipsychotic intolerance. - It has a higher propensity for **hyperprolactinemia** compared to other atypical antipsychotics.
Question 4: What is the treatment of choice for acute panic attacks?
- A. Tricyclic antidepressants (TCAs)
- B. Monoamine oxidase inhibitors (MAOIs)
- C. Barbiturates
- D. Benzodiazepines (Correct Answer)
Explanation: ***Correct: Benzodiazepines*** - Benzodiazepines are the **treatment of choice for acute panic attacks** due to their **rapid onset of action** (within minutes) - They work by enhancing **GABA-A receptor** activity, providing immediate anxiolytic effects - Commonly used agents include **alprazolam, lorazepam, and clonazepam** - While effective acutely, they are not recommended for long-term management due to dependence risk *Incorrect: Tricyclic antidepressants (TCAs)* - TCAs are effective for **long-term prophylaxis** of panic disorder, not acute attacks - They have a **delayed onset of action** (2-4 weeks), making them unsuitable for immediate relief - Significant **anticholinergic effects** and potential cardiotoxicity limit their use *Incorrect: Monoamine oxidase inhibitors (MAOIs)* - MAOIs can be effective for panic disorder but are reserved for **treatment-resistant cases** - **Delayed onset of action** (several weeks) makes them inappropriate for acute attacks - Require **dietary restrictions** and have risk of hypertensive crisis with tyramine-containing foods *Incorrect: Barbiturates* - Largely **obsolete** in psychiatric practice, replaced by safer benzodiazepines - **Narrow therapeutic index** with high risk of overdose and respiratory depression - Greater potential for dependence and withdrawal complications - No role in modern management of panic attacks
Question 5: Which of the following treatments cannot be used for management of Obsessive Compulsive Disorder (OCD)?
- A. Fluoxetine
- B. Carbamazepine (Correct Answer)
- C. Cognitive Behaviour Therapy
- D. Clomipramine
Explanation: ***Carbamazepine*** - **Carbamazepine** is an **anticonvulsant** and **mood stabilizer** primarily used for epilepsy and bipolar disorder. - It does not have established efficacy for the treatment of **Obsessive-Compulsive Disorder (OCD)**. *Fluoxetine* - **Fluoxetine** is a **Selective Serotonin Reuptake Inhibitor (SSRI)** and is a **first-line pharmacotherapy** for OCD. - SSRIs, including fluoxetine, are effective in reducing the severity of **obsessions and compulsions**. *Cognitive Behaviour Therapy* - **Cognitive Behavioural Therapy (CBT)**, specifically **Exposure and Response Prevention (ERP)**, is the **gold standard psychotherapy** for OCD. - It involves gradually exposing patients to feared situations or thoughts while preventing their ritualistic responses. *Clomipramine* - **Clomipramine** is a **tricyclic antidepressant (TCA)** that has potent inhibitory effects on **serotonin reuptake**. - It is one of the **most effective medications** for OCD, often used when SSRIs are insufficient.
Question 6: First agent shown to be effective in manic phase of Bipolar Disorder -
- A. Valproate
- B. Lithium (Correct Answer)
- C. Lamotrigine
- D. Carbamazepine
Explanation: ***Lithium*** - **Lithium** was the first mood stabilizer specifically demonstrating efficacy in treating the **manic phase of bipolar disorder**, revolutionizing its management. - Its discovery in the 1940s and subsequent clinical trials established it as the **gold standard** for acute mania and maintenance therapy. *Valproate* - While effective in treating **acute mania** and bipolar depression, **valproate** was introduced later than lithium as a mood stabilizer. - It works by **enhancing GABAergic transmission** and modulating voltage-sensitive sodium channels. *Lamotrigine* - Primarily indicated for the treatment of **bipolar depression** and as a maintenance therapy to prevent depressive episodes. - It has **limited efficacy** in treating acute manic episodes. *Carbamazepine* - An **anticonvulsant** that also possesses mood-stabilizing properties, effective in some cases of acute mania and rapid cycling. - Its use in bipolar disorder followed the introduction of lithium, and it is considered a **second-line treatment**.
Question 7: Provision of the Mental Health Act 2017, based on WHO guidelines, includes all, except:
- A. Social support
- B. Screening family members (Correct Answer)
- C. Human rights
- D. Communication regarding care and treatment
Explanation: ***Screening family members*** - The Mental Health Act 2017 focuses on the **rights, treatment, and support of individuals with mental illness**, not routine screening of their family members. - The Act does not contain provisions mandating **screening of asymptomatic family members**, though family history may be relevant for clinical assessment. - This is **not a provision** outlined in the Act based on WHO guidelines. *Human rights* - The Act is explicitly grounded in the **protection and promotion of human rights** for persons with mental illness (Chapter I). - Ensures care with **dignity, respect, and freedom from discrimination** as core principles. - Aligns with WHO's mental health action plan and human rights framework. *Communication regarding care and treatment* - **Section 4** emphasizes the right to information and **informed consent** for all treatment decisions. - Patients must receive clear communication about their **diagnosis, treatment options, and care plans**. - Includes provisions for **advance directives** and involvement in treatment decisions. *Social support* - **Chapter V** addresses rehabilitation and community-based services, emphasizing the role of **social support systems**. - Promotes **community integration** and access to social resources for recovery. - Recognizes family and community support as essential for long-term mental health management.
Question 8: In obsessive-compulsive disorder, which medication is NOT used for treatment?
- A. Sertraline
- B. Clomipramine
- C. Carbamazepine (Correct Answer)
- D. Haloperidol
Explanation: ***Carbamazepine*** - **Carbamazepine** is an **anticonvulsant** and **mood stabilizer** primarily used for **epilepsy** and **bipolar disorder**. - It does not have a primary role in the treatment of **obsessive-compulsive disorder (OCD)**. *Sertraline* - **Sertraline** is a **selective serotonin reuptake inhibitor (SSRI)** approved for **OCD** treatment. - SSRIs are considered **first-line pharmacological agents** for OCD due to their efficacy in reducing obsessive thoughts and compulsive behaviors. *Clomipramine* - **Clomipramine** is a **tricyclic antidepressant (TCA)** that is a potent **serotonin reuptake inhibitor**. - It is one of the **most effective medications for OCD** and has been historically used as a first-line treatment. *Haloperidol* - **Haloperidol**, an **antipsychotic**, can be used as an **augmentation strategy** for OCD that is **resistant to SSRI treatment**. - It may be particularly helpful in OCD presentations with **comorbid tic disorders** or significant behavioral disinhibition.
Question 9: A patient was diagnosed to have single skin lesion of Leprosy without any AFB positive bacteria from the scrapings. What should be the treatment of this patient according to latest guidelines?
- A. (Rifampicin + Dapsone) for 12 months
- B. (Rifampicin + Dapsone + Clofazamine) for 6 months
- C. (Rifampicin + Dapsone + Clofazamine) for 12 months
- D. (Rifampicin + Dapsone) for 6 months (Correct Answer)
Explanation: ***(Rifampicin + Dapsone) for 6 months*** - This regimen is the standard **Multi-Drug Therapy (MDT)** for **paucibacillary (PB) leprosy**, which is characterized by a **single skin lesion** and **negative acid-fast bacilli (AFB)** on scrapings. - The 6-month duration is effective in eradicating the infection with high cure rates and low relapse rates. * (Rifampicin + Dapsone) for 12 months* - This 12-month regimen is unnecessarily prolonged for paucibacillary leprosy, increasing the risk of side effects and reducing patient adherence without additional clinical benefit compared to the 6-month regimen. - While Rifampicin and Dapsone are correct drugs for PB leprosy, the duration is not aligned with current WHO guidelines for this specific presentation. * (Rifampicin + Dapsone + Clofazamine) for 6 months* - The addition of **Clofazamine** makes this the regimen for **multibacillary (MB) leprosy**, which presents with multiple skin lesions or positive AFB smears. - This patient's presentation of a **single lesion** and **negative AFB** clearly indicates paucibacillary leprosy, for which Clofazamine is not typically included. * (Rifampicin + Dapsone + Clofazamine) for 12 months* - This is the standard regimen for **multibacillary (MB) leprosy**, due to the presence of Clofazamine and the 12-month duration. - It is not appropriate for a patient with a **single, AFB-negative lesion**, as this presentation denotes paucibacillary leprosy requiring a shorter, two-drug treatment.
Question 10: The patient with leprosy had slightly erythematous, anesthetic plaques on the trunk and upper limbs. He was treated with paucibacillary multidrug therapy (PB-MDT) for 6 months. At the end of 6 months, he had persistent erythema and induration in the plaque. According to the World Health Organization (WHO) guidelines, what is the next recommended step of action for this patient?
- A. Stop antileprosy treatment (Correct Answer)
- B. Continue PB-MDT till erythema subsides
- C. Biopsy the lesion to document activity
- D. Continue dapsone alone for another 6 months
Explanation: ***Stop antileprosy treatment*** - According to **WHO guidelines**, paucibacillary multidrug therapy (PB-MDT) has a **fixed duration of 6 months**, after which treatment should be **stopped regardless of clinical appearance** of the lesions. - The persistent erythema and induration after completing 6 months of PB-MDT represent a **Type 1 lepra reaction (reversal reaction)**, which is an **immunological phenomenon**, not active disease requiring continued antimicrobial therapy. - **Type 1 reactions** should be managed with **corticosteroids (prednisolone 40-60 mg/day)**, not by prolonging MDT, as reactions are inflammatory rather than infectious in nature. - Continuing MDT beyond the recommended duration does **not prevent or treat lepra reactions** and unnecessarily exposes the patient to **drug toxicity and side effects**. *Continue PB-MDT till erythema subsides* - This is **not recommended by WHO guidelines**, which specify a **fixed duration** for PB-MDT (6 months) that should not be extended based on residual erythema or induration. - Persistent inflammation after completing treatment represents a **lepra reaction**, which is managed with **corticosteroids**, not continued MDT. - Extending MDT beyond 6 months for PB cases has no proven benefit and increases risk of **adverse drug reactions** without improving outcomes. *Biopsy the lesion to document activity* - While biopsy could provide histological information, the clinical scenario clearly describes a **Type 1 lepra reaction** occurring at the end of treatment. - The **diagnosis of Type 1 reaction is clinical**, based on erythema, induration, and tenderness in existing lesions after or during treatment. - Biopsy would only delay appropriate management with **corticosteroids** and is not necessary when clinical features are typical. *Continue dapsone alone for another 6 months* - **Monotherapy with dapsone** is absolutely contraindicated in leprosy management due to high risk of **drug resistance**. - After completing the fixed 6-month PB-MDT regimen, **no further antimicrobial therapy is indicated** for paucibacillary leprosy. - The persistent inflammation requires management of the **lepra reaction with corticosteroids**, not continued antimicrobial therapy.
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