Common Mental Disorders — MCQs
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A 39-year-old man presents with a 5-month history of persistent worry about his health, finances, and family safety. He reports feeling 'on edge' constantly, has difficulty concentrating at work, and experiences muscle tension in his shoulders. He has no previous psychiatric history. What is the minimum duration of symptoms required for a diagnosis of generalised anxiety disorder according to ICD-11 criteria?
A 62-year-old woman with moderate depressive disorder is being assessed for suitability for antidepressant therapy. She has a history of epilepsy controlled on carbamazepine. Which antidepressant should be avoided due to the increased risk of drug interaction lowering the seizure threshold?
Which of the following neurotransmitter systems is primarily targeted by selective serotonin reuptake inhibitors (SSRIs) in the treatment of depression?
A 36-year-old woman presents with a 6-month history of excessive worry about various aspects of her life, difficulty sleeping, and muscle tension. She also describes experiencing 4-5 distinct episodes in the past month where she suddenly felt intense fear with palpitations, dizziness, and fear of dying, lasting about 15 minutes each. These episodes occur unpredictably. What is the most accurate diagnosis?
A 55-year-old woman with depression started on venlafaxine 6 weeks ago presents for review. She reports significant improvement in mood but has developed persistently elevated blood pressure (readings 155/95, 158/98, 152/96 mmHg on separate occasions). She has no previous history of hypertension. Her BMI is 26 and cardiovascular examination is otherwise normal. What is the most appropriate management?
A 41-year-old man with generalised anxiety disorder has not responded adequately to CBT and is commenced on sertraline 50mg daily. After 6 weeks at 100mg daily, his symptoms have improved but he still has significant residual anxiety (GAD-7 score 12). What is the most appropriate next step in pharmacological management?
A 47-year-old woman with recurrent depressive disorder has been well-maintained on fluoxetine 20mg daily for 18 months following her most recent depressive episode. She has had three previous moderate-severe episodes over the past 10 years. She feels completely recovered and wishes to discontinue her antidepressant. What is the most appropriate advice regarding continuation of treatment?
A 29-year-old man presents with panic attacks occurring 2-3 times per week for the past 2 months. Between attacks, he experiences persistent anticipatory anxiety and has begun avoiding public transport. He is keen to avoid medication if possible. During a panic attack in the consultation, he hyperventilates and reports tingling in his fingers and around his mouth. What is the pathophysiological mechanism underlying his paraesthesia?
A 34-year-old woman presents with low mood, fatigue, and reduced interest in activities for 5 weeks. She reports feeling guilty about being unable to cope with work demands. She has passive suicidal thoughts but no plans or intent. Her past medical history includes bipolar disorder diagnosed 3 years ago, currently stable on lithium. What is the most appropriate immediate management?
A 42-year-old woman with generalised anxiety disorder has completed an 8-week course of low-intensity psychological intervention without significant improvement. Her GAD-7 score remains 15. She has no history of depression. According to the stepped care model, what is the most appropriate next step in management?
Common Mental Disorders UK Medical PG Practice Questions and MCQs
Question 151: A 39-year-old man presents with a 5-month history of persistent worry about his health, finances, and family safety. He reports feeling 'on edge' constantly, has difficulty concentrating at work, and experiences muscle tension in his shoulders. He has no previous psychiatric history. What is the minimum duration of symptoms required for a diagnosis of generalised anxiety disorder according to ICD-11 criteria?
- A. 2 weeks
- B. 1 month
- C. 3 months (Correct Answer)
- D. 6 months
- E. 12 months
Explanation: ***3 months***- According to **ICD-11 criteria**, the diagnosis of **Generalized Anxiety Disorder (GAD)** requires the presence of symptoms for at least **several months**, specifically a minimum of **3 months**.- This timeframe ensures that the persistent and chronic nature of excessive worry, characteristic of GAD, is captured for accurate diagnosis. *2 weeks*- A **2-week duration** is typically associated with the diagnostic criteria for conditions such as a **major depressive episode** or an **acute stress reaction**, not generalized anxiety disorder.- This timeframe is too short to fulfill the requirement for the pervasive and chronic pattern of worry characteristic of **GAD**. *1 month*- **One month** is a common duration requirement for other anxiety-related disorders, such as **Panic Disorder** or **Post-Traumatic Stress Disorder (PTSD)**.- However, for **Generalized Anxiety Disorder** under **ICD-11**, this duration is insufficient to establish the chronic and pervasive nature of the anxiety symptoms. *6 months*- A **6-month duration** is the diagnostic requirement for **Generalized Anxiety Disorder (GAD)** according to the **DSM-5 criteria**, which differs from the **ICD-11** standard.- It is a common distractor for those who may confuse the criteria between the two major diagnostic manuals. *12 months*- A **12-month duration** is not a standard diagnostic criterion for **Generalized Anxiety Disorder** or most other anxiety disorders in either **ICD-11** or **DSM-5**.- This timeframe is excessively long and would unnecessarily delay necessary diagnosis and intervention for patients experiencing chronic anxiety.
Question 152: A 62-year-old woman with moderate depressive disorder is being assessed for suitability for antidepressant therapy. She has a history of epilepsy controlled on carbamazepine. Which antidepressant should be avoided due to the increased risk of drug interaction lowering the seizure threshold?
- A. Sertraline
- B. Mirtazapine
- C. Bupropion (Correct Answer)
- D. Citalopram
- E. Venlafaxine
Explanation: ***Bupropion***- **Bupropion** is strictly contraindicated in patients with a history of **epilepsy** because it is known to significantly **lower the seizure threshold** in a dose-dependent manner.- In patients taking **carbamazepine**, there is a complex interaction where carbamazepine induces the metabolism of bupropion, but the clinical focus remains the high inherent **seizure risk** associated with bupropion therapy.*Sertraline*- **Sertraline** is an SSRI and is generally considered to have a **low risk** of inducing seizures, making it a safer option for patients with controlled epilepsy.- While most SSRIs can technically affect the threshold, they do not carry the significant **pro-convulsant** warnings associated with bupropion.*Mirtazapine*- **Mirtazapine** has a relatively **low potential** for lowering the seizure threshold compared to older tricyclic antidepressants or bupropion.- It is often considered a viable alternative in patients where SSRIs are not tolerated, provided the **epilepsy** is stable.*Citalopram*- **Citalopram** is an SSRI that is frequently used in patients with epilepsy due to its **favorable safety profile** regarding seizure induction.- Like other SSRIs, it is preferred over bupropion as it does not carry a **dose-related seizure risk** of 0.4% or higher.*Venlafaxine*- **Venlafaxine** is an SNRI that carries a slight risk of seizures, but this risk is markedly **lower than bupropion** at therapeutic doses.- It is generally avoided only in cases of **uncontrolled epilepsy** or severe overdose scenarios, unlike bupropion which is avoided even in controlled cases.
Question 153: Which of the following neurotransmitter systems is primarily targeted by selective serotonin reuptake inhibitors (SSRIs) in the treatment of depression?
- A. Dopaminergic transmission in the mesolimbic pathway
- B. Noradrenergic transmission in the locus coeruleus
- C. Serotonergic transmission via inhibition of SERT (Correct Answer)
- D. GABAergic transmission in the amygdala
- E. Glutamatergic transmission via NMDA receptors
Explanation: ***Serotonergic transmission via inhibition of SERT*** - **SSRIs** (Selective Serotonin Reuptake Inhibitors) primarily block the **serotonin transporter (SERT)**, preventing the reuptake of serotonin from the synaptic cleft. - This action increases the concentration of **serotonin** in the synapse, enhancing serotonergic neurotransmission to alleviate depressive symptoms. *Dopaminergic transmission in the mesolimbic pathway* - This pathway is primarily associated with **reward, motivation**, and pleasure, and is a key target for antipsychotics or stimulants, not SSRIs. - While some indirect effects on dopamine may occur, SSRIs do not directly inhibit **dopamine reuptake** or act on dopamine receptors. *Noradrenergic transmission in the locus coeruleus* - This system is mainly involved in **arousal, attention**, and the stress response, and is the primary target for **SNRIs** (Serotonin-Norepinephrine Reuptake Inhibitors). - SSRIs have negligible affinity for the **norepinephrine transporter** and therefore do not directly affect noradrenergic transmission. *GABAergic transmission in the amygdala* - The **amygdala** plays a critical role in fear and anxiety, and **GABAergic transmission** is the primary inhibitory system. - This system is typically targeted by **benzodiazepines** to enhance inhibitory effects, not directly by SSRIs. *Glutamatergic transmission via NMDA receptors* - **Glutamate** is the main excitatory neurotransmitter, and **NMDA receptors** are targeted by novel, rapid-acting antidepressants like **ketamine**. - SSRIs do not primarily modulate glutamatergic transmission or directly act on **NMDA receptors** as their therapeutic mechanism.
Question 154: A 36-year-old woman presents with a 6-month history of excessive worry about various aspects of her life, difficulty sleeping, and muscle tension. She also describes experiencing 4-5 distinct episodes in the past month where she suddenly felt intense fear with palpitations, dizziness, and fear of dying, lasting about 15 minutes each. These episodes occur unpredictably. What is the most accurate diagnosis?
- A. Generalised anxiety disorder
- B. Panic disorder
- C. Generalised anxiety disorder with panic attacks (Correct Answer)
- D. Mixed anxiety and depressive disorder
- E. Panic disorder with generalised anxiety
Explanation: ***Generalised anxiety disorder with panic attacks***- The patient presents with a 6-month history of **excessive worry** about various aspects of life, difficulty sleeping, and muscle tension, which are diagnostic criteria for **Generalised Anxiety Disorder (GAD)**.- Additionally, she describes 4-5 distinct episodes of intense fear with palpitations, dizziness, and fear of dying, occurring unpredictably and lasting about 15 minutes, which are characteristic of **panic attacks** superimposed on GAD.*Generalised anxiety disorder*- While the patient clearly demonstrates symptoms of **GAD**, including chronic worry and muscle tension, this diagnosis alone is insufficient as it fails to account for the discrete, **sudden panic attacks** she experiences.- A diagnosis of GAD would not fully capture the clinical picture, specifically the recurrent, intense episodes of **acute fear and somatic symptoms**.*Panic disorder*- **Panic disorder** requires recurrent, unexpected panic attacks and at least one month of persistent concern about having additional attacks or their consequences, or significant maladaptive change in behavior related to the attacks.- However, the patient's primary and more pervasive issue is the **chronic, excessive worry** about various aspects of her life, indicating GAD as the underlying and more dominant condition, with panic attacks as a comorbid feature rather than the sole diagnosis.*Mixed anxiety and depressive disorder*- This diagnosis is typically used when symptoms of both **anxiety and depression** are present but neither is sufficiently prominent or severe to meet the criteria for a specific anxiety or depressive disorder.- The patient's presentation clearly meets the full diagnostic criteria for **GAD and panic attacks**, and there is no mention of significant depressive symptoms such as **anhedonia** or persistent low mood.*Panic disorder with generalised anxiety*- The distinction between
Question 155: A 55-year-old woman with depression started on venlafaxine 6 weeks ago presents for review. She reports significant improvement in mood but has developed persistently elevated blood pressure (readings 155/95, 158/98, 152/96 mmHg on separate occasions). She has no previous history of hypertension. Her BMI is 26 and cardiovascular examination is otherwise normal. What is the most appropriate management?
- A. Continue venlafaxine and commence amlodipine 5mg daily
- B. Continue venlafaxine and commence ramipril 2.5mg daily
- C. Reduce venlafaxine dose by half
- D. Switch to sertraline 100mg daily (Correct Answer)
- E. Continue venlafaxine and monitor blood pressure weekly
Explanation: ***Switch to sertraline 100mg daily***- **Venlafaxine**, a **Serotonin-Norepinephrine Reuptake Inhibitor (SNRI)**, is known to cause **dose-dependent hypertension** due to its norepinephrinergic effects.- The most appropriate management for **iatrogenic hypertension** due to a medication is to discontinue or switch the offending agent to one that is **blood pressure neutral**, such as an **SSRI** like sertraline, especially when mood is stable.*Continue venlafaxine and commence amlodipine 5mg daily*- Adding an **antihypertensive** like amlodipine introduces unnecessary **polypharmacy** and potential drug interactions without addressing the root cause.- This approach treats the symptom rather than removing the **iatrogenic cause** of the patient's elevated blood pressure.*Continue venlafaxine and commence ramipril 2.5mg daily*- Initiating an ACE inhibitor like **ramipril** is not the first-line action when hypertension is a direct, **reversible side effect** of another medication.- Clinical guidelines prioritize **removing the causative factor** (venlafaxine) over adding another drug to manage a preventable adverse effect.*Reduce venlafaxine dose by half*- While venlafaxine-induced hypertension is dose-related, reducing the dose might **compromise the antidepressant efficacy**, leading to a potential **relapse of depression**.- A more definitive solution that maintains antidepressant effect while resolving hypertension is to switch to a **blood pressure-neutral alternative**.*Continue venlafaxine and monitor blood pressure weekly*- Persistently elevated blood pressure readings (e.g., 155/95 mmHg) require active clinical intervention to prevent **long-term cardiovascular damage**, not just monitoring.- Continuing the **pressor agent** (venlafaxine) without addressing the hypertension directly is not compliant with safe medication management.
Question 156: A 41-year-old man with generalised anxiety disorder has not responded adequately to CBT and is commenced on sertraline 50mg daily. After 6 weeks at 100mg daily, his symptoms have improved but he still has significant residual anxiety (GAD-7 score 12). What is the most appropriate next step in pharmacological management?
- A. Increase sertraline to 150mg daily
- B. Switch to pregabalin 150mg twice daily
- C. Add pregabalin 75mg twice daily to sertraline
- D. Switch to duloxetine 60mg daily (Correct Answer)
- E. Continue current dose for a further 6 weeks
Explanation: ***Switch to duloxetine 60mg daily*** - According to **NICE guidelines** for Generalised Anxiety Disorder (GAD), if an initial **SSRI** (like sertraline) is only partially effective after an adequate trial, the next step is often to switch to an alternative SSRI or an **SNRI** such as **duloxetine** or venlafaxine. - A **GAD-7 score of 12** after 6 weeks at 100mg indicates significant residual anxiety, justifying a change in medication strategy to achieve better symptom control. *Increase sertraline to 150mg daily* - While sertraline can be increased up to 200mg, evidence suggests that for **GAD**, doses much beyond **100mg** may not consistently provide significant additional benefit and can increase the risk of **side effects**. - Clinical guidelines generally prioritize **switching antidepressant classes** over high-dose escalation when a moderate dose fails to achieve sufficient remission in anxiety disorders. *Switch to pregabalin 150mg twice daily* - **Pregabalin** is typically considered a **third-line option** for patients who have not responded adequately to or cannot tolerate trials of both **SSRIs and SNRIs**. - It is generally not recommended to move directly to pregabalin until a trial of a second-line antidepressant (like an **SNRI**) has been attempted. *Add pregabalin 75mg twice daily to sertraline* - **Augmentation therapy** with pregabalin is not a standard first-line or second-line strategy in the management pathways for GAD. - Managing GAD via **monotherapy** (switching agents) is preferred to minimize **polypharmacy** and potential **drug-drug interactions** when a patient is not yet considered treatment-resistant. *Continue current dose for a further 6 weeks* - A **6-week trial** at a therapeutic dose (100mg sertraline) is typically considered an adequate duration to assess the clinical efficacy of an antidepressant in GAD. - Continuing the same treatment despite **moderate residual symptoms** (**GAD-7 score 12**) delays necessary clinical improvement and increases the risk of chronic GAD.
Question 157: A 47-year-old woman with recurrent depressive disorder has been well-maintained on fluoxetine 20mg daily for 18 months following her most recent depressive episode. She has had three previous moderate-severe episodes over the past 10 years. She feels completely recovered and wishes to discontinue her antidepressant. What is the most appropriate advice regarding continuation of treatment?
- A. Discontinue immediately as she has been well for sufficient time
- B. Continue for at least another 6 months then gradually discontinue
- C. Continue for at least another 4 years before considering discontinuation (Correct Answer)
- D. Continue indefinitely given her history of recurrent episodes
- E. Switch to a lower dose for 6 months before discontinuing
Explanation: ***Continue for at least another 4 years before considering discontinuation*** - For patients with **recurrent depression** (three or more episodes), clinical guidelines suggest maintaining antidepressant treatment for at least **5 years** to significantly reduce the risk of relapse. - Since the patient has only completed **18 months** of maintenance therapy, stopping now would leave her at high risk, given her history of moderate-to-severe episodes. *Discontinue immediately as she has been well for sufficient time* - **Abrupt discontinuation** of antidepressants can lead to **discontinuation syndrome** and carries the highest risk for immediate relapse of depressive symptoms. - 18 months is not considered "sufficient time" for a patient with multiple **recurrent episodes** to achieve long-term stability without medication. *Continue for at least another 6 months then gradually discontinue* - This would result in a total of 2 years of treatment; while standard for a second episode, it is generally considered inadequate for someone with **four lifetime episodes**. - NICE and other psychiatric guidelines advocate for longer periods of **prophylaxis** when the frequency and severity of past episodes are high. *Continue indefinitely given her history of recurrent episodes* - While **long-term maintenance** might eventually be necessary, it is usually discussed as a shared decision after failing several attempts to taper or if episodes are life-threatening. - Initial medical advice should focus on the evidence-based **5-year milestone** rather than committing a patient to indefinite use immediately upon their first request to stop. *Switch to a lower dose for 6 months before discontinuing* - Antidepressants should be maintained at the **full therapeutic dose** that achieved remission; reducing the dose increases the risk of **sub-therapeutic levels** and relapse. - **Dose reduction** is not a recommended strategy for maintenance therapy in recurrent depression unless prompted by side effects.
Question 158: A 29-year-old man presents with panic attacks occurring 2-3 times per week for the past 2 months. Between attacks, he experiences persistent anticipatory anxiety and has begun avoiding public transport. He is keen to avoid medication if possible. During a panic attack in the consultation, he hyperventilates and reports tingling in his fingers and around his mouth. What is the pathophysiological mechanism underlying his paraesthesia?
- A. Hypoxia secondary to inadequate ventilation
- B. Respiratory alkalosis causing decreased ionized calcium (Correct Answer)
- C. Sympathetic nervous system activation causing peripheral vasoconstriction
- D. Hypoglycemia triggered by adrenaline release
- E. Lactic acidosis from increased muscle tension
Explanation: ***Respiratory alkalosis causing decreased ionized calcium*** - Hyperventilation causes excessive **carbon dioxide (CO2) washout**, leading to an increase in blood pH (alkalosis). - This alkalotic state promotes the binding of **calcium ions to albumin**, thereby reducing the concentration of **ionized calcium**, which increases nerve excitability and causes **paraesthesia**. *Hypoxia secondary to inadequate ventilation* - During a panic attack, patients are actually over-ventilating, meaning their **arterial oxygen (PaO2)** levels are typically normal or even elevated. - **Hypoxia** involves a lack of oxygen, whereas the symptoms here are driven by the removal of CO2. *Sympathetic nervous system activation causing peripheral vasoconstriction* - While **sympathetic activation** (the "fight or flight" response) causes tachycardia and sweating, it is not the primary mechanism for **perioral tingling**. - Vasoconstriction may cause cold extremities, but the specific **neuromuscular irritability** of paraesthesia is classically biochemical (calcium-related). *Hypoglycemia triggered by adrenaline release* - **Adrenaline** (epinephrine) actually stimulates **glycogenolysis** in the liver, which tends to increase rather than decrease blood glucose levels. - While hypoglycemia can cause shakiness and anxiety, it is not a physiological consequence of the **hyperventilation** seen in panic disorder. *Lactic acidosis from increased muscle tension* - Panic attacks involve **respiratory alkalosis** due to CO2 loss, which is the functional opposite of **acidosis**. - **Lactic acidosis** would lower the blood pH, which would actually increase the fraction of ionized calcium and prevent the symptoms described.
Question 159: A 34-year-old woman presents with low mood, fatigue, and reduced interest in activities for 5 weeks. She reports feeling guilty about being unable to cope with work demands. She has passive suicidal thoughts but no plans or intent. Her past medical history includes bipolar disorder diagnosed 3 years ago, currently stable on lithium. What is the most appropriate immediate management?
- A. Add sertraline 50mg daily to current lithium
- B. Stop lithium and commence lamotrigine
- C. Check lithium level and refer urgently to psychiatry (Correct Answer)
- D. Increase lithium dose after checking level
- E. Add quetiapine to current lithium
Explanation: ***Check lithium level and refer urgently to psychiatry***- In a patient with **bipolar disorder** presenting with a depressive episode, it is vital to first verify the **therapeutic lithium level** to ensure compliance and rule out sub-therapeutic levels as a cause for relapse.- Managing **bipolar depression** is complex due to the risk of triggering **mania** or **rapid cycling**, requiring **specialist psychiatric input**, particularly when **passive suicidal ideation** is present.*Add sertraline 50mg daily to current lithium*- Using an **SSRI** as monotherapy or even with a mood stabilizer in bipolar disorder carries a high risk of **switching to mania** or hypomania.- Antidepressants should generally only be initiated for bipolar depression under **specialist supervision** and are not first-line choices.*Stop lithium and commence lamotrigine*- Stopping **lithium** abruptly can lead to clinical destabilization and significant risk of **relapse or rebound mania**.- While **lamotrigine** is effective for preventing depressive relapses, it is not the immediate priority over assessing current lithium levels and obtaining a specialist referral.*Increase lithium dose after checking level*- Determining the **lithium level** is the correct first step, but increasing the dose without specialist guidance may lead to **lithium toxicity** if the level is already therapeutic.- Adjusting lithium during an acute depressive episode does not address the complexity of the patient's current **suicidal ideation** and depressive state.*Add quetiapine to current lithium*- **Quetiapine** is an evidence-based treatment for bipolar depression, but it should be initiated in the context of a **specialist management plan** rather than in primary care.- The immediate priority remains safety assessment and ensuring the **lithium level** is within range before adding further pharmacological agents.
Question 160: A 42-year-old woman with generalised anxiety disorder has completed an 8-week course of low-intensity psychological intervention without significant improvement. Her GAD-7 score remains 15. She has no history of depression. According to the stepped care model, what is the most appropriate next step in management?
- A. Commence sertraline 50mg daily
- B. Refer for high-intensity psychological intervention (CBT or applied relaxation) (Correct Answer)
- C. Commence pregabalin 150mg daily
- D. Refer to specialist mental health services
- E. Commence diazepam 5mg twice daily for 4 weeks
Explanation: ***Refer for high-intensity psychological intervention (CBT or applied relaxation)***- According to the **NICE stepped care model**, after an inadequate response to **Step 2 (low-intensity psychological interventions)**, the next recommended step is **Step 3**.- **Step 3** offers either **high-intensity psychological interventions** (like CBT or applied relaxation) or pharmacological treatment, with patient preference often guiding the choice.*Commence sertraline 50mg daily*- While **SSRIs like sertraline** are a valid pharmacological option in Step 3, the stepped care model generally prioritizes high-intensity psychological interventions if low-intensity ones have failed, especially without a strong patient preference for medication.- Pharmacological treatment is an alternative or can be combined with high-intensity psychological interventions at this stage, but often psychological therapy is tried first if available and accepted.*Commence pregabalin 150mg daily*- **Pregabalin** is typically considered a second-line pharmacological option for GAD, recommended if **SSRIs/SNRIs** are not tolerated or ineffective.- It is not the initial pharmacological choice after failure of low-intensity psychological intervention in the stepped care model.*Refer to specialist mental health services*- Referring to specialist mental health services (often **Step 4**) is usually reserved for more **complex or severe cases**, those with significant risk, or those who have not responded to Step 3 interventions.- This patient's presentation, while persistent, indicates a need for intensified Step 3 treatment within primary care or IAPT services, not immediate specialist referral.*Commence diazepam 5mg twice daily for 4 weeks*- **Benzodiazepines** are not recommended for the long-term management of GAD due to risks of **dependence, tolerance, and withdrawal symptoms**.- Their use should be limited to very **short-term (e.g., 2-4 weeks)** management of acute, severe anxiety, and is not appropriate for ongoing treatment after failure of low-intensity interventions.
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