Common Mental Disorders — MCQs
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A 44-year-old woman presents with low mood, anhedonia, and fatigue for 8 weeks. She describes mood that is consistently low throughout the day. Her sleep is poor with early morning wakening. She has passive suicidal thoughts but no intent or plans. Medical history includes hypothyroidism treated with levothyroxine. Recent thyroid function tests show TSH 12.3 mU/L (normal 0.4-4.0). What is the most appropriate initial management?
A 36-year-old man with panic disorder has been taking escitalopram 10mg daily for 8 weeks with partial response. He continues to experience 2-3 panic attacks weekly. His adherence is good and he has no significant side effects. What is the most appropriate next step in his pharmacological management?
Which of the following patient presentations would most clearly indicate a need for same-day specialist psychiatric assessment rather than routine primary care management of depression?
A 31-year-old woman presents to the emergency department with her fourth panic attack in 2 weeks. She describes sudden onset intense fear with palpitations, chest tightness, and fear of dying. Physical examination and ECG are normal. She is extremely distressed and requesting medication. What is the most appropriate immediate management?
A 48-year-old woman with severe depression and significant psychomotor retardation is commenced on phenelzine by a psychiatrist. After 3 weeks, she reports improvement but develops a severe throbbing headache, sweating, and neck stiffness after eating aged cheese. Her blood pressure is 190/110 mmHg. What is the underlying mechanism of this reaction?
A 34-year-old man presents with a 7-month history of constant excessive worry about work performance, finances, and his family's health. He reports muscle tension, irritability, difficulty concentrating, and fatigue. He avoids social situations where he might be judged. His GAD-7 score is 16. He has tried self-help materials without benefit. What is the most appropriate initial management step?
A 55-year-old woman with recurrent depression has been stable on sertraline 100mg daily for 18 months following her third depressive episode. She asks about stopping her antidepressant as she feels completely well. Her previous episodes occurred at ages 35 and 48, both requiring 6-month treatment courses. What is the most appropriate advice regarding continuation of antidepressant therapy?
A 29-year-old woman with panic disorder has been taking propranolol 40mg three times daily as needed for the past 4 weeks. She reports that while it helps reduce her palpitations during panic attacks, she continues to experience frequent attacks with intense fear, dizziness, and depersonalization. What is the most appropriate modification to her management?
A 42-year-old man with generalised anxiety disorder has been experiencing muscle tension, restlessness, and sleep disturbance for 8 months. He has tried two SSRIs (sertraline and escitalopram) at therapeutic doses for adequate durations without benefit. He declines further psychological therapy having completed CBT previously. What is the most appropriate next pharmacological management according to NICE guidelines?
A 38-year-old woman presents with a 6-week history of low mood, anhedonia, disturbed sleep, and poor concentration. She has lost 4kg in weight. On examination, she appears tearful and psychomotor retarded. She denies suicidal ideation. She has no past psychiatric history. Her PHQ-9 score is 18. Which classification best describes the severity of her depressive episode according to ICD-10 criteria?
Common Mental Disorders UK Medical PG Practice Questions and MCQs
Question 61: A 44-year-old woman presents with low mood, anhedonia, and fatigue for 8 weeks. She describes mood that is consistently low throughout the day. Her sleep is poor with early morning wakening. She has passive suicidal thoughts but no intent or plans. Medical history includes hypothyroidism treated with levothyroxine. Recent thyroid function tests show TSH 12.3 mU/L (normal 0.4-4.0). What is the most appropriate initial management?
- A. Commence sertraline 50mg daily and review in 2 weeks
- B. Adjust levothyroxine dose and reassess mood in 6-8 weeks (Correct Answer)
- C. Commence sertraline and refer for cognitive behavioural therapy
- D. Refer for urgent psychiatric assessment given suicidal thoughts
- E. Adjust levothyroxine dose and commence sertraline simultaneously
Explanation: ***Adjust levothyroxine dose and reassess mood in 6-8 weeks*** - The patient's **elevated TSH (12.3 mU/L)** indicates **suboptimally treated hypothyroidism**, a common cause of depressive symptoms, fatigue, and cognitive dysfunction. - Addressing the **underlying medical condition** by adjusting levothyroxine to achieve a **euthyroid state** is the priority before attributing symptoms solely to primary depression.*Commence sertraline 50mg daily and review in 2 weeks* - Initiating an **antidepressant (SSRI)** without first correcting the **thyroid dysfunction** is premature and may lead to unnecessary medication. - The depressive symptoms are likely secondary to **hypothyroidism** and may resolve once the thyroid hormone levels are optimized.*Commence sertraline and refer for cognitive behavioural therapy* - While **CBT** and antidepressants are effective for primary depression, they do not address the **organic cause** of depression in this case (hypothyroidism). - It is crucial to manage the **physical cause** first, as the mood symptoms might resolve without psychiatric intervention.*Refer for urgent psychiatric assessment given suicidal thoughts* - The patient has **passive suicidal thoughts** without intent or a plan, which, while serious, does not typically warrant an **urgent psychiatric assessment** over addressing a clear medical cause in primary care. - **Risk assessment** and appropriate safety planning should be done in primary care, but the immediate focus is on correcting the **metabolic imbalance**.*Adjust levothyroxine dose and commence sertraline simultaneously* - Administering both treatments concurrently complicates the assessment of which intervention is responsible for any improvement, or if one is causing side effects. - It's best practice to **sequentially address issues**, starting with the most identifiable medical cause, to avoid polypharmacy and potential adverse effects.
Question 62: A 36-year-old man with panic disorder has been taking escitalopram 10mg daily for 8 weeks with partial response. He continues to experience 2-3 panic attacks weekly. His adherence is good and he has no significant side effects. What is the most appropriate next step in his pharmacological management?
- A. Increase escitalopram to 20mg daily (Correct Answer)
- B. Add propranolol 40mg as needed for acute attacks
- C. Switch to venlafaxine 75mg daily
- D. Add pregabalin 150mg daily
- E. Continue current dose and review in 4 weeks
Explanation: ***Increase escitalopram to 20mg daily***- In **panic disorder**, if a patient shows a **partial response** after an adequate trial of 6–8 weeks, the first-line recommendation is to **increase the dose** to the maximum licensed level.- Escitalopram is often effective at higher doses for anxiety disorders than for depression, and **optimizing the current SSRI** should occur before switching medications.*Add propranolol 40mg as needed for acute attacks*- **Propranolol** is a beta-blocker primarily used for **performance anxiety** and physical symptoms but is not recommended for treating the core pathology of **panic disorder**.- It does not prevent panic attacks or lead to long-term remission of the underlying psychiatric condition.*Switch to venlafaxine 75mg daily*- **Venlafaxine** (an SNRI) is a valid treatment option, but switching is only indicated after a failed trial at the **maximum tolerated dose** of an SSRI.- Switching at this stage is premature since the patient is already tolerating the current **escitalopram** well and just needs a dose adjustment.*Add pregabalin 150mg daily*- **Pregabalin** is licensed and effective for **generalized anxiety disorder (GAD)** but is not a first-line or standard treatment for **panic disorder**.- Adding an adjunct should only be considered if the patient fails multiple monotherapy trials at **optimized dosages**.*Continue current dose and review in 4 weeks*- After **8 weeks** of treatment, the medication has reached a steady state, and further improvement on the same low dose is unlikely.- Delaying a dose increase Prolongs the patient's distress, as **clinical guidelines** suggest titration is necessary if symptoms persist beyond the initial 6–8 week window.
Question 63: Which of the following patient presentations would most clearly indicate a need for same-day specialist psychiatric assessment rather than routine primary care management of depression?
- A. A 52-year-old with severe depression who is not eating and has lost 8kg in 3 weeks (Correct Answer)
- B. A 38-year-old with depression and a history of three previous episodes
- C. A 61-year-old with depression and mild cognitive impairment
- D. A 28-year-old with postnatal depression 6 weeks after delivery with PHQ-9 score of 15
- E. A 45-year-old with moderate depression and PHQ-9 score of 17 who has failed two SSRIs
Explanation: ***A 52-year-old with severe depression who is not eating and has lost 8kg in 3 weeks***- Significant **biological symptoms** such as the inability to eat and rapid, substantial **weight loss** indicate a psychiatric emergency requiring immediate intervention.- This presentation suggests **melancholic depression** or potential **depressive stupor**, necessitating a same-day specialist assessment to evaluate the need for **urgent hospitalization** or intensive nutritional support.*A 38-year-old with depression and a history of three previous episodes*- While a history of **recurrent depression** increases the risk of future episodes, it does not inherently signal an immediate crisis in the absence of acute risk factors.- Recurrent episodes are typically managed in **primary care** through long-term **maintenance pharmacotherapy** or routine secondary care referral.*A 61-year-old with depression and mild cognitive impairment*- The presence of **mild cognitive impairment (MCI)** with depression requires thorough evaluation to differentiate between **pseudodementia** and neurodegenerative disease.- This assessment is usually conducted through **routine memory clinic** or geriatric psychiatry referrals rather than an emergency same-day assessment.*A 28-year-old with postnatal depression 6 weeks after delivery with PHQ-9 score of 15*- A **PHQ-9 score of 15** indicates moderately severe depression, which warrants close monitoring and treatment but not necessarily immediate specialist intervention unless **suicidal ideation** or **psychosis** is present.- Most cases of **postnatal depression** are managed effectively within **primary care** or community perinatal mental health teams on a non-emergency basis.*A 45-year-old with moderate depression and PHQ-9 score of 17 who has failed two SSRIs*- This patient meets the criteria for **treatment-resistant depression**, which justifies a referral for specialist advice on **augmentation strategies** or alternative classes of medications.- Although specialized input is needed, **failed trials of SSRIs** in a stable patient do not constitute a medical emergency requiring **same-day assessment**.
Question 64: A 31-year-old woman presents to the emergency department with her fourth panic attack in 2 weeks. She describes sudden onset intense fear with palpitations, chest tightness, and fear of dying. Physical examination and ECG are normal. She is extremely distressed and requesting medication. What is the most appropriate immediate management?
- A. Administer diazepam 5mg orally
- B. Provide reassurance and breathing techniques (Correct Answer)
- C. Commence sertraline 50mg and arrange GP follow-up
- D. Administer propranolol 40mg orally
- E. Arrange urgent psychiatric assessment
Explanation: ***Provide reassurance and breathing techniques***- For an **acute panic attack**, the most appropriate immediate management is providing **reassurance** and teaching **controlled breathing** or grounding techniques.- Panic attacks are typically **self-limiting** (resolving within 20-30 minutes); non-pharmacological support is prioritized as it empowers the patient to manage symptoms.*Administer diazepam 5mg orally*- **Benzodiazepines** are generally avoided in the acute setting of panic disorder because they carry a high risk of **dependence** and do not address the underlying cause.- Clinical guidelines, such as **NICE**, specifically recommend against the routine use of benzodiazepines for the management of panic disorder.*Commence sertraline 50mg and arrange GP follow-up*- While **SSRIs** like sertraline are first-line for the long-term management of **panic disorder**, they take weeks to become effective and are not for **immediate** symptom relief.- Initiating maintenance medication like an SSRI is more appropriate in a **primary care** setting after a comprehensive diagnostic review, rather than in the emergency department.*Administer propranolol 40mg orally*- **Propranolol** is a beta-blocker that may help with **peripheral autonomic symptoms** (like palpitations) but does not treat the core psychological distress of a panic attack.- It is not considered first-line for acute management and is less effective than behavioral interventions for stopping an active attack.*Arrange urgent psychiatric assessment*- An uncomplicated panic attack in a patient without **suicidal ideation**, psychosis, or immediate risk to others does not require an **urgent psychiatric assessment**.- Most patients can be safely discharged with advice to follow up with their **General Practitioner** for psychological or pharmacological therapy planning.
Question 65: A 48-year-old woman with severe depression and significant psychomotor retardation is commenced on phenelzine by a psychiatrist. After 3 weeks, she reports improvement but develops a severe throbbing headache, sweating, and neck stiffness after eating aged cheese. Her blood pressure is 190/110 mmHg. What is the underlying mechanism of this reaction?
- A. Accumulation of acetylcholine at muscarinic receptors
- B. Excessive serotonin activity at 5-HT1A receptors
- C. Accumulation of tyramine leading to noradrenaline release (Correct Answer)
- D. Direct stimulation of dopamine receptors in the chemoreceptor trigger zone
- E. Inhibition of GABA transmission in the central nervous system
Explanation: ***Accumulation of tyramine leading to noradrenaline release*** - Phenelzine is a **monoamine oxidase inhibitor (MAOI)**, preventing the breakdown of **tyramine**, a sympathomimetic amine found in **aged cheese** and other fermented foods. - The resulting systemic accumulation of **tyramine** displaces massive amounts of **noradrenaline** from presynaptic vesicles, leading to a life-threatening **hypertensive crisis** with symptoms like severe headache, sweating, and elevated blood pressure. *Accumulation of acetylcholine at muscarinic receptors* - This mechanism is typically associated with **cholinesterase inhibitors** or organophosphate poisoning, causing a **cholinergic crisis**. - Symptoms include salivation, lacrimation, miosis, and bradycardia, which are distinct from the presented sympathetic overdrive. *Excessive serotonin activity at 5-HT1A receptors* - This describes **serotonin syndrome**, often caused by combining MAOIs with other serotonergic drugs like **SSRIs**. - While it can involve hypertension, its hallmark features include **neuromuscular hyperactivity** (e.g., hyperreflexia, clonus, tremor), which are not the primary symptoms here. *Direct stimulation of dopamine receptors in the chemoreceptor trigger zone* - This mechanism is primarily associated with **dopamine agonists** or certain antiemetics, leading to nausea and vomiting. - It does not explain the profound **vasoconstriction** and hypertensive crisis triggered by a dietary interaction. *Inhibition of GABA transmission in the central nervous system* - Decreased **GABAergic** activity is linked to conditions like **seizures** and anxiety, or withdrawal syndromes from central depressants. - This mechanism is unrelated to the specific drug-food interaction involving **MAOIs** and dietary **tyramine** that causes a hypertensive reaction.
Question 66: A 34-year-old man presents with a 7-month history of constant excessive worry about work performance, finances, and his family's health. He reports muscle tension, irritability, difficulty concentrating, and fatigue. He avoids social situations where he might be judged. His GAD-7 score is 16. He has tried self-help materials without benefit. What is the most appropriate initial management step?
- A. Commence sertraline 50mg daily
- B. Refer for individual cognitive behavioural therapy
- C. Commence pregabalin 75mg twice daily
- D. Offer low-intensity psychological intervention (Correct Answer)
- E. Refer to community mental health team
Explanation: ***Offer low-intensity psychological intervention*** - According to **NICE guidelines**, for patients with **Generalised Anxiety Disorder (GAD)** whose symptoms significantly impair function or who have not improved with active monitoring and basic self-help, low-intensity psychological interventions are the next appropriate step (Step 2). - These interventions include **individual non-facilitated self-help**, **guided self-help**, or **psychoeducational groups**, aiming to provide practical strategies for managing worry and anxiety. *Commence sertraline 50mg daily* - **Pharmacological treatment**, such as an **SSRI** like **sertraline**, is generally considered a **Step 3** intervention for GAD, typically offered if low-intensity psychological interventions are ineffective or unacceptable. - While effective, medication is not the initial management step when low-intensity psychological interventions have not yet been formally offered or fully explored. *Refer for individual cognitive behavioural therapy* - **Individual cognitive behavioural therapy (CBT)** is a **high-intensity psychological intervention** (Step 3) for GAD, usually reserved for patients who have not responded to low-intensity interventions. - It is a more intensive and specialized treatment, not typically the very first step after unsuccessful self-help in a moderate case. *Commence pregabalin 75mg twice daily* - **Pregabalin** is an alternative pharmacological treatment for GAD but is generally recommended for patients who have not responded to or cannot tolerate **SSRIs** or **SNRIs**. - It is not considered a first-line pharmacological option and certainly not the initial management step before psychological interventions are exhausted. *Refer to community mental health team* - Referral to a **Community Mental Health Team (CMHT)** is typically reserved for more **severe, complex, or treatment-resistant mental health conditions**, or where there is significant risk. - While the patient has moderate-severe GAD, the initial management in a stepped-care model often falls within primary care or IAPT (Improving Access to Psychological Therapies) services before specialist secondary care referral.
Question 67: A 55-year-old woman with recurrent depression has been stable on sertraline 100mg daily for 18 months following her third depressive episode. She asks about stopping her antidepressant as she feels completely well. Her previous episodes occurred at ages 35 and 48, both requiring 6-month treatment courses. What is the most appropriate advice regarding continuation of antidepressant therapy?
- A. Continue sertraline for at least another 6 months then review
- B. Continue sertraline indefinitely given three episodes (Correct Answer)
- C. Gradually reduce sertraline over 4 weeks and monitor
- D. Switch to a lower maintenance dose of sertraline 50mg daily
- E. Continue sertraline for a total of 2 years from remission then stop
Explanation: ***Continue sertraline indefinitely given three episodes*** - Clinical guidelines recommend long-term or **indefinite maintenance therapy** for patients who have experienced **three or more depressive episodes** due to a very high risk of relapse (approx. 90%). - The patient is at a high risk for a fourth episode; therefore, continuing the treatment that successfully achieved stability is the most effective **relapse prevention strategy**. *Continue sertraline for at least another 6 months then review* - This approach is typically reserved for a **single episode** of depression, where treatment is continued for 6–9 months following **remission**. - Given the history of three episodes, a simple 6-month extension is insufficient to address the patient's long-term **recurrence risk**. *Gradually reduce sertraline over 4 weeks and monitor* - Discontinuing medication after multiple episodes significantly increases the likelihood of a **relapse** within a short period. - This strategy does not align with best practices for **recurrent Major Depressive Disorder**, which prioritize stability over cessation. *Switch to a lower maintenance dose of sertraline 50mg daily* - Guidelines specify that the **effective dose** used to achieve remission should be the same dose used for **maintenance therapy**. - Reducing the dose increases the risk of **sub-therapeutic levels**, which can lead to breakthrough symptoms and eventual relapse. *Continue sertraline for a total of 2 years from remission then stop* - While 2 years is often cited as a minimum for recurrent depression, the presence of **three discrete episodes** frequently warrants treatment beyond this fixed timeframe. - Stopping at exactly 2 years does not account for the patient's specific history and the high statistical probability of **future recurrence**.
Question 68: A 29-year-old woman with panic disorder has been taking propranolol 40mg three times daily as needed for the past 4 weeks. She reports that while it helps reduce her palpitations during panic attacks, she continues to experience frequent attacks with intense fear, dizziness, and depersonalization. What is the most appropriate modification to her management?
- A. Increase propranolol to 80mg three times daily
- B. Continue propranolol and add alprazolam for acute attacks
- C. Discontinue propranolol and commence an SSRI (Correct Answer)
- D. Continue propranolol and add venlafaxine
- E. Switch propranolol to atenolol for better beta-blockade
Explanation: ***Discontinue propranolol and commence an SSRI*** - **SSRIs** are the **first-line pharmacological treatment** for panic disorder as they effectively target the core psychological symptoms, such as intense fear, dizziness, and depersonalization, and reduce attack frequency. - While **beta-blockers** like propranolol can alleviate peripheral **somatic symptoms** (e.g., palpitations), they do not address the central fear, **dizziness**, or **depersonalization** central to panic attacks, indicating the need for a more comprehensive treatment. *Increase propranolol to 80mg three times daily* - Increasing the dose of a **beta-blocker** will only enhance its peripheral effects and will not treat the underlying **pathophysiology of panic disorder** or reduce the frequency of attacks. - Higher doses increase the risk of side effects such as **bradycardia**, **hypotension**, and **fatigue** without providing further benefit for the psychological aspects of panic. *Continue propranolol and add alprazolam for acute attacks* - While **benzodiazepines** (like alprazolam) can acutely reduce anxiety, they are generally avoided for long-term or regular use in panic disorder due to the significant risk of **dependence**, tolerance, and withdrawal. - This approach would only provide symptomatic relief without addressing the long-term management and prevention of attacks, which an **SSRI** would achieve. *Continue propranolol and add venlafaxine* - While **SNRIs** (like venlafaxine) are effective treatments for panic disorder, **SSRIs** are typically considered first-line due to a generally more favorable side effect profile and established efficacy. - Continuing propranolol is unnecessary as an effective **SSRI** or **SNRI** will manage both the somatic and psychological components, rendering the beta-blocker redundant. *Switch propranolol to atenolol for better beta-blockade* - Switching to a different **beta-blocker** (atenolol) will not address the core issue that beta-blockers primarily manage **peripheral symptoms** and do not effectively treat the central psychological symptoms of panic disorder. - Atenolol, like propranolol, is a beta-blocker and shares the same limitations in treating **panic disorder**, offering no significant advantage for the patient's core symptoms.
Question 69: A 42-year-old man with generalised anxiety disorder has been experiencing muscle tension, restlessness, and sleep disturbance for 8 months. He has tried two SSRIs (sertraline and escitalopram) at therapeutic doses for adequate durations without benefit. He declines further psychological therapy having completed CBT previously. What is the most appropriate next pharmacological management according to NICE guidelines?
- A. Switch to mirtazapine
- B. Switch to pregabalin
- C. Add buspirone to current SSRI
- D. Switch to duloxetine (Correct Answer)
- E. Add low-dose quetiapine to current SSRI
Explanation: ***Switch to duloxetine*** - According to **NICE guidelines** for the management of **Generalized Anxiety Disorder (GAD)**, if two SSRIs have been ineffective, an alternative SSRI or an **SNRI** such as **venlafaxine** or **duloxetine** should be offered. - The patient's failure on two SSRIs (sertraline and escitalopram) at therapeutic doses makes switching to an **SNRI** the most appropriate next pharmacological step. *Switch to mirtazapine* - **Mirtazapine** is generally not recommended as a first-line or sequential treatment for **GAD** according to established guidelines like NICE. - It is more commonly used for **major depressive disorder**, especially when associated with insomnia due to its sedating properties, not typically for GAD after SSRI failure. *Switch to pregabalin* - While **pregabalin** is an effective treatment for GAD, NICE guidelines typically recommend it after trials of **SSRIs** and **SNRIs** have been unsuccessful. - Due to concerns regarding **dependence** and **potential for abuse**, it is usually reserved for later stages of treatment, or when other options are contraindicated or not tolerated. *Add buspirone to current SSRI* - **Buspirone** is primarily considered as a monotherapy for GAD or as an alternative in specific circumstances, not typically as an **augmentation agent** in primary care after SSRI failure. - Its efficacy as an add-on therapy is less established compared to switching to an SNRI in the current scenario. *Add low-dose quetiapine to current SSRI* - Augmentation with **atypical antipsychotics** like **quetiapine** is not recommended by NICE for the routine management of GAD due to potential for significant side effects. - Such strategies are usually considered only in **specialist mental health settings** for severe, treatment-resistant cases, given risks like **weight gain** and **metabolic syndrome**.
Question 70: A 38-year-old woman presents with a 6-week history of low mood, anhedonia, disturbed sleep, and poor concentration. She has lost 4kg in weight. On examination, she appears tearful and psychomotor retarded. She denies suicidal ideation. She has no past psychiatric history. Her PHQ-9 score is 18. Which classification best describes the severity of her depressive episode according to ICD-10 criteria?
- A. Moderate depressive episode (Correct Answer)
- B. Severe depressive episode with psychotic symptoms
- C. Recurrent depressive disorder, current episode moderate
- D. Mild depressive episode
- E. Severe depressive episode without psychotic symptoms
Explanation: ***Moderate depressive episode*** - A **moderate depressive episode** is diagnosed when at least two of the three **core symptoms** (depressed mood, anhedonia, loss of energy) are present, along with at least 3-4 other symptoms, leading to significant distress or functional impairment. - The patient exhibits two core symptoms (**low mood**, **anhedonia**) and several other symptoms including **disturbed sleep**, **poor concentration**, **weight loss**, and **psychomotor retardation**, totaling more than 5 symptoms, consistent with a moderate episode and a PHQ-9 score of 18. *Severe depressive episode with psychotic symptoms* - This classification requires the presence of **hallucinations** or **delusions**, which are explicitly absent in this patient's presentation. - While the patient has significant symptoms, the **absence of psychotic features** means this specific diagnosis is inappropriate. *Recurrent depressive disorder, current episode moderate* - This diagnosis applies only when there is a history of at least two prior depressive episodes, with periods of complete or partial recovery in between. - The case clearly states the patient has **no past psychiatric history**, indicating this is her first depressive episode, ruling out a recurrent disorder. *Mild depressive episode* - A **mild depressive episode** typically involves two core symptoms and only two additional symptoms, with the patient generally able to continue most daily activities with some effort. - The presence of **psychomotor retardation**, significant **weight loss**, and a PHQ-9 score of 18 (indicating significant severity) exceeds the criteria for a mild episode. *Severe depressive episode without psychotic symptoms* - A **severe depressive episode** usually involves all three core symptoms and a total of at least eight symptoms, leading to extreme distress and near-total inability to function socially or occupationally, often with **suicidal ideation**. - Although the patient has significant symptoms, the absence of suicidal ideation, and the overall symptom count align more closely with the **moderate** category, as not all three core symptoms (loss of energy is not explicitly mentioned as a primary complaint distinct from psychomotor retardation) and 8 symptoms are clearly met for severe.
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