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PS5.1-2,PS6.1 | Mood Disorders — Graded Quiz
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A 38-year-old businessman presents with a 3-week history of depressed mood, anhedonia, early-morning awakening, poor concentration, and feelings of hopelessness. He denies suicidal ideation. He has hypertension managed with amlodipine. Which antidepressant is the MOST appropriate first-line choice?
Correct. Escitalopram (SSRI) is first-line. It is well tolerated, safe in overdose, and has minimal cardiovascular interactions.
SSRIs are first-line for MDD in primary care. TCAs and MAOIs are reserved for specialist-supervised treatment-resistant cases.
Incorrect. SSRIs are universally first-line. TCAs (imipramine) are cardiotoxic; MAOIs (tranylcypromine) require dietary restriction; benzodiazepines are not antidepressants.
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A 42-year-old woman with major depressive disorder achieves full remission on sertraline after 8 weeks of treatment. She asks if she can stop the medication as she 'feels completely normal.' What is the MOST appropriate advice?
Correct. At least 6–12 months of continuation therapy after full remission is recommended to prevent relapse of a first depressive episode. Abrupt discontinuation causes discontinuation syndrome.
Continue antidepressants for at least 6–12 months after remission (first episode). Always taper — never stop abruptly. Longer maintenance for recurrent depression.
Incorrect. Stopping antidepressants immediately upon remission is the most common cause of relapse. Continuation therapy for 6–12 months is mandatory.
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A 55-year-old retired teacher presents with a 5-week history of depression. She mentions she is not eating and has lost 6 kg, feels that her bowels have 'stopped working' (nihilistic delusion), and believes she deserves punishment for imagined sins. She has no suicidal plan. What is the MOST appropriate next step?
Correct. Nihilistic delusions (e.g., believing organs have stopped functioning) and guilt delusions are features of psychotic depression. This requires specialist care — antipsychotics combined with antidepressants — and is beyond primary-care scope.
Psychotic depression (delusions of nihilism, guilt, poverty; auditory hallucinations) is a red flag for immediate psychiatric referral. It requires antipsychotics + antidepressants, often inpatient.
Incorrect. Nihilistic and guilt-laden delusions in the context of severe depression indicate psychotic depression, which is a specialist-level diagnosis and management challenge.
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A 30-year-old woman on sertraline 100 mg/day for depression is also started on tramadol by a colleague for back pain. She presents 2 days later with agitation, diaphoresis, myoclonus, and hyperreflexia. What is the MOST likely diagnosis?
Correct. Tramadol inhibits serotonin reuptake and combined with an SSRI causes serotonin syndrome — the classic triad of neuromuscular abnormalities (myoclonus, hyperreflexia), autonomic instability (diaphoresis, tachycardia), and altered mental status (agitation). Onset is rapid (hours to days) after drug addition or dose increase.
Serotonin syndrome: rapid onset, myoclonus/hyperreflexia/clonus, autonomic instability, agitation — triggered by any serotonergic drug combination (SSRI + tramadol, linezolid, fentanyl, triptans). NMS: slower onset, lead-pipe rigidity, fever, antipsychotic exposure, elevated CK.
Incorrect. The rapid onset after adding tramadol (a serotonergic agent) to sertraline, with myoclonus and hyperreflexia, is the hallmark of serotonin syndrome. NMS is associated with antipsychotics and has lead-pipe rigidity, not myoclonus.
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A 26-year-old student is brought by her family after 8 days of elevated mood, talking continuously, not sleeping but feeling energised, spending all her savings online, and believing she has invented a solution to climate change. On examination she is distractible, irritable when interrupted, and has pressured speech. What is the MOST appropriate primary-care action?
Correct. This is a full manic episode (8 days, severe impairment, grandiosity, decreased sleep, pressured speech, disinhibited spending). Primary-care role: immediate psychiatric referral, and if behavioural control is needed, an atypical antipsychotic (risperidone, olanzapine) may be used pending transfer.
Acute mania: primary care stabilises (antipsychotic if needed for safety) and refers urgently. Lithium is initiated by specialists after investigations. Antidepressants are absolutely contraindicated.
Incorrect. Lithium initiation requires specialist supervision. Antidepressants are contraindicated in mania. A 2-week wait is unsafe for a patient with full manic episode and significant functional impairment.
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A 35-year-old man with bipolar disorder is maintained on lithium. His general practitioner orders routine monitoring. Which combination of investigations is MOST important to monitor during long-term lithium therapy?
Correct. Lithium is excreted entirely by the kidneys (monitor creatinine/eGFR for nephrotoxicity) and causes hypothyroidism in up to 40% of long-term users (monitor TSH). Serum lithium level must be measured at 12 hours post-dose every 3–6 months and whenever toxicity is suspected.
Lithium monitoring: serum level (12h post-dose; target 0.6–1.2 mEq/L), serum creatinine/eGFR (nephrotoxicity), and TSH (lithium-induced hypothyroidism). Also calcium (hypercalcaemia) and ECG (T-wave changes) in selected patients.
Incorrect. The key lithium monitoring parameters are renal function (creatinine/eGFR) and thyroid function (TSH), in addition to serum levels. Liver function is not affected by lithium.
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A 32-year-old man is started on fluoxetine 20 mg/day for a first depressive episode. He returns at 6 weeks with partial improvement — his mood is better but he still has significant anhedonia and poor concentration. What is the MOST appropriate next step?
Correct. Partial response at 6 weeks on the starting dose is an indication to optimise (increase) the dose before declaring failure. Fluoxetine can be increased from 20 mg to 40 mg. Augmentation strategies (lithium, atypical antipsychotics) and medication switches are appropriate only after an adequate dose trial has also failed.
Treatment algorithm: (1) Adequate dose SSRI for 4–6 weeks → partial response → optimise dose → reassess. (2) Failure of optimised dose → switch within SSRIs or refer. (3) Failure of two SSRI trials → refer to specialist for augmentation.
Incorrect. Partial response at 6 weeks warrants dose optimisation — not an immediate switch to a different class. Augmentation is a specialist strategy. MAOIs are never first or second line in primary care.
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Which of the following patients with depression managed at a primary health centre MOST urgently requires psychiatric referral?
Correct. A patient with a history of manic episodes has bipolar disorder. Prescribing antidepressants without mood stabilisers in bipolar depression can trigger a manic switch or rapid cycling — a potentially dangerous error. This patient requires urgent psychiatric assessment before any antidepressant is initiated.
Antidepressant monotherapy in bipolar disorder is contraindicated without concurrent mood stabiliser. Any patient with a history of manic or hypomanic episodes presenting with depression must be referred to psychiatry before antidepressant initiation.
Incorrect. Past manic episodes indicate bipolar disorder. Antidepressant monotherapy in bipolar depression can precipitate mania or rapid cycling. This is a red flag requiring urgent specialist involvement before prescribing.
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A patient with a manic episode is started on haloperidol by the primary-care physician while awaiting psychiatric transfer. 6 hours later, she develops sustained muscle spasm of the neck with head twisted to one side, and her eyes deviated upward. She is distressed but conscious. What is the MOST likely diagnosis and immediate treatment?
Correct. Acute dystonic reaction (torticollis, oculogyric crisis) is a common early side effect of typical antipsychotics (especially haloperidol), occurring within hours to days of initiation. Treatment: anticholinergic agents (benztropine, procyclidine, or antihistamine promethazine) given IM/IV, with rapid resolution.
Haloperidol side effects by timeline: acute dystonia (hours–days; treat with anticholinergics), akathisia (days–weeks; reduce dose/propranolol), parkinsonism (weeks–months; benztropine), tardive dyskinesia (months–years; switch antipsychotic). NMS is idiosyncratic, any time, with fever and rigidity.
Incorrect. Acute dystonia (torticollis, oculogyric crisis) within hours of haloperidol initiation is the classic acute drug reaction. NMS occurs over days and includes fever, rigidity, and autonomic instability. Tardive dyskinesia occurs after months of exposure.
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A 48-year-old woman has a 4-week history of low mood, anhedonia, and insomnia following the death of her husband 6 weeks ago. She reports crying episodes, misses him intensely, but can still feel joy at times (e.g., when her grandchildren visit). She has no suicidal ideation and is functioning with family support. Which is the MOST appropriate initial approach?
Correct. This presentation has features of normal grief (preserved capacity for joy, functional with support, recent bereavement). DSM-5 no longer excludes bereavement from MDD diagnosis, but clinical judgment requires distinguishing grief from a full depressive episode. The appropriate initial approach is psychoeducation, grief counselling, and watchful waiting before pharmacotherapy.
Distinguish normal grief (preserved joy, time-limited, grief-focused distress, functional) from MDD superimposed on bereavement (persistent anhedonia, vegetative symptoms, suicidality, functional impairment). In grief, watchful waiting with counselling is first-line. Pharmacotherapy is reserved for those who develop a full depressive episode.
Incorrect. While DSM-5 removed the bereavement exclusion, this patient has preserved joy, functioning, and support — suggesting normal grief rather than MDD requiring immediate pharmacotherapy. Watchful waiting with counselling is appropriate.
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