PS5.1-2,PS6.1 | Mood Disorders — Practice Quiz

Correct. SSRIs such as sertraline are the first-line pharmacological treatment for major depressive disorder in primary care — they have a favourable side-effect profile, are safe in overdose, and require no cardiac monitoring. Starting dose is 50 mg/day, with reassessment at 2–4 weeks.

SSRIs are universally first-line for major depressive disorder in primary care. TCAs and MAOIs are reserved for specialist-supervised, treatment-resistant cases.

Incorrect. TCAs (amitriptyline) and MAOIs (phenelzine) are not first-line due to toxicity and drug-interaction risks. Benzodiazepines are not antidepressants and carry dependence risk.

Correct. SSRIs have a delayed onset of antidepressant effect of 2–4 weeks. Non-adherence due to premature discontinuation is the most common cause of apparent SSRI failure. Psychoeducation about this delay is essential at initiation.

Patients must be counselled that antidepressant effect takes 2–4 weeks. Initial side effects (nausea, insomnia) may appear early and often resolve. Premature discontinuation is the single most common cause of apparent treatment failure.

Incorrect. It is far too early to declare SSRI failure — adequate trials last at least 4–6 weeks at an adequate dose. Switching prematurely or escalating the dose without evidence of partial response is inappropriate.

Correct. Suicidal ideation — even passive ('better if I were not around') — in a patient who is socially isolated (lives alone), under acute psychosocial stress (crop failure), and on an antidepressant (early treatment weeks are higher risk) constitutes a red flag requiring urgent psychiatric referral and safety planning. Under MHCA 2017, the clinician has a duty of care.

Red flags for urgent psychiatric referral include: any suicidal ideation (passive or active), social isolation, acute psychosocial stressors, psychotic features, and failure to respond to two adequate antidepressant trials.

Incorrect. Passive suicidal ideation in a socially isolated patient under acute stress is a red flag, not a routine finding. It requires urgent action, not watchful waiting or pharmacological adjustment alone.

Correct. Psychotic features (command auditory hallucinations) in depression constitute psychotic depression — a psychiatric emergency requiring inpatient management with antipsychotics alongside antidepressants. This is well beyond primary-care scope.

Absolute referral triggers: psychotic features, active suicidal ideation with plan/intent, severe agitation with self-harm risk, suspected bipolar depression (antidepressants alone can trigger mania), and failure of two adequate antidepressant trials.

Incorrect. Psychotic depression (auditory hallucinations, especially command hallucinations) is an absolute indication for emergency psychiatric referral — it cannot be safely managed in primary care.

Correct. Guidelines recommend continuing the antidepressant for at least 6–12 months after full remission of a first episode to prevent early relapse. Longer maintenance (2–3 years or indefinitely) is recommended for recurrent depression (≥3 episodes) or severe presentations.

Continuation therapy for 6–12 months post-remission is mandatory for first-episode MDD. For recurrent depression, maintenance therapy for several years is appropriate. Always taper — never stop abruptly.

Incorrect. Stopping antidepressants immediately upon feeling well (or after only 2–4 weeks) is the leading cause of relapse. Current guidelines mandate at least 6–12 months of continuation therapy after first-episode remission.

Correct. The presentation — grandiosity, decreased need for sleep, pressured speech, impulsive spending, religious delusions — describes a manic episode with psychotic features. DSM-5 and ICD-11 require ≥7 days (or less if severity demands hospitalisation). This patient has been symptomatic for 10 days and requires inpatient management.

Manic episode: ≥7 days of abnormally elevated/irritable mood + increased energy, causing marked impairment or requiring hospitalisation, possibly with psychotic features. Hypomanic episode: ≥4 days, no severe impairment, no psychosis. The distinction drives management (hospitalisaton vs outpatient monitoring).

Incorrect. The severity of impairment (spending savings, grandiose delusions, hospitalisation required) places this firmly in a manic episode, not a hypomanic episode. Hypomania is ≥4 days without severe impairment or psychotic features.

Correct. In acute mania with agitation and aggression, immediate safety takes priority. Haloperidol (oral or IM) provides rapid tranquillisation at the primary-care level. Lithium is not appropriate for acute primary-care initiation (requires monitoring, slow onset). Urgent psychiatric referral — potentially under MHCA 2017 involuntary provisions — is mandatory.

Primary-care management of acute mania: ensure safety, use antipsychotics (haloperidol, olanzapine) for rapid tranquillisation if needed, and arrange urgent psychiatric referral. Antidepressants are CONTRAINDICATED in mania (can worsen or precipitate cycling). Lithium is a specialist-initiated drug.

Incorrect. An acutely agitated manic patient with aggression requires immediate sedation/tranquillisation and urgent specialist referral. Lithium initiation at primary care, antidepressants, and a 2-week wait are all dangerous errors.

Correct. The therapeutic range for lithium is 0.6–1.2 mEq/L (some sources allow up to 1.0 for maintenance). Levels above 1.5 mEq/L with symptoms (coarse tremor, vomiting, confusion) indicate toxicity. Management: withhold lithium, ensure adequate hydration (IV saline), monitor renal function, and arrange urgent transfer. Dialysis may be needed at very high levels.

Lithium therapeutic range: 0.6–1.2 mEq/L. Toxicity: >1.5 mEq/L. Features of toxicity: coarse tremor (fine tremor is side effect), GI symptoms, ataxia, confusion, seizures. Note: fine tremor at therapeutic levels is a common side effect, not toxicity. Regular monitoring of renal function and thyroid is mandatory as lithium is nephrotoxic and can cause hypothyroidism.

Incorrect. Lithium toxicity begins at levels >1.5 mEq/L, and symptomatic toxicity (coarse tremor, vomiting, confusion) at 1.8 mEq/L is a medical emergency requiring immediate action.

Correct. The MHCA 2017 introduced Advance Directives (Section 5) allowing persons with mental illness to document treatment preferences and nominate a personal representative. These must be respected unless they endanger the person or others. The Act also establishes Mental Health Review Boards for oversight of involuntary admission and enshrines rights to confidentiality, dignified treatment, and legal aid.

MHCA 2017 key provisions: (1) presumption of capacity; (2) Advance Directives; (3) nominated personal representatives; (4) Mental Health Review Boards; (5) right to community living; (6) decriminalisation of suicide attempt. Clinicians must document the basis for any involuntary admission.

Incorrect. The MHCA 2017 explicitly recognises the legal capacity of persons with mental illness and their right to Advance Directives. It applies to all mental health establishments, not just government hospitals. Emergency involuntary treatment is permissible without a court order when there is imminent risk.