A 48-year-old woman with bipolar I disorder has been stable on lithium for 6 years, with levels of 0.6-0.8 mEq/L. Two weeks ago a physician started hydrochlorothiazide for hypertension. She now has vomiting, diarrhoea, coarse tremor, slurred speech and an unsteady gait. Serum lithium 2.1 mEq/L, creatinine 1.0 mg/dL. What is the mechanism of her toxicity?

More lithium reabsorbed in the proximal tubule

Displacement of lithium from plasma proteins

Increased absorption of lithium from the small intestine

Slower hepatic metabolism of lithium

A 34-year-old woman on sodium valproate for bipolar disorder had lamotrigine added for recurrent depressive episodes; a relative advised her to take 100 mg a day from the start. Two weeks later she has fever, painful target lesions on the trunk, oral and conjunctival erosions and skin detachment over 6% of her body. What is the most likely reason for this reaction?

Valproate inhibits lamotrigine glucuronidation

Lamotrigine induces valproate metabolism

Valproate displaces lamotrigine from albumin

Lamotrigine inhibits valproate renal excretion

A 36-year-old woman with bipolar I disorder has been on lithium (level 0.8 mEq/L) for 3 years without a manic relapse. For 4 weeks she has had low mood, poor sleep, low energy and passive death wishes but no plan, and her thyroid tests are normal. What is the most appropriate change in treatment?

Stop lithium and start lamotrigine

Stop lithium and start sertraline

A 24-year-old postgraduate student was started on escitalopram 10 mg daily for a depressive episode. Three weeks later she sleeps 3 hours a night without feeling tired, talks rapidly, has spent her savings on online shopping and says she will soon head a global company. The symptoms have continued for 10 days. What is the next best step?

Stop escitalopram and start a mood stabiliser

Switch escitalopram to bupropion

Increase escitalopram to 20 mg daily

Continue escitalopram and add clonazepam

Depression, bipolar disorder and suicide risk

22 NEET-PG practice questions on Depression, bipolar disorder and suicide risk, part of Psychiatry. The first 22 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard
A 48-year-old woman with bipolar I disorder has been stable on lithium for 6 years, with levels of 0.6-0.8 mEq/L. Two weeks ago a physician started hydrochlorothiazide for hypertension. She now has vomiting, diarrhoea, coarse tremor, slurred speech and an unsteady gait. Serum lithium 2.1 mEq/L, creatinine 1.0 mg/dL. What is the mechanism of her toxicity?
1. ADisplacement of lithium from plasma proteins
2. BIncreased absorption of lithium from the small intestine
3. CMore lithium reabsorbed in the proximal tubule
4. DSlower hepatic metabolism of lithium
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Answer: C · More lithium reabsorbed in the proximal tubule
Her features are lithium toxicity. Thiazides cause sodium loss, and the kidney responds by reabsorbing more sodium in the proximal tubule; lithium is handled like sodium there, so lithium clearance falls and the level rises. NSAIDs and ACE inhibitors raise lithium levels in a similar way, and dehydration from vomiting worsens it. Lithium is stopped, fluids are given, and haemodialysis is considered for severe neurological toxicity or poor renal function.
- A: Lithium does not bind plasma proteins.
- B: Lithium is almost completely absorbed already; thiazides do not change this.
- D: Lithium is not metabolised by the liver; it is excreted unchanged by the kidney.
Question 2 · Medium
A 34-year-old woman on sodium valproate for bipolar disorder had lamotrigine added for recurrent depressive episodes; a relative advised her to take 100 mg a day from the start. Two weeks later she has fever, painful target lesions on the trunk, oral and conjunctival erosions and skin detachment over 6% of her body. What is the most likely reason for this reaction?
1. AValproate inhibits lamotrigine glucuronidation
2. BLamotrigine induces valproate metabolism
3. CValproate displaces lamotrigine from albumin
4. DLamotrigine inhibits valproate renal excretion
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Answer: A · Valproate inhibits lamotrigine glucuronidation
She has Stevens-Johnson syndrome, the serious rash of lamotrigine. The risk rises with a high starting dose, rapid titration and co-prescription of valproate, which inhibits the glucuronidation of lamotrigine and roughly doubles its level. When the two are combined, lamotrigine is started at a lower dose and increased more slowly. Lamotrigine is stopped at once and she needs care in a burns or dermatology unit.
- B: Lamotrigine does not induce valproate metabolism to any useful extent.
- C: Protein binding displacement is not the cause of lamotrigine toxicity here.
- D: Lamotrigine does not block valproate excretion; valproate is cleared mainly by the liver.
Question 3 · Medium
A 36-year-old woman with bipolar I disorder has been on lithium (level 0.8 mEq/L) for 3 years without a manic relapse. For 4 weeks she has had low mood, poor sleep, low energy and passive death wishes but no plan, and her thyroid tests are normal. What is the most appropriate change in treatment?
1. AAdd quetiapine to lithium
2. BStop lithium and start lamotrigine
3. CStop lithium and start sertraline
4. DAdd amitriptyline to lithium
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Answer: A · Add quetiapine to lithium
This is a depressive episode of bipolar I disorder. Quetiapine is effective for acute bipolar depression and can be added to the lithium, which is continued because it prevents mania and reduces suicide risk. Antidepressant monotherapy, and tricyclics in particular, carry a high risk of switching to mania and of rapid cycling. Her passive death wishes need regular review and limited supplies of lithium, which is dangerous in overdose.
- B: Stopping lithium removes protection against mania, and lamotrigine titration takes weeks.
- C: Antidepressant monotherapy in bipolar I disorder risks a switch to mania.
- D: Tricyclics have the highest switch risk and are lethal in overdose.
Question 4 · Medium
A 31-year-old man of Han Chinese ancestry working in Bengaluru has bipolar disorder that did not respond to lithium, and carbamazepine is being considered. Consider four statements: 1. He should be tested for HLA-B*15:02 before carbamazepine is started. 2. Carbamazepine is the preferred mood stabiliser in the first trimester. 3. Carbamazepine can cause hyponatraemia. 4. Carbamazepine induces its own metabolism over the first weeks. Which statements are correct?
1. A1, 2, 3 and 4
2. B2 and 3 only
3. C1 and 4 only
4. D1, 3 and 4 only
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Answer: D · 1, 3 and 4 only
Statements 1, 3 and 4 are correct. HLA-B*15:02, common in people of Han Chinese and some South-East Asian ancestry, strongly predicts carbamazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis, so carriers should not receive it. Carbamazepine causes hyponatraemia through an ADH-like effect and induces its own hepatic metabolism, so levels fall over the first weeks and the dose may need adjustment. Statement 2 is false: it is teratogenic, with a raised risk of neural tube defects.
- A: Includes first-trimester use, which is wrong because carbamazepine is teratogenic.
- B: Leaves out HLA screening and autoinduction, and includes use in early pregnancy.
- C: Leaves out hyponatraemia, a recognised adverse effect of carbamazepine.
Question 5 · Medium
A 24-year-old postgraduate student was started on escitalopram 10 mg daily for a depressive episode. Three weeks later she sleeps 3 hours a night without feeling tired, talks rapidly, has spent her savings on online shopping and says she will soon head a global company. The symptoms have continued for 10 days. What is the next best step?
1. ASwitch escitalopram to bupropion
2. BIncrease escitalopram to 20 mg daily
3. CStop escitalopram and start a mood stabiliser
4. DContinue escitalopram and add clonazepam
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Answer: C · Stop escitalopram and start a mood stabiliser
Antidepressant treatment has unmasked a full manic episode, so the diagnosis is revised to bipolar I disorder. The antidepressant is stopped, and the mania is treated with an antimanic drug such as lithium, valproate or an atypical antipsychotic. Antidepressant monotherapy is avoided in bipolar disorder because it can trigger switches and rapid cycling. Every young patient with depression should be asked about past hypomania and a family history of bipolar disorder before an antidepressant is started.
- A: Bupropion is still an antidepressant and can also precipitate mania.
- B: A higher dose would drive the mania further.
- D: Clonazepam may calm sleep but leaves the trigger in place and the mania untreated.
Question 6 · Medium
A 60-year-old woman comes to the OPD in Jaipur 6 weeks after her husband died suddenly. She cries daily, thinks about him often and sometimes hears his voice calling her name as she falls asleep. She still cooks for her grandchildren, sleeps 6 hours, feels she is a good person and has no wish to die. What is the most appropriate approach?
1. AExplain normal grief and offer supportive follow-up
2. BStart risperidone for auditory hallucinations
3. CRefer for electroconvulsive therapy
4. DStart sertraline for a depressive episode
Answer and explanation in LearnFree account
Question 7 · Medium
A 46-year-old schoolteacher has taken lithium for bipolar disorder for 4 years with no mood episodes. She now reports tiredness, weight gain, constipation and feeling cold. TSH is 12 mIU/L (reference 0.4-4.0) and free T4 is low; lithium level is 0.7 mEq/L. What is the best management?
1. AReduce the lithium dose by half
2. BContinue lithium and start levothyroxine
3. CAdd carbimazole and recheck in 6 weeks
4. DStop lithium and start valproate
Answer and explanation in LearnFree account
Question 8 · Medium
A 30-year-old man on fluoxetine 40 mg daily for depression was given tramadol for a back sprain by a local doctor. Twelve hours later he is restless and sweating, with temperature 38.6°C, pulse 128/min, dilated pupils, diarrhoea, brisk reflexes and inducible clonus in both ankles. What is the most appropriate specific drug after stopping both medicines?
1. ACyproheptadine
2. BDantrolene
3. CHaloperidol
4. DBromocriptine
Answer and explanation in LearnFree account
Question 9 · Medium
A 72-year-old retired headmaster is brought by his son for forgetfulness over 2 months, after his wife's death. He answers most questions with 'I don't know', complains loudly about his poor memory, looks sad and eats little. His performance on testing varies from day to day, and he had a depressive episode at 55. What is the most likely diagnosis?
1. ADelirium
2. BAlzheimer disease
3. CDepressive pseudodementia
4. DVascular dementia
Answer and explanation in LearnFree account
Question 10 · Medium
A 38-year-old cotton farmer from Vidarbha is shifted from the ICU after recovering from organophosphate poisoning, taken after crop failure and heavy debts. He says he is sorry he survived, has thought of hanging himself at home, sleeps poorly and has lost interest in everything. What is the most appropriate next step?
1. APsychiatric admission with close observation
2. BDischarge with an SSRI and a review in a month
3. CDischarge to family with sleeping tablets
4. DInform police so he can be prosecuted
Answer and explanation in LearnFree account
Question 11 · Medium
A 58-year-old retired railway employee in Kolkata, widowed last year, lives alone and drinks heavily. He was treated for a paracetamol overdose 3 months ago and now has insomnia and hopelessness. The intern lists four statements about his assessment: 1. His sex and age raise his risk of suicide. 2. Living alone after losing his wife raises his risk. 3. Asking him directly about suicidal plans may put the idea in his mind. 4. His previous attempt is one of the strongest predictors of suicide. 5. His heavy drinking adds to his risk. Which statements are correct?
1. A2, 3 and 5 only
2. B1, 2 and 4 only
3. C1, 2, 3, 4 and 5
4. D1, 2, 4 and 5 only
Answer and explanation in LearnFree account
Question 12 · Easy
Which mood stabiliser has the strongest evidence for reducing suicide and suicide attempts in bipolar disorder?
1. ALamotrigine
2. BCarbamazepine
3. CLithium
4. DSodium valproate
Answer and explanation in LearnFree account
Question 13 · Hard
A 74-year-old widow in Mysuru was started on escitalopram 10 mg daily for depression 2 weeks ago. She now has nausea, unsteadiness and a fall, but is oriented. She is clinically euvolaemic with normal BP. Serum sodium 124 mmol/L (previously 138), serum osmolality 258 mOsm/kg, urine osmolality 420 mOsm/kg, urine sodium 45 mmol/L; TSH and cortisol are normal. What is the most appropriate management?
1. AInfuse 2 litres of 0.9% saline over 4 hours
2. BStop escitalopram and restrict fluids
3. CContinue escitalopram and add lithium
4. DCorrect sodium to 140 mmol/L within 24 hours
Answer and explanation in LearnFree account
Question 14 · Easy
A 35-year-old bank clerk in Kochi has had low mood for 3 weeks, has lost interest in his children and his cricket, wakes at 4 a.m., eats less and feels he has failed his family. He has never had a period of elevated mood, does not use alcohol, and his thyroid tests are normal. What is the most likely diagnosis?
1. ADepressive episode
2. BGeneralised anxiety disorder
3. CCyclothymia
4. DDysthymia
Answer and explanation in LearnFree account
Question 15 · Hard
A 67-year-old retired engineer with hypertension and no past psychiatric illness is brought by his wife with 2 weeks of reduced sleep, excessive talking, spending sprees and irritability. He has no family history of mood disorder and does not use alcohol. Examination shows mild left-sided facial weakness and a brisk left plantar reflex that the family had not noticed. What is the most appropriate next step?
1. ACheck serum lithium and valproate levels
2. BStart donepezil for frontotemporal dementia
3. CStart lithium for bipolar disorder
4. DMRI of the brain
Answer and explanation in LearnFree account
Question 16 · Easy
A 29-year-old woman with bipolar I disorder, well controlled on lithium, finds that she is 7 weeks pregnant. She asks what risk the drug carries for her baby's heart. Which cardiac anomaly is classically linked with first-trimester lithium exposure?
1. ATransposition of the great arteries
2. BCoarctation of the aorta
3. CEbstein anomaly
4. DTetralogy of Fallot
Answer and explanation in LearnFree account
Question 17 · Easy
A 26-year-old software engineer from Pune with bipolar I disorder has recovered from his second manic episode on olanzapine, and the psychiatrist plans to add lithium for long-term prevention. Which baseline tests are most important before lithium is started?
1. ALiver function tests and lipid profile
2. BRenal and thyroid function tests
3. CSerum prolactin and an EEG
4. DFasting glucose and HbA1c
Answer and explanation in LearnFree account
Question 18 · Medium
A 55-year-old woman in Madurai has had worsening depression for 2 months. She now believes her intestines have rotted and that she has no money left; for 4 days she has refused food and water, is barely speaking and has dry mucosa and a postural drop in BP. Which treatment is most appropriate?
1. AOral lithium augmentation
2. BCognitive behaviour therapy
3. CEscitalopram alone
4. DElectroconvulsive therapy
Answer and explanation in LearnFree account
Question 19 · Hard
A 64-year-old man on lithium for 20 years for bipolar disorder bought ibuprofen over the counter for knee pain 3 weeks ago. He is brought to casualty drowsy and confused, with coarse tremor, myoclonic jerks, slurred speech and a generalised seizure in the ambulance. Serum lithium 3.8 mEq/L (target 0.6-1.0), creatinine 2.6 mg/dL (previously 1.1), sodium 138 mmol/L. Lithium and ibuprofen have been stopped and IV normal saline started. What is the most appropriate next step?
1. AIV sodium bicarbonate infusion
2. BForced diuresis with IV furosemide
3. CActivated charcoal by nasogastric tube
4. DHaemodialysis
Answer and explanation in LearnFree account
Question 20 · Medium
A 40-year-old woman on lithium for 8 years for bipolar disorder complains of passing large volumes of urine and drinking about 5 litres of water a day. Lithium level is 0.7 mEq/L, serum sodium 146 mmol/L, and urine osmolality stays low after desmopressin. Her mood has been stable and she wants to continue lithium. Which drug is most appropriate for her polyuria?
1. ADesmopressin
2. BAmiloride
3. CFurosemide
4. DCarbamazepine
Answer and explanation in LearnFree account
Question 21 · Medium
A 24-year-old woman with bipolar I disorder has been stable for 2 years on sodium valproate. She is newly married and tells the psychiatrist she would like to conceive within the year. What is the main reason to review her valproate now?
1. ARisk of Ebstein anomaly in the foetus
2. BRisk of neural tube defects and neurodevelopmental harm
3. CRisk of persistent pulmonary hypertension
4. DRisk of neonatal hypothyroidism and goitre
Answer and explanation in LearnFree account
Question 22 · Medium
A 22-year-old man is brought to casualty by his parents in Lucknow. For 10 days he has barely slept, has been shouting at neighbours, claims he is a messenger of God and is now threatening staff. He has no fever, the urine drug screen is negative and he refuses oral medicines in the ward. What is the most appropriate immediate treatment?
1. AOral escitalopram with clonazepam
2. BIntravenous phenytoin loading dose
3. COral lamotrigine with a slow titration
4. DIntramuscular haloperidol with lorazepam
Answer and explanation in LearnFree account

Depression, bipolar disorder and suicide risk

A 36-year-old woman with bipolar I disorder has been on lithium (level 0.8 mEq/L) for 3 years without a manic relapse. For 4 weeks she has had low mood, poor sleep, low energy and passive death wishes but no plan, and her thyroid tests are normal. What is the most appropriate change in treatment?

A 46-year-old schoolteacher has taken lithium for bipolar disorder for 4 years with no mood episodes. She now reports tiredness, weight gain, constipation and feeling cold. TSH is 12 mIU/L (reference 0.4-4.0) and free T4 is low; lithium level is 0.7 mEq/L. What is the best management?

Which mood stabiliser has the strongest evidence for reducing suicide and suicide attempts in bipolar disorder?

A 29-year-old woman with bipolar I disorder, well controlled on lithium, finds that she is 7 weeks pregnant. She asks what risk the drug carries for her baby's heart. Which cardiac anomaly is classically linked with first-trimester lithium exposure?

A 26-year-old software engineer from Pune with bipolar I disorder has recovered from his second manic episode on olanzapine, and the psychiatrist plans to add lithium for long-term prevention. Which baseline tests are most important before lithium is started?

A 55-year-old woman in Madurai has had worsening depression for 2 months. She now believes her intestines have rotted and that she has no money left; for 4 days she has refused food and water, is barely speaking and has dry mucosa and a postural drop in BP. Which treatment is most appropriate?

A 24-year-old woman with bipolar I disorder has been stable for 2 years on sodium valproate. She is newly married and tells the psychiatrist she would like to conceive within the year. What is the main reason to review her valproate now?