Mood Disorders for NEET PG 2026: Depression & Bipolar Guide

Master DSM-5 mood disorders for NEET PG 2026 — MDD, bipolar I/II, antidepressants, mood stabilizers, ECT, and the Mental Healthcare Act 2017.

Specifiers that change management

Persistent depressive disorder (dysthymia)

A chronic low-grade depressed mood for 2 or more years (1 year in children/adolescents) with at least 2 of: poor appetite, insomnia/hypersomnia, low energy, low self-esteem, poor concentration, hopelessness. Symptoms cannot be absent for more than 2 months. Patients can have superimposed major depressive episodes — termed "double depression," a classic NEET PG vignette.

Bipolar spectrum — mania vs hypomania

The single most testable distinction in mood-disorder MCQs is the line between mania and hypomania.

Both share the DIG FAST symptom set (3 needed if mood is elevated, 4 if mood is only irritable):

• Distractibility
• Irresponsibility/risky behaviour (sexual, financial, legal)
• Grandiosity
• Flight of ideas / racing thoughts
• Activity increase / psychomotor agitation
• Sleep decreased need
• Talkativeness / pressured speech

Mixed features and rapid cycling

• Mixed features specifier: at least 3 symptoms of the opposite pole during a current episode. Higher suicide risk; valproate or atypical antipsychotic preferred over lithium.
• Rapid cycling: 4 or more mood episodes in 12 months. Worse prognosis. Valproate or lamotrigine preferred. Antidepressants can induce switching.

Cyclothymic disorder

Two years (1 year in adolescents) of fluctuating hypomanic and depressive symptoms not meeting threshold for full episodes. Symptom-free intervals less than 2 months.

Pharmacotherapy of depression — choose by side-effect fit

SSRIs — first-line

Fluoxetine, sertraline, escitalopram, paroxetine, citalopram, fluvoxamine.

• Onset: mood lift takes 2-4 weeks; sleep and appetite improve earlier.
• Common side effects: nausea, sexual dysfunction (50%), insomnia, GI upset, hyponatremia (especially elderly).
• Discontinuation syndrome: flu-like symptoms, dizziness, electric-shock sensations on abrupt stop, especially with paroxetine (short half-life).
• Serotonin syndrome: triad of mental status change, autonomic instability, neuromuscular hyperactivity (clonus, hyperreflexia). Stop the drug, give cyproheptadine.
• Pregnancy: sertraline preferred; paroxetine contraindicated (Ebstein-like cardiac defects, FDA Category D).

SNRIs

Venlafaxine, duloxetine, desvenlafaxine. Also useful for chronic pain, neuropathic pain, fibromyalgia. Venlafaxine causes dose-dependent hypertension above 225 mg/day.

Atypical antidepressants

• Bupropion — NDRI, no sexual side effects, weight neutral, smoking cessation aid. Avoid in seizure history, eating disorders.
• Mirtazapine — α2 antagonist, sedating, increases appetite. Useful in elderly with insomnia and weight loss.
• Trazodone — sedating; mostly used for insomnia in low doses. Risk of priapism.
• Vortioxetine — multimodal; useful for cognitive symptoms.
• Agomelatine — melatonergic, hepatotoxicity monitoring required.

TCAs and MAOIs

TCAs (amitriptyline, imipramine, nortriptyline, clomipramine) — effective but cardiotoxic in overdose (QRS widening, arrhythmia). Anticholinergic, antihistaminic, alpha-blockade side effects. MAOIs (phenelzine, tranylcypromine, selegiline) — tyramine-rich food causes hypertensive crisis; 2-week washout from SSRI before switching.

Mood stabilizers — bipolar cornerstones

Lithium

Gold standard for classic mania and maintenance. Reduces suicide risk independently — a uniquely valuable property.

• Therapeutic range: 0.6-1.2 mEq/L (acute mania up to 1.5).
• Toxicity: >1.5 mEq/L. Tremor, ataxia, dysarthria, confusion, seizures, coma. Hemodialysis if >2.5 or symptomatic.
• Side effects: fine tremor, polyuria/polydipsia (nephrogenic DI), hypothyroidism, weight gain, acne, T-wave flattening, leukocytosis, Ebstein anomaly in pregnancy.
• Drug interactions: thiazides, ACEi, NSAIDs raise lithium levels (decreased renal clearance).
• Monitoring: TSH, creatinine, electrolytes, lithium level every 6 months once stable.

Valproate

First-line for mixed features, rapid cycling, and dysphoric mania.

• Therapeutic range: 50-125 mcg/mL.
• Side effects: weight gain, alopecia, tremor, thrombocytopenia, hepatotoxicity, hyperammonemia, pancreatitis.
• Pregnancy: contraindicated — high neural tube defect risk and intellectual impairment in offspring.

Lamotrigine

First-line for bipolar depression maintenance. Slow titration mandatory (Stevens-Johnson syndrome risk if dose escalated rapidly). Less effective for acute mania.

Atypical antipsychotics

Olanzapine, quetiapine, risperidone, aripiprazole, lurasidone, cariprazine — all FDA-approved for various phases. Quetiapine and lurasidone are the only monotherapies approved for bipolar depression. Olanzapine + fluoxetine combination (Symbyax) approved for bipolar depression.

Critical NEET PG rule

Never give antidepressant monotherapy in bipolar disorder. It risks switching to mania or rapid cycling. Always cover with a mood stabilizer or atypical antipsychotic first.

Electroconvulsive therapy — when and why

ECT remains the most effective treatment for severe depression, with response rates 70-90%.

Absolute and relative indications

• Severe MDD with active suicidality
• Depression with psychotic features
• Catatonic depression or catatonia of any cause
• Treatment-resistant depression (failure of 2+ adequate antidepressant trials)
• Severe mania unresponsive to medication
• Postpartum psychosis (fast, safe, allows continued breastfeeding)
• Pregnancy when medications are unsafe
• Patients refusing food/fluids ("danger to self by neglect")
• Neuroleptic malignant syndrome refractory to bromocriptine

Practical pearls

• Stimulus dosing: unilateral right-sided causes less cognitive impairment; bilateral has faster response.
• Adverse effects: transient anterograde amnesia, headache, myalgia. No absolute contraindications. Relative caution: recent MI, raised ICP, unstable cervical spine.
• Pre-ECT workup: ECG, electrolytes, anaesthesia review. Pregnancy is NOT a contraindication.

Suicide risk assessment

Previous attempt is the single strongest predictor of completed suicide. Other risk factors: male sex, advancing age, alcohol/substance use, hopelessness, social isolation, recent loss, access to lethal means, family history, chronic illness, command hallucinations.

Practical scales

• SAD PERSONS scale — 10-item screening (Sex, Age, Depression, Previous attempt, Ethanol, Rational thinking loss, Social support lacking, Organised plan, No spouse, Sickness).
• Columbia Suicide Severity Rating Scale (C-SSRS) — gold standard in clinical research and emergency settings.

For NEET PG, examiners often ask: "What is the strongest single predictor of suicide?" — answer is previous suicide attempt, especially within the last year.

Postpartum mood states

Postpartum psychosis is a psychiatric emergency. Risk of infanticide and suicide is dramatically elevated. Strong association with bipolar disorder.

High-yield NEET PG MCQ traps

1. Bereavement vs MDD — DSM-5 removed the bereavement exclusion; MDD can be diagnosed during grief if criteria are met.
2. Antidepressant-induced mania — first manic episode triggered by SSRI in a previously depressed patient often unmasks bipolar disorder.
3. Lithium toxicity precipitants — dehydration, NSAIDs, ACEi, thiazide diuretics, low-sodium diet.
4. Lamotrigine titration — slow titration prevents Stevens-Johnson syndrome; valproate doubles lamotrigine levels.
5. MAOI tyramine reactions — aged cheese, fermented foods, wine, cured meats. Hypertensive crisis treated with phentolamine.
6. Serotonin syndrome vs NMS — both have hyperthermia and altered mental status. Serotonin syndrome has clonus and hyperreflexia; NMS has lead-pipe rigidity and hyporeflexia.
7. Bupropion contraindications — seizure disorder, anorexia/bulimia (electrolyte risk).
8. Pregnancy and breastfeeding — sertraline is the SSRI of choice; valproate and paroxetine are avoided.
9. Catatonia first-line — lorazepam challenge (1-2 mg IV); ECT if refractory.
10. Psychotic depression — never use antidepressant alone; combine with antipsychotic OR use ECT.

Mental Healthcare Act 2017 — the legal layer

The Mental Healthcare Act 2017 replaced the Mental Health Act 1987 and reframed Indian mental health law around dignity, autonomy, and right-to-care. NEET PG and FMGE both ask conceptual questions on the Act.

• Decriminalisation of suicide: Section 115 — anyone attempting suicide is presumed to have severe stress and shall not be prosecuted under Section 309 IPC (now BNS 2023 equivalent). Government must provide care and rehabilitation.
• Advance directive: Patients can specify in writing how they wish to be treated when unable to consent.
• Nominated representative: every patient appoints one; replaces "guardian" concept.
• Independent admission: voluntary, patient-driven, can self-discharge.
• Supported admission: requires nominated representative consent + medical-officer certification. Reviewed by Mental Health Review Board if >30 days.
• Mental Health Review Boards: state-level quasi-judicial bodies with appellate function.
• Right to community living, dignity, confidentiality, equality, free legal aid.
• Insurance parity: every insurer must provide medical insurance for mental illness on same basis as physical illness.

Recent updates and Indian context

• Esketamine (Spravato) — intranasal NMDA antagonist approved for treatment-resistant depression. Rapid onset within hours. Requires REMS-supervised administration in India.
• Brexanolone and zuranolone — neuroactive steroid GABA-A modulators approved for postpartum depression.
• Psilocybin trials — Phase 3 trials in treatment-resistant depression; not yet approved in India.
• District Mental Health Programme (DMHP) — operational under National Mental Health Programme; integrates mental health into primary care across all districts.
• Tele-MANAS: national tele-mental-health helpline (14416) launched 2022 — important for PSM/community medicine cross-questions.

Frequently asked questions

What are the DSM-5 criteria for major depressive disorder?

MDD requires five or more symptoms during the same 2-week period including either depressed mood or anhedonia, plus weight or appetite change, sleep disturbance, psychomotor changes, fatigue, worthlessness or guilt, decreased concentration, and recurrent thoughts of death. Symptoms must cause significant impairment and not be due to substance or medical condition.

How do you differentiate bipolar I from bipolar II?

Bipolar I requires at least one full manic episode lasting 7 days or any duration if hospitalisation is needed, with marked impairment or psychosis possible. Bipolar II requires at least one hypomanic episode (4 or more days, less severe, no hospitalisation) plus at least one major depressive episode. Mania automatically rules out bipolar II.

Which antidepressant is safest in pregnancy and lactation?

Sertraline is generally considered the SSRI of choice in pregnancy and breastfeeding due to lowest serum levels in breastmilk and reassuring safety data. Paroxetine is avoided due to first-trimester cardiac defect risk. Always discuss risk-benefit of untreated maternal depression versus medication exposure with the patient.

What are the absolute indications for ECT in mood disorders?

Severe MDD with acute suicidality, depression with psychotic features, catatonic depression, treatment-resistant depression after multiple failed trials, severe mania, postpartum psychosis, and patients who refuse food or fluids. ECT is also first-line when rapid response is essential or pharmacotherapy is contraindicated such as in pregnancy.

What does the Mental Healthcare Act 2017 say about admission?

The Act mandates dignity-based care, decriminalises suicide attempts, and creates supported admission categories. Independent admission is voluntary; supported admission requires nominated representative consent and medical board review beyond 30 days. Advance directives and right to community living are guaranteed. The Act replaced the Mental Health Act 1987.

Written by: NEETPGAI Editorial Team Reviewed by: Pending SME Review Last reviewed: April 2026