A 66-year-old man with a chronic nonpsychiatric medical condition develops a moderate major depressive episode. His medical team asks whether antidepressant medication is likely to help, given his other illness. What does the Canadian guideline conclude about antidepressants in this situation?

Antidepressants are more effective than placebo across a range of medical comorbidities

Antidepressants are ineffective when another medical illness is present

Antidepressants are not indicated in medically ill patients

Only electroconvulsive therapy should be used in this situation

A 45-year-old man describes recurrent episodes of low mood, fatigue, and increased sleep that begin each November and resolve by March. His symptoms are mild and he prefers a non-drug option. Which intervention is recommended first-line for this seasonal pattern?

Bright light therapy of 10,000 lux for 30 minutes each morning

Sleep deprivation by staying awake for 36 hours each week

Melatonin 5 mg each morning for the winter

A 40-year-old woman with a diagnosis of generalized anxiety disorder is being treated with alprazolam 1 mg three times daily. She reports significant improvement in her symptoms, but is concerned about the potential for dependence. What is the primary mechanism of action of benzodiazepines, such as alprazolam, in the treatment of anxiety disorders?

Inhibition of serotonin reuptake

Stimulation of norepinephrine release

A 15-year-old girl with ADHD and no other medical history is referred because of weight loss and food restriction. She describes episodes in which eating feels out of control. According to the cited Canadian statement, how are ADHD symptoms related to eating disorders?

ADHD symptoms, particularly in females, increase the risk of an eating disorder

Stimulant treatment for ADHD removes the risk of an eating disorder

The association is limited to males with ADHD

An eating disorder excludes a diagnosis of ADHD

A 14-year-old girl with an anxiety disorder has not attended school for six weeks. Despite primary care treatment her avoidance persists and her parents are concerned. According to the British Columbia guideline, which finding indicates referral to a specialist?

Worry that improves with reassurance

A single episode of test anxiety

Anxiety that resolves fully within four weeks of treatment

A 52-year-old man with major depressive disorder has had a partial response to sertraline 100 mg daily after 8 weeks. He has no troublesome side effects and his adherence is good, but he reports continued anhedonia and low energy. Which medication strategy does the guideline recommend in this situation?

Add an adjunctive agent such as aripiprazole to the current antidepressant

Stop sertraline and start an antipsychotic alone

Switch to a different antidepressant class immediately

Increase sertraline to the maximum dose and add lithium at the same time

A 48-year-old woman reports that for the past 3 years she has felt low and has had poor appetite and disturbed sleep on most days. She has not met full criteria for a major depressive episode at any point, and she has not been free of these symptoms for more than 2 months at a time. Which diagnosis best fits this presentation?

Major depressive disorder, single episode

Adjustment disorder with depressed mood

A 38-year-old woman with a moderate major depressive episode has started sertraline and is responding. Her clinician discusses whether adding a structured psychological treatment to her plan is worthwhile. What does the guideline state about combining psychological treatment with pharmacotherapy during acute treatment?

Combining the two is more effective than either alone and also lowers recurrence risk

The combination helps only if the antidepressant is stopped first

Psychological treatment should replace medication once a response occurs

Combining the two provides no added benefit

MCCQE Part I Depression and anxiety Questions: 10 Free Practice MCQs

Depression and anxiety questions test severity, risk and the treatment ladder. The MCC objectives expect a structured assessment, direct questions about suicide, and a plan that matches severity: psychotherapy for mild illness, combined treatment for moderate to severe illness. Canadian questions also test the family physician's role, wait times for psychotherapy and the follow-up that keeps the patient safe between visits.

Where candidates lose marks

Missing suicidal intent because the question was never asked directly.
Starting a drug for mild depression without offering psychotherapy first.
Forgetting to screen for bipolar disorder and substance use.
Continuing treatment without review when the patient has not responded.

Guideline to follow: The MCCQE Part I follows the CANMAT guidelines for depression and anxiety and the Canadian Psychiatric Association guidance on suicide risk assessment.

Ten MCCQE Part I-style depression and anxiety questions with the answer and the reasoning behind it. They come from the CA.med bank, which has 61 depression and anxiety questions and many more across every topic.

Free timed mock exam

1 / 10
A 66-year-old man with a chronic nonpsychiatric medical condition develops a moderate major depressive episode. His medical team asks whether antidepressant medication is likely to help, given his other illness.
What does the Canadian guideline conclude about antidepressants in this situation?
Show answer
Answer: C. Antidepressants are more effective than placebo across a range of medical comorbidities
Why: The guideline notes that rates of comorbid major depressive disorder are high in patients with nonpsychiatric medical conditions and that the relationship is bidirectional. Patients with psychiatric and medical comorbidities have a worse treatment response to antidepressants than those without, but antidepressants remain indicated, and an umbrella meta-analysis of randomized trials in depression comorbid with many other medical conditions reported that antidepressants were more efficacious than placebo. Clinicians should minimize polypharmacy, check for drug interactions, and choose side effect profiles that do not worsen comorbid conditions. Psychological treatments such as cognitive behavioural therapy and behavioural activation also benefit patients with medical comorbidity.
- A. The guideline reports the opposite, that antidepressants remain more effective than placebo across a range of medical comorbidities.
- B. Antidepressants remain indicated for treating major depressive disorder when comorbid medical conditions are present.
- D. Electroconvulsive therapy is reserved for severe or treatment-resistant illness rather than first treatment in a medically ill patient.
Sources: CANMAT 2023 update on clinical guidelines for management of major depressive disorder (MDD) in adults
2 / 10
A 31-year-old man is diagnosed with panic disorder. He has two or three unexpected panic attacks each week. He has no other medical or psychiatric conditions and takes no other medication.
Which is a recommended first-line pharmacotherapy for his panic disorder?
Show answer
Answer: A. Sertraline
Why: First-line pharmacotherapy for panic disorder includes the SSRIs citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR and sertraline, and the SNRI venlafaxine XR. Cognitive behavioural therapy, alone or combined with pharmacotherapy, is also a first-line treatment. If response to an optimal dose of a first-line agent is inadequate, or the agent is not tolerated, treatment should be switched to another first-line agent before second-line options such as the tricyclics, mirtazapine, reboxetine or benzodiazepines are considered. Buspirone, propranolol, tiagabine and trazodone are not recommended for panic disorder.
- B. This agent has not shown efficacy in panic disorder and is listed among the treatments that are not recommended.
- C. This benzodiazepine is effective but is a second-line option, reserved largely for short-term use or early treatment while an antidepressant takes effect, because of the risk of dependence.
- D. Beta-blockade has not demonstrated efficacy for panic disorder and is not recommended.
Sources: Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders
3 / 10
A 45-year-old man describes recurrent episodes of low mood, fatigue, and increased sleep that begin each November and resolve by March. His symptoms are mild and he prefers a non-drug option.
Which intervention is recommended first-line for this seasonal pattern?
Show answer
Answer: D. Bright light therapy of 10,000 lux for 30 minutes each morning
Why: Light therapy is a chronobiological intervention in which a device delivers timed exposure to supplemental bright light; a typical protocol uses 10,000 lux of white light for 30 minutes daily in the morning, shortly after awakening. It remains recommended as first-line monotherapy for seasonal winter depression and places as a second-line treatment for mild nonseasonal depression and as an adjunct to medication for moderate nonseasonal depression, with larger effects when combined with antidepressants. Sleep deprivation is only a third-line recommendation and may precipitate hypomania, while diet is a third-line adjunct.
- A. Wake therapy is a third-line option and can also precipitate hypomanic episodes.
- B. The first-line recommendation for a seasonal winter pattern is bright light therapy rather than melatonin.
- C. Diet is a third-line adjunct and is not the first-line treatment for a seasonal pattern.
Sources: CANMAT 2023 update on clinical guidelines for management of major depressive disorder (MDD) in adults
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4 / 10
A 40-year-old woman with a diagnosis of generalized anxiety disorder is being treated with alprazolam 1 mg three times daily. She reports significant improvement in her symptoms, but is concerned about the potential for dependence.
What is the primary mechanism of action of benzodiazepines, such as alprazolam, in the treatment of anxiety disorders?
Show answer
Answer: D. Enhancement of GABA activity
Why: Benzodiazepines, such as alprazolam, enhance the activity of the inhibitory neurotransmitter GABA, which helps to reduce anxiety symptoms. According to the Canadian Thoracic Society (CTS) guidelines, benzodiazepines are effective in the short-term treatment of anxiety disorders, but their use should be limited due to the potential for dependence.
- A. Inhibition of serotonin reuptake is the primary mechanism of action of selective serotonin reuptake inhibitors (SSRIs), not benzodiazepines.
- B. Blockade of dopamine receptors is the primary mechanism of action of antipsychotic medications, not benzodiazepines.
- C. Stimulation of norepinephrine release is not the primary mechanism of action of benzodiazepines.
Sources: Canadian Thoracic Society (CTS) guidelines
5 / 10
A 15-year-old girl with ADHD and no other medical history is referred because of weight loss and food restriction. She describes episodes in which eating feels out of control.
According to the cited Canadian statement, how are ADHD symptoms related to eating disorders?
Show answer
Answer: B. ADHD symptoms, particularly in females, increase the risk of an eating disorder
Why: ADHD symptoms, especially in females, increase the risk for eating disorders, and this comorbidity may underlie difficulties with treatment and remission in some eating disorders. ADHD is most commonly comorbid with other psychiatric and neurodevelopmental conditions, and the clinician should first address whichever condition is causing the greatest impairment, whether that is the ADHD or a comorbid disorder.
- A. No such protective effect is described; the statement links ADHD symptoms with an increased risk rather than protection from eating disorders.
- C. The increased risk is described especially in females, so restricting the association to males reverses the reported pattern.
- D. The two conditions can coexist, and the reported link is that ADHD symptoms raise the risk of an eating disorder rather than ruling it in or out.
Sources: ADHD in children and youth: Part 1. Etiology, diagnosis, and comorbidity. Canadian Paediatric Society, 2018 (reaffirmed 2024)
6 / 10
A 14-year-old girl with an anxiety disorder has not attended school for six weeks. Despite primary care treatment her avoidance persists and her parents are concerned.
According to the British Columbia guideline, which finding indicates referral to a specialist?
Show answer
Answer: D. Persistent school avoidance
Why: Indications for specialist referral include depression or anxiety that has not responded to primary treatment, high suicide risk, severe obsessive compulsive disorder or panic, persistent school avoidance, possible bipolarity and postpartum depression. The guideline also cautions that avoidance of school, friends, work and feared situations is instinctive but unhelpful, so treatment should discourage it while encouraging attendance at school and activities.
- A. Worry that settles with reassurance is a mild presentation and does not meet the guideline's referral indications.
- B. An isolated episode of situational anxiety does not by itself indicate that specialist care is needed.
- C. Full resolution with primary treatment argues against referral, which is reserved for anxiety that has not responded.
Sources: Anxiety and Depression in Children and Youth: Diagnosis and Treatment. BC Guidelines and Protocols Advisory Committee, Government of British Columbia
7 / 10
A 52-year-old man with major depressive disorder has had a partial response to sertraline 100 mg daily after 8 weeks. He has no troublesome side effects and his adherence is good, but he reports continued anhedonia and low energy.
Which medication strategy does the guideline recommend in this situation?
Show answer
Answer: C. Add an adjunctive agent such as aripiprazole to the current antidepressant
Why: Switching should be considered first when there is no response to the initial antidepressant or when the first medication has troublesome side effects, whereas adjunctive strategies should be considered first when there is a partial response and minimal or no tolerability issues. Adjunctive strategies, especially with serotonin and dopamine activity modulators, have greater evidence for efficacy and shorter time to response or remission, although they carry a greater side effect burden. Aripiprazole and brexpiprazole are listed as first-line adjunctive agents for difficult-to-treat depression. Meta-analyses show that switching to another antidepressant is not superior to continuing the same one, and response rates diminish beyond the first switch.
- A. Stopping a partially effective antidepressant risks losing the gains already made.
- B. Switching is favoured when there is no response to the initial antidepressant or when it causes troublesome side effects.
- D. Making two medication changes at once is not the recommended next step, and lithium is a second-line adjunct.
Sources: CANMAT 2023 update on clinical guidelines for management of major depressive disorder (MDD) in adults
8 / 10
A 48-year-old woman reports that for the past 3 years she has felt low and has had poor appetite and disturbed sleep on most days. She has not met full criteria for a major depressive episode at any point, and she has not been free of these symptoms for more than 2 months at a time.
Which diagnosis best fits this presentation?
Show answer
Answer: A. Persistent depressive disorder
Why: The guideline states that a chronic major depressive episode with full criteria is classified as a persistent depressive disorder specifier, which is characterized by 2 or more depressive symptoms present for more than 2 years. Dysthymia, a chronic course of subthreshold symptoms that does not meet criteria for a major depressive episode, also sits within this category. A single major depressive episode, cyclothymic disorder, and adjustment disorder do not fit a 3-year course of low-grade symptoms that has not reached full episode criteria.
- B. An episode of major depressive disorder requires a distinct major depressive episode, and this patient has not met full criteria for one.
- C. A pattern of shifts between hypomanic and depressive symptoms defines this condition, and no hypomanic symptoms are described.
- D. Adjustment disorder follows an identifiable stressor within 3 months, which is not the 3-year pattern reported here.
Sources: CANMAT 2023 update on clinical guidelines for management of major depressive disorder (MDD) in adults
9 / 10
A 22-year-old university student reports 6 months of intense fear whenever he has to speak in seminars or eat in front of others. He worries for days beforehand that he will blush or say something foolish, and he has begun missing classes to avoid these situations. He feels fine when he is alone with close friends.
What is the most likely diagnosis?
Show answer
Answer: C. Social anxiety disorder
Why: Social anxiety disorder is characterised by intense fear or anxiety relating to social or performance situations in which the individual is exposed to scrutiny by others, and these situations are often actively avoided. The fear is out of proportion to the actual danger and causes functional impairment. The Canadian anxiety guidelines note that social anxiety disorder is common, frequently comorbid with major depression and other anxiety disorders, and that cognitive behaviour therapy and exposure are effective first-line options, while first-line pharmacotherapy includes an SSRI or SNRI such as escitalopram, sertraline, paroxetine or venlafaxine XR. Panic disorder and generalised anxiety disorder have different defining features.
- A. Recurrent unexpected panic attacks would be expected, whereas his anxiety is consistently tied to being observed by others.
- B. Worry across many domains characterises generalised anxiety disorder, not fear confined to scrutiny in social and performance settings.
- D. Intrusive obsessions or repetitive compulsions are required for obsessive-compulsive disorder, and his symptoms are better explained by fear of negative evaluation.
Sources: Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders
10 / 10
A 38-year-old woman with a moderate major depressive episode has started sertraline and is responding. Her clinician discusses whether adding a structured psychological treatment to her plan is worthwhile.
What does the guideline state about combining psychological treatment with pharmacotherapy during acute treatment?
Show answer
Answer: A. Combining the two is more effective than either alone and also lowers recurrence risk
Why: The guideline states that combining psychological treatment with pharmacotherapy is more effective than either alone for acute treatment, and that combined treatment is also associated with a reduced risk of recurrence. Adding psychological treatment is effective whether the antidepressant is continued or not, but the highest chances of sustained recovery are seen when the antidepressant is continued with the added psychological treatment. Planned sequential treatment, in which psychotherapy is added after an initial response to medication, is especially useful for recurrent and severe forms of depression. Structured psychotherapy, specifically cognitive behavioural therapy, is slightly more efficacious than antidepressants at 6 to 12 months.
- B. The highest chance of sustained recovery is seen when the antidepressant is continued alongside the added psychological treatment.
- C. Adding psychological treatment does not require stopping the antidepressant, and stopping may lose gains already made.
- D. That statement contradicts the guideline, which reports greater effectiveness for the combination than for either treatment alone.
Sources: CANMAT 2023 update on clinical guidelines for management of major depressive disorder (MDD) in adults

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MCCQE Part I Depression and anxiety Questions: 10 Free Practice MCQs

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