Psychiatry for NEET PG 2026: ECT, Antipsychotics, Lithium Toxicity, and High-Yield Topics

Psychiatry contributes 3 to 5 percent of the NEET PG paper — approximately 5 to 9 questions out of 180. These questions follow predictable patterns: drug mechanisms and adverse effects, diagnostic criteria, ECT indications, and clinical scenario-based distinctions between disorders. Aspirants who approach Psychiatry systematically through PYQ analysis routinely score 80 to 100 percent accuracy in this subject.

Unlike subjects where new research shifts what gets tested, Psychiatry PYQs are stable. The same ECT indications, the same lithium toxicity features, the same extrapyramidal side effect profiles appear cycle after cycle. This guide covers every high-yield topic with the depth NEET PG actually demands. For where this sits against the rest of the paper, see the subject wise weightage for Psychiatry.

Before starting subject revision, use the NEET PG 2026 score calculator to understand how your current Psychiatry accuracy contributes to your projected rank. Getting every Psychiatry question correct versus getting none correct is a score swing of 20 to 36 marks — and at competitive rank ranges, that difference can move you 1,000 to 2,000 positions.

Psychiatry sits inside the Medicine cluster, alongside Dermatology for NEET PG 2026 — both are frequently asked as Medicine-style clinical stems. And neuroleptic malignant syndrome, covered below, is examined just as often from the anaesthetic side, so read it against Anaesthesia for NEET PG 2026 where it appears as the malignant hyperthermia comparison.

The 16 Most-Tested Psychiatry Topics in NEET PG PYQs

Rank	Topic	Frequency	Question Format
1	ECT — indications, contraindications, technique	Very High	Clinical scenario + direct factual
2	Antipsychotic adverse effects — EPS and tardive dyskinesia	Very High	Drug adverse effect MCQ
3	Lithium — indications, toxicity, monitoring	Very High	Pharmacology MCQ
4	Antipsychotic classification — typical vs atypical	Very High	Classification + drug-receptor MCQ
5	Schizophrenia — diagnostic criteria	High	Diagnostic MCQ
6	Depression — diagnostic criteria, drug choice	High	Clinical + pharmacology MCQ
7	OCD — drug of choice, treatment sequence	High	Pharmacology MCQ
8	Clozapine — agranulocytosis, monitoring	High	Drug safety MCQ
9	Antidepressant classification — SSRIs, TCAs, MAOIs	High	Classification MCQ
10	SSRI — mechanism, adverse effects, interactions	Moderate	Pharmacology MCQ
11	Benzodiazepine — mechanism, uses, withdrawal	Moderate	Pharmacology MCQ
12	Alcohol dependence — delirium tremens, treatment	Moderate	Clinical scenario
13	Bipolar disorder — mood stabilisers, drug choice	Moderate	Pharmacology MCQ
14	Personality disorders — classification, features	Moderate	Diagnostic MCQ
15	Substance use disorders — CAGE, ICD criteria	Low-Moderate	Direct factual
16	PTSD and anxiety disorders — criteria and treatment	Low-Moderate	Diagnostic + pharmacology

Topic 1: Electroconvulsive Therapy

ECT is the most consistently tested topic in NEET PG Psychiatry. It appears in every cycle, sometimes in multiple questions.

Electroconvulsive therapy delivers a controlled electrical stimulus to the brain to induce a generalised tonic-clonic seizure under general anaesthesia and muscle relaxation. It is the most rapidly effective biological treatment in psychiatry — response occurs within 1 to 2 weeks, against 4 to 6 weeks for antidepressants.

Indications

Strong indications, where ECT is the treatment of choice:

Indication	Why ECT Is Preferred
Severe depression with suicidal risk	Fastest response; removes the suicide window during the medication lag
Catatonia of any cause	Very high response rate; faster than lorazepam alone in severe cases
Psychotic depression	Antidepressant plus antipsychotic is less effective than ECT
Depression with refusal to eat or drink	Life-threatening; ECT is the fastest intervention
Treatment-resistant depression	Failure of two or more adequate antidepressant trials
Mania unresponsive to medication	When lithium, valproate and antipsychotics have failed
Neuroleptic malignant syndrome	When pharmacological treatment fails
Severe postpartum depression or psychosis	When medication cannot be used

Relative indications include depression in pregnancy where antidepressants are contraindicated, Parkinson's disease with severe depression — ECT also improves motor symptoms — and schizophrenia as augmentation, particularly for affective symptoms.

Contraindications

There are no absolute contraindications in modern practice with proper anaesthetic management. Significant relative contraindications:

Contraindication	Reason
Raised intracranial pressure	ECT transiently raises ICP — herniation risk
Recent myocardial infarction (under 3 months)	ECT causes cardiovascular stress
Intracranial space-occupying lesion	Herniation risk from the ICP rise
Recent cerebral haemorrhage	Risk of re-bleed
Phaeochromocytoma	The catecholamine surge can be fatal
Aortic aneurysm	ECT-induced hypertension
Severe anaesthetic risk	Patient cannot safely undergo general anaesthesia
Retinal detachment	Risk of worsening

Technique

Pre-ECT workup covers informed consent from the patient or guardian, full blood count, ECG, chest X-ray, serum electrolytes — hypokalaemia lowers the seizure threshold and is dangerous — blood glucose, brain imaging if a space-occupying lesion is suspected, and an anaesthetic fitness assessment.

Electrode placement is bilateral (bitemporal) as standard and more effective for severe depression; right unilateral produces fewer cognitive side effects but may need a higher dose; bifrontal sits between the two.

For anaesthesia, the muscle relaxant is suxamethonium, a short-acting depolarising agent. Induction uses methohexitone traditionally, with propofol, thiopentone and etomidate also used. Atropine is given beforehand to prevent bradycardia and reduce secretions, with 100 percent oxygen before and after.

The therapeutic seizure requires a minimum EEG seizure duration of 25 seconds. The stimulus itself lasts 0.5 to 2 seconds as a brief-pulse square wave. The clinical motor seizure may appear shorter because of muscle relaxation, which is why EEG monitoring is required.

A standard course is 6 to 12 sessions given two to three times per week, with response expected by session 4 to 6. Maintenance ECT uses monthly sessions to prevent relapse.

Adverse Effects

Adverse Effect	Details
Memory impairment	Most common; retrograde more than anterograde; usually reversible
Post-ictal confusion	Resolves within 30 to 60 minutes
Headache	Common, transient
Muscle aches	From suxamethonium fasciculations
Cardiovascular effects	Transient hypertension and arrhythmias around the stimulus
Prolonged seizure	Over 3 minutes becomes status epilepticus — treat with IV diazepam
Missed seizure	No seizure occurs — increase stimulus intensity
Tardive seizure	A seizure occurring hours after the session

PYQ patterns: the muscle relaxant in ECT is suxamethonium; the minimum EEG seizure duration is 25 seconds; the most common adverse effect is memory impairment; the drug given beforehand to prevent bradycardia is atropine.

Topic 2: Antipsychotic Drugs

Typical (First-Generation) Antipsychotics

Drug	Potency	Key Feature
Chlorpromazine	Low	Prototype; most sedating; alpha blockade
Thioridazine	Low	Highest risk of retinal pigmentation
Trifluoperazine	High	High EPS risk
Haloperidol	High	Most studied; highest EPS; available IV and depot
Fluphenazine	High	Available as decanoate depot; high EPS risk
Droperidol	High	Antiemetic; IV use; QTc prolongation

Atypical (Second-Generation) Antipsychotics

Drug	Receptor Profile	Unique Feature
Clozapine	D4 over D2, plus 5HT2A	Only drug for treatment-resistant schizophrenia; 1–2% agranulocytosis risk
Risperidone	D2 plus 5HT2A	Most EPS of the atypicals at high dose; raises prolactin
Olanzapine	D2, 5HT2A, H1, M1	Most weight gain and metabolic syndrome; minimal EPS
Quetiapine	D2, 5HT2A, H1	Most sedating atypical; also used in bipolar depression
Aripiprazole	Partial D2 agonist	Least weight gain and metabolic effect; most activating
Ziprasidone	D2 plus 5HT2A	QTc prolongation; little weight gain
Amisulpride	D2 and D3	No 5HT blockade; highest prolactin elevation
Paliperidone	Active metabolite of risperidone	9-hydroxyrisperidone

Extrapyramidal Side Effects

The most tested antipsychotic adverse effect cluster. Know each type, its timing and its treatment.

EPS Type	Onset	Features	Treatment
Acute dystonia	Hours to days	Involuntary spasms — torticollis, oculogyric crisis, opisthotonus	Anticholinergics (benztropine, procyclidine) IV or IM immediately
Akathisia	Days to weeks	Subjective restlessness; inability to sit still	Propranolol first-line; benzodiazepines; anticholinergics are less effective
Parkinsonism	Weeks	Tremor, rigidity, akinesia, postural instability	Anticholinergics (benztropine, trihexyphenidyl)
Tardive dyskinesia	Months to years	Orofacial dyskinesias — lip smacking, tongue protrusion, choreiform movements	Stop the offending drug where possible; valbenazine, deutetrabenazine

Key distinctions: acute dystonia responds to anticholinergics, fastest by IM injection. Akathisia responds to propranolol, not anticholinergics. Tardive dyskinesia is treated with VMAT2 inhibitors, and anticholinergics make it worse.

Tardive Dyskinesia

A delayed-onset hyperkinetic movement disorder caused by prolonged dopamine receptor blockade, leading to receptor upregulation and supersensitivity. By definition onset follows at least 3 months of antipsychotic exposure, or 1 month in patients over 60.

Movements are orofacial dyskinesias — lip smacking, chewing, tongue protrusion — with limb choreic and trunk movements. Risk factors are older age, female sex, higher dose, longer duration, typical rather than atypical agents, prior EPS, and mood disorders.

Treatment is prevention first: the lowest effective dose and atypical agents. Switching to clozapine or quetiapine helps, as these carry the lowest EPS risk. VMAT2 inhibitors — valbenazine and deutetrabenazine — deplete presynaptic dopamine and are the approved treatments. Tetrabenazine is the older agent, with a risk of depression. Clonazepam is an adjunct.

Clozapine

Clozapine is used specifically for treatment-resistant schizophrenia — failure of adequate trials of at least two antipsychotics at adequate dose and duration. Its profile combines high D4 affinity, moderate D2 blockade and strong 5HT2A, H1, M1 and alpha-1 blockade, which explains both its efficacy and its side effects.

Adverse Effect	Frequency	Monitoring
Agranulocytosis	1–2%	Weekly WBC for 6 months, then fortnightly
Metabolic syndrome	Very common	Weight, glucose, lipids
Hypersalivation	Very common	Hyoscine or clonidine
Seizures	Dose-dependent	Keep below 600 mg; add valproate if needed
Myocarditis and cardiomyopathy	Rare but fatal	Troponin and CRP in the first month
Sedation	Very common	Give the main dose at night
Hypotension	Common	Slow titration
Constipation	Common	Bowel monitoring, laxatives

Topic 3: Lithium

Indications and Monitoring

Lithium is first-line for acute mania and for bipolar prophylaxis, where it has the most evidence. It is effective in bipolar depression, used to augment antidepressants in treatment-resistant depression, and used for cluster headache prophylaxis.

It has a narrow therapeutic index, so monitoring is not optional.

Parameter	Frequency	Reason
Serum lithium	Every 3–6 months when stable	Therapeutic range 0.6–1.2 mEq/L; 1.0–1.2 in acute mania
Renal function	Every 6 months	Renally excreted and nephrotoxic
Thyroid function	Every 6 months	Causes hypothyroidism in around 40% on long-term treatment
Calcium	Every 6 months	Causes hyperparathyroidism
ECG	Baseline then annually	T-wave flattening or inversion at therapeutic levels

The serum sample is drawn 12 hours after the last dose, as a trough level.

Lithium Toxicity

Severity	Serum Level	Clinical Features
Mild	1.5–2.0 mEq/L	Nausea, vomiting, diarrhoea, coarse tremor, thirst, polyuria, drowsiness
Moderate	2.0–2.5 mEq/L	Confusion, ataxia, slurred speech, muscle twitching, blurred vision, lethargy
Severe	Above 2.5 mEq/L	Seizures, coma, arrhythmias with QTc prolongation, neurotoxicity

Precipitants — remember "DENT": Dehydration, Electrolyte imbalance (low sodium), NSAIDs, Thiazides. A low-sodium state makes renal tubules retain lithium in place of sodium. ACE inhibitors and renal failure also reduce clearance.

Management: stop lithium immediately, give IV normal saline since sodium loading promotes excretion, maintain urine output, and monitor cardiac rhythm. Haemodialysis is indicated when the level exceeds 4 mEq/L with any symptoms, or exceeds 2.5 mEq/L with renal failure or persistent neurological features. There is no specific antidote — haemodialysis is the definitive treatment.

PYQ patterns: the most important interaction is with thiazide diuretics; severe toxicity is treated with haemodialysis.

Topic 4: Diagnostic Criteria

Schizophrenia

Duration is at least one month, with at least two core symptoms from: hallucinations (most commonly auditory), delusions, disorganised thinking, disorganised or abnormal psychomotor behaviour including catatonia, and negative symptoms — flat affect, alogia, avolition, anhedonia, asociality.

Schneider's first-rank symptoms remain high-yield: auditory hallucinations as running commentary, third-person discussion or thought echo; thought insertion, withdrawal and broadcasting; somatic passivity and made feelings, impulses or actions; and delusional perception.

Treatment-resistant schizophrenia is defined as failure of two or more adequate antipsychotic trials of different classes, each at therapeutic dose for at least 6 weeks — at which point the answer is clozapine.

Depression

Three core symptoms are required for at least two weeks: depressed mood, markedly diminished interest or pleasure, and increased fatigue or reduced energy. Additional features include reduced concentration, worthlessness or guilt, hopelessness, disturbed sleep, disturbed appetite or weight, psychomotor change and suicidal ideation.

Mania

Duration is at least 7 days, or any duration if hospitalisation is required. The core feature is persistently elevated, expansive or irritable mood together with increased activity or energy. Associated features — three required with euphoric mood, four with irritable mood — include decreased need for sleep (feeling rested on less, not insomnia), pressure of speech, flight of ideas, grandiosity, distractibility, increased goal-directed activity and reckless behaviour.

Acute mania is treated with lithium for classic euphoric presentations, valproate especially for dysphoric or mixed features, atypical antipsychotics for faster onset than lithium, haloperidol in severe agitation, and ECT where medication fails.

OCD

Obsessions are intrusive, unwanted, recurrent thoughts, images or urges, recognised as one's own but experienced as ego-dystonic. Compulsions are repetitive behaviours or mental acts performed in response to obsessions or rigid rules. The disorder must be time-consuming — over an hour a day — or cause significant distress or impairment.

Drug treatment is fluvoxamine as the first-choice SRI in Indian practice, clomipramine as the most potent antiobsessional agent and first-line in many international guidelines, and the other SSRIs — fluoxetine, sertraline, paroxetine — all effective.

OCD responds to serotonin reuptake inhibitors specifically, not to antidepressants generally. Doses are higher than for depression and response takes 8 to 12 weeks. For treatment-resistant OCD, an antipsychotic is added to the SRI.

Topic 5: Antidepressants

SSRIs — fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram. First-line for depression, OCD, panic disorder, social anxiety, PTSD and GAD. Sexual dysfunction is the most troublesome adverse effect. Fluoxetine has the longest half-life, over 7 days including its active metabolite, so it causes the least withdrawal; paroxetine has the shortest and causes the most.

SNRIs — venlafaxine, desvenlafaxine, duloxetine. Effective for depression with neuropathic pain. Venlafaxine raises blood pressure at high dose. Duloxetine is used in diabetic neuropathy, fibromyalgia and stress urinary incontinence.

TCAs — amitriptyline, imipramine, clomipramine, nortriptyline, desipramine. Multiple receptor blockade means multiple side effects, and they are dangerous in overdose through cardiac arrhythmias with QRS prolongation and anticholinergic crisis. Amitriptyline is the most sedating and anticholinergic; nortriptyline is the best tolerated; imipramine was the first discovered and is also used for enuresis.

MAOIs — phenelzine and tranylcypromine are irreversible; moclobemide is reversible. Irreversible MAOIs with tyramine-rich food cause a hypertensive crisis. Combining them with SSRIs causes serotonin syndrome and requires a two-week washout.

Others — mirtazapine is the most appetite-stimulating and causes no sexual dysfunction; bupropion is a noradrenaline-dopamine reuptake inhibitor also used for smoking cessation, with no sexual dysfunction but a lowered seizure threshold; trazodone is sedating and carries a rare risk of priapism; agomelatine normalises circadian rhythm and needs LFT monitoring; vortioxetine is multimodal and improves cognition.

Feature	Serotonin Syndrome	Hypertensive Crisis (Cheese Reaction)
Cause	SSRIs with MAOIs; tramadol or linezolid with SSRIs	MAOIs with tyramine-rich food
Mechanism	Excess serotonin	Tyramine, normally metabolised by MAO, releases catecholamines
Features	Altered mental status, autonomic instability, neuromuscular abnormality with clonus and hyperreflexia	Severe hypertension, pounding headache, cerebrovascular risk
Treatment	Stop the agents; cyproheptadine; benzodiazepines; supportive care	Phentolamine; avoid beta-blockers

Topic 6: Benzodiazepines

Benzodiazepines bind the GABA-A receptor at a site distinct from the GABA binding site and increase the *frequency* of chloride channel opening — barbiturates increase the *duration*. The result is increased chloride conductance, hyperpolarisation and inhibition.

Indication	Preferred Agent
Acute anxiety or panic	Alprazolam, lorazepam
Alcohol withdrawal and delirium tremens	Diazepam; lorazepam in liver disease
Status epilepticus	IV diazepam or lorazepam
Acute catatonia	IV lorazepam first-line; ECT if no response
Pre-anaesthetic medication	Midazolam
Short-term insomnia	Temazepam, nitrazepam

Prolonged use produces physical dependence. Withdrawal causes anxiety, insomnia, tremor, diaphoresis and, in severe cases, seizures. Treatment is gradual tapering, switching to a long-acting agent to cover the taper.

Topic 7: Alcohol Dependence

The CAGE questionnaire asks whether the patient has felt they should Cut down, been Annoyed by criticism of their drinking, felt Guilty about it, or needed an Eye-opener first thing in the morning. A score of 2 or more is clinically significant, with 71 percent sensitivity and 90 percent specificity.

Delirium tremens begins 48 to 96 hours after the last drink — not immediately. Features are confusion, disorientation and agitation; autonomic instability with tachycardia, hypertension, diaphoresis and fever; visual and tactile hallucinations, classically of insects or animals crawling; seizures; and tremor.

Treatment is benzodiazepines first-line — diazepam, or lorazepam and oxazepam in liver disease since they have no active metabolites. Thiamine is given before glucose to prevent Wernicke's encephalopathy, alongside IV fluids and electrolyte correction.

Component	Feature
Wernicke's encephalopathy	Acute triad of confusion, ophthalmoplegia and ataxia from thiamine deficiency
Korsakoff's psychosis	Chronic anterograde amnesia with confabulation, other cognition relatively preserved
Treatment	IV or IM thiamine, given before any glucose

Topic 8: Personality Disorders

Cluster	Character	Disorders
A — odd or eccentric	Odd, suspicious, isolated	Paranoid, schizoid, schizotypal
B — dramatic or emotional	Emotional, dramatic, impulsive	Antisocial, borderline, histrionic, narcissistic
C — anxious or fearful	Fearful, anxious, rigid	Avoidant, dependent, obsessive-compulsive

Borderline personality disorder is the most tested: impulsivity, self-harm, unstable relationships, fear of abandonment, identity disturbance and affective instability. Dialectical behaviour therapy is the only evidence-based psychotherapy for it.

Antisocial personality disorder cannot be diagnosed before 18 and requires conduct disorder before 15. Schizotypal personality disorder involves magical thinking and odd beliefs on the schizophrenia spectrum, and is a high-risk state for schizophrenia.

High-Yield Psychiatry PYQ Checklist

Work through this alongside the NEET PG 3-month study plan, and test the recall under time pressure with a HAMMER weekly grand test.

• ECT's most important indication — severe depression with suicidal risk
• ECT muscle relaxant — suxamethonium
• ECT induction agent — methohexitone or propofol
• Minimum EEG seizure duration for ECT — 25 seconds
• Most common ECT side effect — memory impairment
• Drug given before ECT — atropine, to prevent bradycardia
• Clozapine — treatment-resistant schizophrenia, with agranulocytosis monitoring
• Clozapine monitoring — weekly WBC for the first 6 months
• Acute dystonia — IV or IM anticholinergics
• Akathisia — propranolol, not anticholinergics
• Tardive dyskinesia — valbenazine or tetrabenazine
• Anticholinergics worsen tardive dyskinesia
• Lithium monitoring — level, renal function, thyroid function and calcium every 6 months
• Lithium sampling — 12 hours post-dose, trough
• Lithium toxic level — above 1.5 mEq/L
• Lithium with thiazides or NSAIDs — raises the level
• Haemodialysis — above 4 mEq/L, or above 2.5 with symptoms
• Lithium side effects — hypothyroidism, hyperparathyroidism, diabetes insipidus, weight gain
• Depression core triad — depressed mood, anhedonia, fatigue, for 2 weeks
• OCD drug of choice — fluvoxamine in India, clomipramine globally
• OCD response time — 8 to 12 weeks
• Serotonin syndrome — SSRIs with MAOIs; treat with cyproheptadine
• MAOIs with tyramine — hypertensive crisis
• CAGE — a score of 2 or more is significant
• Delirium tremens onset — 48 to 96 hours after the last drink
• Delirium tremens treatment — diazepam; lorazepam in liver disease
• Thiamine before glucose in alcoholics
• Wernicke's triad — confusion, ophthalmoplegia, ataxia
• Korsakoff's — anterograde amnesia with confabulation
• Borderline personality disorder — dialectical behaviour therapy
• Bupropion — NDRI, no sexual dysfunction, smoking cessation
• Mirtazapine — appetite stimulating, no sexual dysfunction