Pretest self-assessment question (answer at the end of the case)

What is the evidence to support the use of clonazepam (Klonopin) in manic patients?

A. It is not approved but meta-analysis studies show effectiveness

B. It is not approved but small-scale studies show effectiveness

C. It is not approved but case series and case studies show effectiveness

D. It is approved, based on large-scale regulatory studies

E. A, B, and C

Patient evaluation on intake

35-year-old woman with a chief complaint of difficulty coping at her job

Psychiatric history

The patient has had psychiatric symptoms since her 20s. She reports depression and agitation as her predominant, albeit fluctuating symptoms

States that she has alienated friends and co-workers by being verbally intrusive at times

Cannot complete work assignments and feels depressed

Admits full MDD symptoms now but is not suicidal

Simultaneously is agitated, has rapid speech, intrusive behaviors, condescending demeanor, distractibility, and appears thought disorganized with blocking

States that she also suffers interruptions

• – These are described initially as her own thoughts taking over her brain, or as her own thoughts making their own comments to her, but never defined as other voices or hallucinations. These events cause her thought blocking

History includes at least two psychiatric hospitalizations for depression She has had no suicide attempts

• – A review of psychiatric systems revealed no formal anxiety disorder, eating disorder, SUD over the last decade. She states the only addictive drugs she has used are those provided by her previous psychiatrist (d/l-mixed amphetamine salts [Adderall])

• – Attended eclectic, supportive psychotherapy in the past but has not had formal CBT or PDP

• – There is no evidence of marked personality disorder

• – Patient states that she suffers from ADHD per her previous prescriber and has utilized stimulants more recently as a result. Her inability to focus right now is a main concern as she cannot get tasks completed

• – Presents with no medications as her previous psychiatrist has terminated with her

• – Previously failed to respond to adequately dosed SSRIs (escitalopram [Lexapro] 30 mg/d, fluoxetine [Prozac] 40 mg/d, paroxetine [Paxil] 40 mg/d) and SNRIs (venlafaxine-XR [Effexor-XR] 300 mg/d) in the past

• – Responded to typical antipsychotics (thiothixene [Navane] 40 mg/d, haloperidol [Haldol] 10–20 mg/d), and atypical antipsychotics (risperidone [Risperdal] 4 mg/d), but has had abnormal movements, which she states were TD, as a result

• – Has responded to divalproex sodium (Depakote) 1500 mg/d but developed elevated ammonia levels with an altered mental state

• – Lamotrigine (Lamictal) was not therapeutic as she developed a non-serious rash at low doses and had to discontinue it

• – Most recently has been taking mixed amphetamine salts (Adderall) 50 mg/d and subsequently lisdexamfetamine (Vyvanse) 60 mg/d in order to improve energy, concentration, and focus, but has run out of medications between providers

Social and personal history

Married and has no children

Is college educated, works as a social worker at a local hospital

Does not drink alcohol, smoke cigarettes, or take illegal drugs

Medical history

Asthma

Migraines

Possible history of drug-induced dyskinesia

Family history

None

Current psychiatric medications

None as she has been off her stimulant and SSRI for two weeks

Current medical medications

None

Question

Based on what you know about this patient’s history and current symptoms, what would you consider her working diagnosis to be?

Psychotic MDD

Bipolar mania

Bipolar or MDD with mixed features

Stimulant intoxication

Borderline personality

What would you do first?

Obtain information from previous provider

Obtain information from previous inpatient stays

Obtain information from her pharmacy regarding medications filled to better assess the completeness of her medication trials and to corroborate her fragmented history

Add an antidepressant

Add lithium or divalproex sodium (Depakote) or carbamazepine (Equetro)

Add an atypical antipsychotic