Posttest self-assessment question and answer

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

Answer: E

As noted in the prior section, clonazepam (Klonopin) is not FDA approved but is suggested as an augmentation strategy per the APA guidelines. Its use as a monotherapy has supportive small clinical trials and case reports to condone its use, especially when other therapies fail or are not tolerated. Large, 200–300-patient, randomized and controlled regulatory trials are nonexistent, and therefore, no formal approval exists.

References

1.Emsley R, Berwaerts J, Eerdekens M, et al. Efficacy and safety of oral paliperidone extended-release tablets in the treatment of acute schizophrenia: pooled data from three 52-week open-label studies. Int Clin Psychopharmacol 2008; 23:343–56.

2.Stahl SM. Stahl’s Essential Psychopharmacology, 4th edn. New York, NY: Cambridge University Press, 2013.

3.Stahl SM. Stahl’s Essential Psychopharmacology: The Prescriber’s Guide, 5th edn. New York, NY: Cambridge University Press, 2014.

4.American Psychiatric Association. Practice Guideline for the Treatment of Patients with Bipolar Disorder, 2nd edn. Washington, DC: American Psychiatric Association Press, 2002.

5.Twiss J, Jones S, Anderson I. Validation of the mood disorder questionnaire for screening for bipolar disorder in a UK sample. J Affect Disord 2008; 110:180–4.

6.Zimmerman M, Mattia JI. The psychiatric diagnostic screening questionnaire: development, reliability and validity. Compr Psychiatry 2001; 42:175–89.

7.Frye MA, Grunze H, Suppes T, et al. A placebo-controlled evaluation of adjunctive modafinil in the treatment of bipolar depression. Am J Psychiatry 2007; 164:1242–9.

8.Calabrese JR, Ketter TA, Youakim JM, et al. Adjunctive armodafinil for major depressive episodes associated with bipolar I disorder: a randomized, multicenter, double-blind, placebo-controlled, proof-of-concept study. J Clin Psychiatry 2010; 71:1363–70.

9.Chen J, Fang Y, Kemp DE, Calabrese JR, Gao K. Switching to hypomania and mania: differential neurochemical, neuropsychological, and pharmacologic triggers and their mechanisms. Curr Psychiatry Rep 2010; 12:512–21.

10.Shelton RC, Reddy R. Adjunctive use of modafinil in bipolar patients: just another stimulant or not? Curr Psychiatry Rep 2008; 10:520–4.

11.Pagano ME, Demeter CA, Faber JE, Calabrese JR, Findling RL. Initiation of stimulant and antidepressant medication and clinical presentation in juvenile bipolar I disorder. Bipolar Disord 2008; 10:334–41.

12.Lydon E, El-Mallakh RS. Naturalistic long-term use of methylphenidate in bipolar disorder. J Clin Psychopharmacol 2006; 26:516–18.

13.Scheffer RE, Kowatch RA, Carmody T, Rush AJ. Randomized, placebo-controlled trial of mixed amphetamine salts for symptoms of comorbid ADHD in pediatric bipolar disorder after mood stabilization with divalproex sodium. Am J Psychiatry 2005; 162:58–64.

14.Hellander M. Medication-induced mania: ethical issues and the need for more research. J Child Adolesc Psychopharmacol 2003; 13:199.

15.American Psychiatric Association. Practice Guidelines for the Treatment of Patients with Bipolar Disorder. http://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines. Accessed March 26, 2011.

16.American Psychiatric Association. Treating Bipolar Disorder. A Quick Reference Guide. http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar-guide.pdf. Accessed March 26, 2011.

17.Nardi AE, Perna G. Clonazepam in the treatment of psychiatric disorders: an update. Intern Clin Psychopharmacol 2006; 21:131–42.

18.Nihalani N, Schwartz TL, Siddiqui UA, Megna JL. Weight gain, obesity, and psychotropic prescribing. J Obes 2011; 2011:893629.

Patient file

The Case:

The lady and the man who sat on couches

The Question:

Are the symptoms of apathy of an elderly man and woman due to depression, dementia, or side effects of medication?

The Dilemma:

How to tell depression from vascular dementia (and everything in between as well)

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

Which are correct regarding vascular depression?

A. There is evidence that cerebrovascular disease creates vulnerability to depression, as well as cognitive impairment and neurologic signs

B. Clinical presentation suggests a medial frontal lobe syndrome with psychomotor retardation, apathy, and marked disability

C. Cerebrovascular lesions on neuroimaging results in poor outcomes, including persistence of depression with unstable remission and increased risk for dementia

D. Depression–executive dysfunction syndrome (DED) is similar but may have multifactorial causes, that is, vascular disease, aging-related changes, degenerative brain disease, combined in a cumulative or synergistic effect

E. All of the above