Comments and Controversies
Dr. Scott Freeman’s useful discussion of targeting acute risk factors in suicidal patients (“Suicide assessment: Targeting acute risk factors,” Current Psychiatry, January 2012, p. 52-57) ends by resolving the clinical vignette with a summary of hospital treatment. Apart from failing to indicate any psychotherapeutic inroads, Dr. Freeman seems to support prescribing clonazepam, 0.5 mg twice daily and 1 mg at bedtime. Clonazepam apparently “worked” by alleviating the patient’s anxiety and insomnia, but defied any pharmacologic rationale insofar as clonazepam has a slow onset and long half-life, making 3 doses per day irrational. This treatment strategy also risks problems of cumulative excess in the long run after discharge.
Aggressive pharmacotherapy may be the hallmark of modern acute hospital treatment, but surely it should incorporate careful understanding of specific medications’ pharmacodynamics, especially when relying on benzodiazepines. Needless to say, beginning a psychological process in the hospital also appears to have been shortchanged.
Sara Hartley, MD
Lecturer, Clinical Skills Program
University of California,
Berkeley-University of California,
San Francisco Joint Medical Program
Dr. Freeman responds
I appreciate Dr. Hartley’s interest in my article. Although I agree with her that psychotherapy is an integral part of any treatment plan, the clinical vignette was used only to emphasize the need to aggressively and quickly start antidepressant and, more importantly, anxiolytic pharmacologic treatment in acutely suicidal patients with severe anxiety and depression.
With regard to clonazepam’s pharmacokinetics, although it does have a long half-life, it is only weakly lipophilic compared with other long-acting benzodiazepines such as diazepam. In fact, clonazepam has been shown to be less lipophilic than lorazepam,1 meaning it has a much smaller volume of distribution and less accumulation in peripheral adipose tissue. Therefore, one would not be concerned about significant drug accumulation leading to unexpected toxicity with a less lipophilic agent such as clonazepam.
I do not agree that dosing clonazepam 3 times a day, especially in an acute crisis, is “irrational,” as Dr. Hartley suggests. According to the package insert, although clonazepam is recommended to be administered twice daily for panic disorder, it can be given 3 times a day for seizure disorders.2
Scott A. Freeman, MD
Schizophrenia and Bipolar Disorder Inpatient Unit