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Suicidal Behavior and Clozapine Use David N. Osser, MD, Associate Professor of Psychiatry Harvard Medical School Brockton Division of the VA Boston Healthcare System General Editor - Psychopharmacology Algorithm Project Harvard South Shore Residency Training Program

Suicidality in schizophrenia Common issue Importance of identification Role of clozapine

Approximately 50% of patients attempt suicide Approximately 10% of patients die of suicide

The InterSePT trial 980 patients Clozapine Olanzapine Meltzer, H. Y et al (2003). Clozapine treatment for suicidality in schizophrenia: international suicide prevention trial (InterSePT). Archives of general psychiatry, 60(1), 82-91

The InterSePT trial 980 patients Clozapine Olanzapine Hx of suicide attempt within last 3 yrs Suicidal ideation with depressive symptoms Only 27% were TR Meltzer, H. Y et al (2003). Clozapine treatment for suicidality in schizophrenia: international suicide prevention trial (InterSePT). Archives of general psychiatry, 60(1), 82-91

25% reduction of suicidal behaviors The InterSePT trial Clozapine 25% reduction of suicidal behaviors 980 patients Olanzapine Hx of suicide attempt within last 3 yrs Suicidal ideation with depressive symptoms Only 27% were TR Meltzer, H. Y et al (2003). Clozapine treatment for suicidality in schizophrenia: international suicide prevention trial (InterSePT). Archives of general psychiatry, 60(1), 82-91

The InterSePT trial 25% reduction of suicidal behaviors 980 patients Clozapine 25% reduction of suicidal behaviors 980 patients Hx of suicide attempt within last 3 yrs Suicidal ideation with depressive symptoms Only 27% were TR Approval for use in patients with suicidality in schizophrenia Meltzer, H. Y et al (2003). Clozapine treatment for suicidality in schizophrenia: international suicide prevention trial (InterSePT). Archives of general psychiatry, 60(1), 82-91

1st Trial 2nd Trial Clozapine Clozapine Suicidality

Rates of suicide or attempts Clozapine Other APs Meta-analysis: 6 RCTs Rates of suicide or attempts Hennen, J., & Baldessarini, R. J. (2005). Suicidal risk during treatment with clozapine: a meta-analysis. Schizophrenia research, 73(2), 139-145.

Three-fold overall reduction of risk of suicidal behaviors Clozapine Other APs Meta-analysis: 6 RCTs Rates of suicide or attempts Hennen, J., & Baldessarini, R. J. (2005). Suicidal risk during treatment with clozapine: a meta-analysis. Schizophrenia research, 73(2), 139-145.

Recommendation(s)

Recommendations Consider clozapine earlier for: Patients with active suicidal thought and behavior Even if not treatment-resistant No other medication has evidence of effectiveness (e.g. antidepressants)  Consider clozapine earlier for: Clozapine

Recommendations Consider clozapine earlier for: Patients with active suicidal thought and behavior Even if not treatment-resistant No other medication has evidence of effectiveness (e.g. antidepressants)  Consider clozapine earlier for: Clozapine

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