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Am J Psychiatry 1995; 152:183-190
Copyright © 1995 by American Psychiatric Association
Reduction of suicidality during clozapine treatment of neuroleptic- resistant schizophrenia: impact on risk-benefit assessment
HY Meltzer and G Okayli
Department of Psychiatry, Case Western Reserve University School of Medicine, Cleveland.
OBJECTIVE: Suicide has been reported to occur in 9%-13% of schizophrenic
patients. It has been suggested that neuroleptic- resistant or
neuroleptic-intolerant schizophrenic patients are at higher risk for
suicide than neuroleptic-responsive patients. Clozapine is the treatment of
choice for neuroleptic-resistant patients, but its use has been greatly
limited because of its ability to cause potentially fatal agranulocytosis.
The purpose of this study was to compare the suicidality of
neuroleptic-resistant and neuroleptic- responsive patients and to determine
if clozapine treatment decreased suicidality in the former group. METHOD:
Prior episodes of suicidality were assessed in a total of 237
neuroleptic-responsive and 184 neuroleptic-resistant patients with
schizophrenia or schizoaffective disorder. Eighty-eight of the
neuroleptic-resistant patients were treated with clozapine and
prospectively evaluated for suicidality for periods of 6 months to 7 years.
RESULTS: There was no significant difference in prior suicidal episodes
between neuroleptic-responsive and neuroleptic-resistant patients.
Clozapine treatment of the neuroleptic-resistant patients during the
follow-up period resulted in markedly less suicidality. The number of
suicide attempts with a high- probability of success decreased from five to
zero. This decrease in suicidality was associated with improvement in
depression and hopelessness. CONCLUSIONS: These results suggest a basis for
reevaluation of the risk-benefit assessment of clozapine, i.e., that the
overall morbidity and mortality of patients with neuroleptic- resistant
schizophrenia are less with clozapine treatment than with typical
neuroleptic drugs because of less suicidality. This conclusion also has
implications for increasing the use of clozapine with
neuroleptic-responsive patients.
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