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2. 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

3. Suicidality in schizophrenia
Common issue
Importance of identification
Role of clozapine

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

5. 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

6. 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

7. 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

8. 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

9. 1st Trial
2nd Trial
Clozapine
Clozapine
Suicidality

10. 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),

11. 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),

12. Recommendation(s)

13. 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

14. 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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