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Suicide I Schizophrenia I Schizoaffective disorder I Nonadherence, Long-acting injectable I Substance abuse I Clozapine I Side effects I Risk factors, Depression, Antidepressants, Citalopram, Naltrexone Opinion statement In the aftermath of a serious suicide attempt, 25-50 % of patients with schizophrenia or schizoaffective disorder will make another attempt within 2 years; within 10 years, 3 % will have completed suicide, which represents about 60 % of all patients with these diagnoses who complete suicide. When treating such high suicide risk patients, initiating or continuing treatment with clozapine must always be the initial consideration. Clozapine is the only treatment approved to reduce suicide risk in this (or any other) population. Its efficacy for this purpose is supported by the highest quality evidence, including a prospective, randomized controlled trial, InterSePT. A trial of clozapine should be strongly considered even for first-episode patients and those whose psychotic symptoms have responded to other antipsychotics, as amelioration of psychotic symptoms may be insufficient to reduce suicide risk. When recommending a trial of clozapine, thorough psychoeducation for the patient and his or her support system is necessary. This should include informing patients that indefinite treatment with clozapine may be needed because of the elevated risks of suicide and relapse to psychosis upon drug discontinuation. Discussion of the anticipated side effects and the providers' commitment to help minimize side effects are needed to make the trial of clozapine more attractive. If a trial of clozapine is unacceptable or impossible, alternative antipsychotic medications should be used and adherence monitored. A long-acting injectable atypical antipsychotic drug is preferable to oral medication, and certainly, to no antipsychotic treatment. The clinician should regularly inquire about suicidal thoughts and hopelessness and limit patients' access to means of self-harm. In addition, one should identify the symptoms, behaviors and social factors that contribute to each patient's suicide risk, and provide a combination of pharmacotherapy, psychosocial rehabilitation modalities, and psychotherapeutic interventions to address these factors.

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