Schizophrenia and Suicide: Treatment Optimization

Abstract

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.

Towards Precision Dosing of Clozapine in Schizophrenia: External Evaluation of Population Pharmacokinetic Models and Bayesian Forecasting

“…3 Furthermore, it is the only second-generation antipsychotic drug approved to minimize the risk of suicide in patients with a history of schizophrenia. 4 However, clozapine has a narrow therapeutic range (350–600 ng/mL), 5 with significant inter- and intraindividual variability in serum concentrations for a given dose, partly due to its complex metabolism. 6 Clozapine undergoes first-pass metabolism and is metabolized by CYP1A2 and CYP3A4 to norclozapine and N-desmethylclozapine.…”

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“…Se estima que la esquizofrenia aumenta el riesgo de suicidio 30 y 140 veces, respectivamente, para hombres y mujeres menores de 35 años, y alrededor del 4.9% de las personas con esquizofrenia acabarán por suicidarse. Los factores de riesgo específicos de la enfermedad incluyen la fase temprana de la enfermedad (dos tercios de los suicidios ocurren dentro de los tres años posteriores al inicio de esta), hospitalización reciente, temor al deterioro cognitivo, incumplimiento del tratamiento, alta funcionalidad premórbida y elevada conciencia de los deterioros, lo que en conjunto puede conducir a la desmoralización y la desesperanza 21 .…”

“…La clozapina es el único tratamiento que se ha demostrado que reduce las muertes por suicidio en pacientes con esquizofrenia, aunque en el estudio que demostró disminución de riesgo de suicidio con clozapina, esta se comparó únicamente con olanzapina. Actualmente, clozapina es el único medicamento con indicación de la Food and Drugs Administration (FDA) para reducir el riesgo de suicidio en esta población 21 . Es también el fármaco recomendado por la APA en personas con esquizofrenia si el riesgo de suicidio sigue siendo sustancial a pesar de otros tratamientos 8 .…”

Happiness and Mental Illness: Virtue ethics in Dialogue with Psychology

“…About 5% will die by suicide. 11 Case Illustration with Willa: Willa, who is now 44 years old, has chronic schizophrenia. She was well educated with an honours degree in history.…”