Clozapine: in prevention of suicide in patients with schizophrenia or schizoaffective disorder

Letter to the FDA Proposing Major Changes in the US Clozapine Package Insert Supported by Clozapine Experts Worldwide. Part II: A Review of Fatal Outcomes in US Pharmacovigilance Data and Proposed Changes

PURPOSE/BACKGROUND

This is the second part of a 2-part article that proposes improving the United States (US) clozapine package insert. Part II focuses on fatal outcomes and the 5 boxed warnings, 4 specifically for clozapine: severe neutropenia, seizure, orthostatic hypotension and myocarditis, and 1 for all antipsychotics (elderly with dementia).

METHODS

US reports to the World Health Organization's global pharmacovigilance database were analyzed from clozapine's introduction to January 15, 2023.

FINDINGS/RESULTS

The US was the top reporter worldwide for clozapine with 56,003 reports and 9587 associated fatal outcomes. The 4 clozapine boxed warnings were associated with 534 fatal outcomes (218 with severe neutropenia, 131 with seizures, 125 with orthostasis, 36 with myocarditis, 24 with cardiomyopathy, and 0 with mitral valve prolapse). With no boxed warnings, pneumonia was associated with 674 fatal outcomes and increased white blood cell count (a sign of infection) with 596 fatal outcomes. After considering overlaps, pneumonia and increases in white blood cell count explained 900 fatalities, or 9.4% of 9587 fatal outcomes. The Food and Drug Administration continues to focus on severe neutropenia which was associated with only 218 or 2.3% of fatal outcomes, whereas 97.7% of fatal outcomes reported in US clozapine-treated patients had another cause.

IMPLICATIONS/CONCLUSIONS

To help prevent future deaths in clozapine-treated patients, the clozapine package insert should focus on fatal outcomes during infections. Part II offers detailed solutions regarding current boxed warnings and lack of a warning for pneumonia and other infections. The Supplementary Material includes letters of support from 124 non-US clozapine experts from 44 countries/regions who support Parts I and II.

Clozapine may consistently protect from suicidal behaviors while other antipsychotics may lack a specific protective effect: a comprehensive VigiBase study interpreted in the context of the prior literature

BACKGROUND

In the United States, clozapine was first approved for treatment-resistant schizophrenia and then for suicidality in schizophrenia psychoses. Systematic reviews support clozapine's anti-suicidal effect, but the forensic literature stresses its lethality during overdoses.

RESEARCH DESIGN AND METHODS

Clozapine reports to the international pharmacovigilance database (VigiBase) were analyzed for suicidal ideation, suicide attempts, intentional overdose, and completed suicides from introduction to 1 January 2024. VigiBase uses the information component (IC) as a disproportionality analysis.

RESULTS

The clozapine ICs (range: other antipsychotics) were: 1) suicidal ideation IC = 0.570 with IC025 = 0.454 to IC975 = 0.680 (IC = 3.568 for aripiprazole and 1.729 for risperidone), 2) suicide attempt IC = 1.428 with IC025 = 1.323 to IC975 = 1.529 (IC = 4.150 for quetiapine and 2.968 for risperidone), 3) intentional overdose: IC = 0.995 with IC025 = 0.864 to IC975 = 1.120 (IC = 4.080 for quetiapine and 1.957 for aripiprazole), and 4) completed suicide IC = 1.133 with IC025 = 1.026 to IC975 = 1.235 (IC = 4.648 for quetiapine and 2.160 for risperidone). In summary, all clozapine ICs were significantly lower. We found 2391 clozapine-treated patients on the suicidality spectrum (627 cases with suicidal ideation, 752 with suicide attempt, 488 with intentional overdose, and 731 with completed suicide) but many were taking other antipsychotics. The most frequent reporting countries were the United States, the United Kingdom, and Croatia.

CONCLUSION

This pharmacovigilance study, with all its inherent limitations, provides independent proof, not overlapping with prior literature, that clozapine may have specific strong anti-suicidal effects that do not appear to be present in other antipsychotics. Further VigiBase studies are needed to compare the lethality of an intentional overdose of clozapine (14.3%) with other antipsychotics.

Prevention of suicide by clozapine in mental disorders: systematic review

BACKGROUND

Previous research has investigated the efficacy of clozapine in reducing suicidality in patients with schizophrenia and schizoaffective disorder. We aimed to systematically review published evidence, including studies concerning clozapine administration to treat: (a) refractory suicidality in other mental disorders, including bipolar disorder and borderline and other personality disorders; and (b) refractory cases of non-suicidal self-injury.

METHOD

We performed a PUBMED-search (last day: July 17, 2022) of English-language studies, combining the keywords "clozapine", "suicidality", and "suicide" with various psychopathological terms (e.g. "schizophrenia"). All duplications were eliminated.

RESULTS

Fifty-one studies were eligible for inclusion in the review. Most studies suggest a superior anti-suicide effect of clozapine in schizophrenia/schizoaffective disorder, compared to other antipsychotics, or no antipsychotic therapy, which is not due to the close monitoring of patients for blood dyscrasias. No consensus exists as to whether other antipsychotic drugs share this effect. Discontinuation of clozapine is associated with increases in suicidality. Reductions in refractory suicidality/NSSI are observed in clozapine-treated patients with bipolar disorder or borderline personality disorder, but the evidence is limited. Potential biological underpinnings of the anti-suicide effect of clozapine include its unique profile of modulation of brain neurotransmitters; its non-selectivity for neurotransmitter receptors; specific genetic and hormonal factors; effects on neuroinflammation; and ability to elicit epileptiform activity.

CONCLUSION

The superior anti-suicide effect of clozapine in schizophrenia/schizoaffective disorder patients is well established. It may have a role in severe and refractory cases of suicidality and non-suicidal self-injury in patients with bipolar disorder or borderline personality disorder, but the level and quality of supporting evidence is limited.

Clozapine utilization at the United States Veterans Health Administration: a descriptive report of prescribing patterns and patient characteristics among Operation Enduring Freedom/Operation Iraqi Freedom Veterans

To identify the clozapine utilization rate at Veterans Health Administration, as well as patient characteristics, and correlates of use to garner a better understanding of the Veterans Health Administration-treated clozapine population. A longitudinal retrospective cohort analysis was conducted on all Operation Enduring Freedom/Operation Iraqi Freedom Veterans treated with clozapine prescriptions through Veterans Health Administration from 2006 to 2016. Descriptive and inferential analyses were conducted. The sample of 1.3 million veterans had 15 416 with schizophrenia-spectrum disorders, however; only 197 filled outpatient clozapine prescriptions through Veterans Health Administration, a clozapine utilization rate of 1.28%. Median days on clozapine were 305. Median number of antipsychotic medications was 12, with a median rank of clozapine being the eighth antipsychotic trialed. 59.90% of individuals had at least one period of maintenance clozapine treatment. The median number of psychiatric hospitalizations was four, and Clozapine rank was strongly associated with number of hospitalizations. There were no associations between acute versus maintenance clozapine use and either hospitalizations or mortality. Clozapine utilization was very low relative to recommended prescribing rates. Delayed initiation of clozapine was noted and was associated with increased number of hospitalizations. Lack of observed differences in mortality may be explained by low number of mortalities.

Clozapine associated pulmonary embolism: systematic review

Background: Clozapine is a second-generation antipsychotic used in refractory schizophrenia. Clozapine can lead to pulmonary embolism (PE) by various mechanisms including immobility, weight gain and increased platelet aggregation.

Objectives: We performed a systematic review on published cases of PE associated with clozapine.

Methods: Comprehensive search of Medline, Embase and Cochrane library was done for relevant articles from inception until June 2017

Results: Total of 34 cases from 24 articles were included in the analysis. The mean age was 43.2 years with male predominance (63.6%). The mean dosage of clozapine was 281.4 mg daily. Duration of intake ranged from few days to many years. Nearly half of patients (47.82%) had no other co-morbidities for PE other than clozapine. For those reporting treatment, anticoagulation was chosen in 80%, thrombolysis in 10% and inferior vena cava filter placement in 5%. Mortality was 36.36% with three dying on presentation and an additional 9 dying during the follow-up period. Of the 18 patients in which follow-up data of clozapine were available, the drug was discontinued in 14 patients.

Conclusion: PE can occur at doses lower than usual dose of clozapine (300 mg daily). It is important to consider this association especially in patients with no other risk factors for PE.

Cardiometabolic effects of psychotropic medications

Background Many psychiatric disorders including schizophrenia, bipolar disorder and major depression convey an excess burden of cardiovascular morbidity and mortality. The medications used to treat these conditions may further adversely affect cardiovascular risk and exacerbate health disparities for vulnerable populations. There is a clinical need to appreciate the cardiometabolic adverse effects of psychotropic medications. Methods This paper reviews the most relevant cardiometabolic effects of psychotropic medications, organized around the components of metabolic syndrome. When known, the molecular and physiological mechanisms underlying any adverse cardiometabolic effects are detailed. Results Many commonly used psychotropic medications, particularly antipsychotics, mood stabilizers and some antidepressants, have been independently associated with cardiometabolic risk factors such as insulin resistance, obesity and dyslipidemia. Stimulants, antidepressants that inhibit reuptake of norepinephrine, some antipsychotics and valproic acid derivatives may also increase blood pressure. Conclusion Understanding, assessing and subsequently managing cardiometabolic complications of psychotropic medications are important to mitigate the excess cardiovascular morbidity and mortality in the clinical populations prescribed psychotropic medications. There is considerable variability in risk between medications and individuals. Timely management of iatrogenic cardiometabolic effects is critical.

Do Atypical Antipsychotics Have Antisuicidal Effects? A Hypothesis-Generating Overview

Modern antipsychotic drugs are employed increasingly in the treatment of mood disorders as well as psychoses, stimulating interest in their possible contributions to altering suicidal risk. Clozapine remains the only treatment with an FDA-recognized indication for reducing suicidal risk (in schizophrenia). We carried out a systematic, computerized search for reports of studies involving antipsychotic drug treatment and suicidal behaviors. A total of 19 reports provide data with preliminary support for potential suicide risk-reducing effects of olanzapine, quetiapine, ziprasidone, aripiprazole, and asenapine in addition to clozapine, and provide some support for antipsychotic drug treatment in general. These preliminary findings encourage further testing of antipsychotics for effects on suicidal behavior, making use of explicit, pre-planned assessments of suicidal behavior.

Comparative analysis of pharmacological properties of xanomeline and N-desmethylclozapine in rat brain membranes

BACKGROUND

3(3-Hexyloxy-1,2,5-thiadiazol-4-yl)-1,2,5,6-tetrahydro-1-methylpyridine (xanomeline) and N-desmethylclozapine are of special interest as promising antipsychotics with better efficacy, especially for negative symptoms and/or cognitive/affective impairment.

METHODS

The guanosine-5'-O-(3-[(35)S]thio)triphosphate ([(35)S]GTPγS) binding experiments were performed using (1) conventional filtration technique, (2) antibody-capture scintillation proximity assay, and (3) immunoprecipitation method, in brain membranes prepared from rat cerebral cortex, hippocampus, and striatum.

RESULTS

Xanomeline had agonistic activity at the M1 muscarinic acetylcholine receptor (mAChR) in all brain regions, as well as at the 5-HT1A receptor in the cerebral cortex and hippocampus. On the other hand, N-desmethylclozapine exhibited slight agonistic effects on the M1 mAChR, and agonistic properties at the 5-HT1A receptor in the cerebral cortex and hippocampus. This compound also behaved as an agonist at the δ-opioid receptor in the cerebral cortex and striatum. In addition, the stimulatory effects of N-desmethylclozapine on [(35)S]GTPγS binding to Gαi/o were partially mediated through mAChRs (most likely M4 mAChR subtype), at least in striatum.

CONCLUSIONS

The agonistic effects on the mAChRs (particularly M1 subtype, and also probably M4 subtype), the 5-HT1A receptor and the δ-opioid receptor expressed in native brain tissues, some of which are common to both compounds and others specific to either, likely shape the unique beneficial effectiveness of both compounds in the treatment for schizophrenic patients. These characteristics provide us with a clue to develop newer antipsychotics, beyond the framework of dopamine D2 receptor antagonism, that are effective not only on positive symptoms but also on negative symptoms and/or cognitive/affective impairment.

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia. Part 3: Update 2015 Management of special circumstances: Depression, Suicidality, substance use disorders and pregnancy and lactation

These updated guidelines are based on the first edition of the World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia published in the years 2005 and 2006. For this 2015 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations which are clinically and scientifically relevant. They are intended to be used by all physicians diagnosing and treating patients with schizophrenia. Based on the first version of these guidelines a systematic review, as well as a data extraction from national guidelines have been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and subsequently categorised into six levels of evidence (A-F) and five levels of recommendation (1-5). This third part of the updated guidelines covers the management of the following specific treatment circumstances: comorbid depression, suicidality, various comorbid substance use disorders (legal and illegal drugs), and pregnancy and lactation. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication and other pharmacological treatment options) of patients with schizophrenia.

Characterization of human cytochrome P450s involved in the bioactivation of clozapine

Clozapine is known to cause hepatotoxicity in a small percentage of patients. Oxidative bioactivation to reactive intermediates by hepatic cytochrome P450s (P450s) has be proposed as a possible mechanism. However, in contrast to their role in formation of N-desmethylclozapine and clozapine N-oxide, the involvement of individual P450s in the bioactivation to reactive intermediates is much less well characterized. The results of the present study show that 7 of 14 recombinant human P450s were able to bioactivate clozapine to a glutathione-reactive nitrenium ion. CYP3A4 and CYP2D6 showed the highest specific activity. Enzyme kinetical characterization of these P450s showed comparable intrinsic clearance of bioactivation, implicating that CYP3A4 would be more important because of its higher hepatic expression, compared with CYP2D6. Inhibition experiments using pooled human liver microsomes confirmed the major role of CYP3A4 in hepatic bioactivation of clozapine. By studying bioactivation of clozapine in human liver microsomes from 100 different individuals, an 8-fold variability in bioactivation activity was observed. In two individuals bioactivation activity exceeded N-demethylation and N-oxidation activity. Quinidine did not show significant inhibition of bioactivation in any of these liver fractions, suggesting that CYP2D6 polymorphism is not an important factor in determining susceptibility to hepatotoxicity of clozapine. Therefore, interindividual differences and drug-drug interactions at the level of CYP3A4 might be factors determining exposure of hepatic tissue to reactive clozapine metabolites.

Role of residue 87 in the activity and regioselectivity of clozapine metabolism by drug-metabolizing CYP102A1 M11H: application for structural characterization of clozapine GSH conjugates

In the present study, a site-saturation mutagenesis library of drug-metabolizing CYP102A1 M11H with all 20 amino acids at position 87 was applied as a biocatalyst for the production of stable and reactive metabolites of clozapine. Clozapine is an atypical antipsychotic drug in which formation of reactive metabolites is considered to be responsible for several adverse drug reactions. Reactive intermediates of clozapine can be inactivated by GSH to multiple GSH conjugates by nonenzymatic and glutathione transferase (GST)-mediated conjugation reactions. The structures of several GST-dependent metabolites have not yet been elucidated unequivocally. The present study shows that the nature of the amino acid at position 87 of CYP102A1 M11H strongly determines the activity and regioselectivity of clozapine metabolism. Some mutants showed preference for N-demethylation and N-oxidation, whereas others showed high selectivity for bioactivation to reactive intermediates. The mutant containing Phe87 showed high activity and high selectivity for the bioactivation pathway and was used for the large-scale production of GST-dependent GSH conjugates by incubation in the presence of recombinant human GST P1-1. Five human-relevant GSH adducts were produced at high levels, enabling structural characterization by (1)H NMR. This work shows that drug-metabolizing CYP102A1 mutants, in combination with GSTs, are very useful tools for the generation of GSH conjugates of reactive metabolites of drugs to enable their isolation and structural elucidation.

Elucidating biological risk factors in suicide: role of protein kinase A

Suicide is a major public health concern. Although there have been several studies of suicidal behavior that focused on the roles of psychosocial and sociocultural factors, these factors are of too little predictive value to be clinically useful. Therefore, research on the biological perspective of suicide has gained a stronghold and appears to provide a promising approach to identify biological risk factors associated with suicidal behavior. Recent studies demonstrate that an alteration in synaptic and structural plasticity is key to affective illnesses and suicide. Signal transduction molecules play an important role in such plastic events. Protein kinase A (PKA) is a crucial enzyme in the adenylyl cyclase signal transduction pathway and is involved in regulating gene transcription, cell survival, and plasticity. In this review, we critically and comprehensively discuss the role of PKA in suicidal behavior. Because stress is an important component of suicide, we also discuss whether stress affects PKA and how this may be associated with suicidal behavior. In addition, we also discuss the functional significance of the findings regarding PKA by describing the role of important PKA substrates (i.e., Rap1, cyclic adenosine monophosphate response element binding protein, and target gene brain-derived neurotrophic factor). These studies suggest the interesting possibility that PKA and related signaling molecules may serve as important neurobiological factors in suicide and may be relevant in target-specific therapeutic interventions for these disorders.

Role of human glutathione S-transferases in the inactivation of reactive metabolites of clozapine

The conjugation of reactive drug metabolites to GSH is considered an important detoxification mechanism that can be spontaneous and/or mediated by glutathione S-transferases (GSTs). In case GSTs play an important role in GSH conjugation, genetically determined deficiencies in GSTs may be a risk factor for adverse drug reactions (ADRs) resulting from reactive drug metabolites. So far, the role of GSTs in the detoxification of reactive intermediates of clozapine, a drug-causing idiosyncratic drug reactions (IDRs), has not been studied. In the present study, we studied the ability of four recombinant human GSTs (hGST A1-1, hGST M1-1, hGST P1-1, and hGST T1-1) to catalyze the GSH conjugation of reactive metabolites of clozapine, formed in vitro by human and rat liver microsomes and drug-metabolizing P450 BM3 mutant, P450 102A1M11H. Consistent with previous studies, in the absence of GSTs, three GSH conjugates were identified derived from the nitrenium ion of clozapine. In the presence of three of the GSTs, hGST P1-1, hGST M1-1, and hGST A1-1, total GSH conjugation was strongly increased in all bioactivation systems tested. The highest activity was observed with hGST P1-1, whereas hGST M1-1 and hGST A1-1 showed slightly lower activity. Polymorphic hGST T1-1 did not show any activity in catalyzing GSH conjugation of reactive clozapine metabolites. Interestingly, the addition of hGSTs resulted in major changes in the regioselectivity of GSH conjugation of the reactive clozapine metabolite, possibly due to the different active site geometries of hGSTs. Two GSH conjugates found were completely dependent on the presence of hGSTs. Chlorine substitution of the clozapine nitrenium ion, which so far was only observed in in vivo studies, appeared to be the major pathway of hGST P1-1-catalyzed GSH conjugation, whereas hGST A1-1 and hGST M1-1 also showed significant activity. The second GSH conjugate, previously also only found in in vivo studies, was also formed by hGST P1-1 and to a small extent by hGST A1-1. These results demonstrate that human GSTs may play a significant role in the inactivation of reactive intermediates of clozapine. Therefore, further studies are required to investigate whether genetic polymorphisms of hGST P1-1 and hGST M1-1 contribute to the interindividual differences in susceptibility to clozapine-induced adverse drug reactions.

Management of schizophrenia with suicide risk

Suicidal behavior remains a major source of morbidity and mortality among schizophrenics. The National Institute of Mental Health Longitudinal Study of Chronic Schizophrenia found that over a mean of 6 years, 38% of the patients had at least one suicide attempt and 57% admitted to substantial suicidal ideation. Suicide is also a major issue among inpatients, with serious implications for clinical practice and patient-doctor relationships. The management of schizophrenic patients with suicide risk remains a difficult area for clinicians despite attempts to better understand it by gathering experts in the field. This article discusses the frequency of suicidal behavior in schizophrenia, offers a model for understanding it, and discusses various aspects of the management of the at-risk schizophrenic patient.

Clozapine-Induced Pulmonary Embolism: A Case Report and Literature Review

Purpose

To report a case of pulmonary emboli induced by clozapine in a patient who was also using nicotine gum. This case is presented to alert health care providers of this rare adverse effect, to call attention to the risks associated with thromboembolism, and to enable prompt recognition of symptoms so that morbidity and mortality may be decreased in future cases.

Summary

A 51-year-old white woman was admitted to the psychiatric ward of a hospital for depression. She had suicidal ideation, was experiencing ethanol abuse relapse, and had had auditory hallucinations caused by concomitant medication nonadherence for 2 weeks prior to admission. The patient smoked 2 packs of cigarettes per day and was adhering to a smoking cessation program that included the use of nicotine gum. She developed diffuse pulmonary emboli 15 days after clozapine initiation. Application of the Naranjo Adverse Drug Reaction Probability Scale to this case indicated a probable relationship between initial clozapine titration and the development of pulmonary emboli in the patient. Clozapine was discontinued without tapering, and the patient was discharged with prescriptions for fluphenazine and warfarin.

Discussion

The exact mechanism by which clozapine causes pulmonary emboli is unclear, but there have been some hypotheses. This case is similar to previously reported cases because pulmonary embolism was seen on the initiation of clozapine therapy; however, it is unclear whether the concurrent use of nicotine gum increased the risk of developing pulmonary embolism.

Conclusion

Based on previous case studies and the literature, it was concluded that clozapine alone was the cause of pulmonary embolism in this patient. The role of nicotine remains questionable.

The influence of clozapine treatment and other antipsychotics on the 18 kDa translocator protein, formerly named the peripheral-type benzodiazepine receptor, and steroid production

It has been shown that the atypical antipsychotic drug clozapine increases the levels of the neurosteroid allopregnanolone in the rat brain. The 18 kDa translocator protein (TSPO), formerly known as the peripheral-type benzodiazepine receptor, has been demonstrated to be involved in the process of steroid biosynthesis, in peripheral steroidogenic tissues as well as in glia cells in the brain. In the current study, we investigated the influence of chronic treatment with clozapine and other antipsychotics (thioridazine,sulpiride and risperidone) on TSPO binding in cell cultures and rat tissues. Clozapine significantly increased TSPO binding density in C6 rat glioma cells and in MA-10 mouse Leydig tumor cells, while the antipsychotic sulpiride had no effect on TSPO binding density in both cell lines. In addition, clozapine, but not sulpiride, significantly increased progesterone synthesis by MA-10 Leydig tumor cells. In an animal experiment, male Sprague-Dawley rats were treated with clozapine (20 mg/kg), risperidone (0.5 mg/kg), thioridazine (20 mg/kg), or sulpiride (20 mg/kg) for 21 days, followed by 7 days of withdrawal. Clozapine induced significant increases in TSPO binding in brain and peripheral steroidogenic tissues, whereas the other antipsychotics did not show such pronounced effects on TSPO binding. Our results suggest that TSPO may be involved in the modulation of steroidogenesis by clozapine.

Assessment and treatment of suicide risk in schizophrenia

Schizophrenic patients at risk of suicide are more likely to be young, male, white, never married, with post-psychotic depression, and a history of substance abuse and suicide attempts. Hopelessness, social isolation, awareness of illness and hospitalization are also related to suicide risk. Deteriorating health with a high level of premorbid functioning, recent loss or rejection, limited external support, family stress or instability are other features that have been reported in schizophrenic patients who commit suicide. Atypical antipsychotics, especially clozapine, have emerged as important tools in the therapeutic armamentarium. Psychosocial intervention and psychotherapy may play an important role in the management of suicide risk, especially if such interventions help the patient face daily difficulties, loneliness and conflicts inside the family.

Managing Psychotic Illness in Young People: A Practical Overview

  The management of early onset psychosis poses a significant challenge to professionals working in Child and Adolescent Mental Health Services. Young people with psychotic illness often present with a mixed clinical picture and a wide variety of attendant issues. Over the last decade there has been accumulating research, mainly based on work with adults, regarding the efficacy and effectiveness of medical and psychosocial interventions for patients with schizoaffective spectrum disorders. This article takes a symptoms-based approach, collating and summarising recent evidence, where it exists, regarding best practice when managing young people affected by schizophrenia, schizoaffective or bipolar affective disorder.

Schizophrenia and Suicide: A 10-Year Review of Kentucky Medical Examiner Cases

The risk of suicide is significantly increased in schizophrenics; it is estimated that 10-13% of individuals suffering from schizophrenia commit suicide. Schizophrenia is marked by psychotic exacerbations and remissions, with persistent deterioration in baseline functioning with each relapse. We present a 10-year (1993-2002) retrospective review of Medical Examiners' cases of suicide of schizophrenic victims. Twenty-nine cases were between the ages of 20 and 75 (mean age of 41.6 years). The majority of victims were male (62.1%) and Caucasian (86.2%). The leading method of suicide for both males and females was firearm injury (48.3%) mostly of the head, followed by overdose (20.7%), and hanging (13.8%). A comprehensive investigation of the biopsychosocial factors is warranted in cases of schizophrenics who commit suicide. This study offers an insightful analysis pertaining to the determination of intent in formulating the manner of death in this unique population.

Clozapine-induced sialorrhea: pathophysiology and management strategies

RATIONALE

Clozapine is an atypical antipsychotic agent with proven efficacy in refractory schizophrenia, but its widespread use is limited by adverse effects such as agranulocytosis, seizures, sedation, weight gain, and sialorrhea. Clozapine-induced sialorrhea (CIS) is bothersome and has socially stigmatizing adverse effects, which result in poor treatment compliance. The pathophysiology of this condition is poorly understood and the treatment options available are based mostly on case reports and open-label studies.

OBJECTIVE

To review the available studies on CIS.

METHOD

All relevant studies available through PUBMED search supplemented with manual search were undertaken.

RESULT

The clinical features, complications, assessment, pathophysiology, and management of CIS are discussed.

CONCLUSION

Although the studies evaluating the therapeutic options has limitations and no drug has been found to be superior, judicious use of pharmacological agents along with behavioral methods will reduce this troublesome side effect and enhance compliance.

Luces y sombras de la prestación farmacéutica en España: a propósito de los antidepresivos y antipsicóticos

Mental disorders mortality rates are low but they are extremely disabling so that the diagnosis and treatment of mental illness is an important task for public health and it is central in current therapy strategies and sanitary policy. The aim of this study is to analyse conditions influencing antidepressants and antipsychotics use in Spain from 1997 to 2004. Tryciclic antidepressants have been of first-choice in depression treatment for many years but their side effects profile are related to a lack of treatment adherence. Trying to increase tolerance, new antidepressants have been developed and research into new therapeutic uses is being done. These are some of the reasons causing an increase in medical utilization and costs. Medical boxes sold have increased from 14,14 million in 1997 to 26,76 million in 2004, meaning 168,61 and 447,11 million euros respectively. Antipsychotic use has been maintained, 11,74 million boxes in 1997 and 12,65 in 2004; however, there has been a rise in price from 61,84 to 317,46 million euros due to second generation antipsychotics prescription (mainly risperidone and olanzapine) Some conditions have contributed to current situation: increased number of diagnosed patients with depression and other mental disorders, new approved therapeutic uses and a rise in elderly people receiving new antipsychotic agents. Moreover, promotional marketing is causing an increase in new recently commercialised drugs use.

Effect of anticholinergics in preventing acute deterioration in patients undergoing abrupt clozapine withdrawal

BACKGROUND

The most serious adverse effect of clozapine, agranulocytosis, was described for the first time in Finland in 1975. It caused the immediate withdrawal of clozapine from the market and immediate discontinuation of this medication in all patients. It is now known that abrupt withdrawal of clozapine may cause a rapid deterioration in psychotic symptoms.

OBJECTIVE

The aim of this retrospective study was to investigate the effect of abrupt clozapine withdrawal on psychiatric patients, and to examine whether anticholinergic drugs are effective in preventing acute deterioration.

MATERIALS AND METHODS

We reviewed the hospital case records from Pitkäniemi Psychiatric Hospital, Tampere, Finland, of the 28 patients with schizophrenia who had been receiving clozapine and from whom it was abruptly withdrawn due to the withdrawal of the drug from the market in the summer of 1975. We assessed the incidence of deterioration and whether or not patients in whom this occurred were receiving anticholinergic drugs.

RESULTS

We found a rapid deterioration after clozapine withdrawal in almost half (46.4%; n = 13) of the patients. Patients receiving anticholinergic drugs (such as antiparkinsonians, tricyclic antidepressants and antipsychotics with anticholinergic properties) were significantly less likely to deteriorate than those not receiving these drugs (21.4% vs 71.4%, p = 0.008). The condition of the patients who deteriorated was poor for up to 1 month after discontinuation, but had improved slightly by the end of 1975.

CONCLUSION

Anticholinergic medication should be considered for preventing possible symptom deterioration when clozapine is abruptly discontinued.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, Part 1: acute treatment of schizophrenia

These guide lines for the biological treatment of schizophrenia were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBO). The goal during the development of these guidelines was to review systematically all available evidence pertaining to the treatment of schizophrenia, and to reach a consensus on a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating people with schizophrenia. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for schizophrenia, as well as from meta-analyses, reviews and randomised clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of schizophrenia, as well as the management of the acute phase treatment. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication, other pharmacological treatment options, electroconvulsive therapy, adjunctive and novel therapeutic strategies) of adults suffering from schizophrenia.

Comparison of Classical and Clozapine Treatment on Schizophrenia Using Positive and Negative Syndrome Scale of Schizophrenia (PANSS) and SPECT Imaging

Many neuroimaging studies of schizophrenia have shown abnormalities in the frontal cortex, limbic system, basal ganglia, temporal and parietal lobes. These findings are not specific or consistent enough to build up a coherent theory of the origin of the brain abnormality in schizophrenia. This paper describes a state-of-the-art approach of SPECT to correlate neuropsychological evaluation. PANSS scores and different brain focal abnormalities of two groups of patients receiving Clozapine and classical antipsychotic treatments were observed. A total of 20 drug-free patients, actively psychotic schizophrenic, were selected according to the DSM-IV criteria. Pre-Post-treatment was designed using PANSS and 99mTc- ECD-SPECT to assess regional Cerebral Blood Flow (rCBF). The results showed that after treatment, differences in PANSS scores were significant in both groups, with superior scores resulting from the Clozapine therapy. Results were supported by SPECT, which showed a greater improvement in the Clozapine group. Both positive and negative symptoms were improved with Clozapine as well. Before treatment, hypofrontality was the most common (85%) finding, whereas after treatment hypofrontality was mostly cleared. However, in some areas like temporal and caudate, hyperfrontality was induced. Negative symptoms showed linkage to hypofrontality in both groups before and after treatment, and both positive and negative symptoms were improved more with Clozapine therapy than with classical treatment.

Mourning, insight, and reduction of suicide risk in schizophrenia

Literature on the assessment of suicide risk in individuals with schizophrenia is summarized, including the risk factors shared in common with the general population, illness-specific risk factors, and times of heightened risk in the course of the illness. Because depression emerges as a significant risk factor, it is differentiated from conditions that can mimic depression: mourning, aprosodia, and negative symptoms. Because insight or awareness of illness carries risk, as does the lack of insight, the psychological and neurocognitive components of impaired and of accurate insight are described. Finally, the role of mourning in the attainment of accurate, usable insight that can reduce suicidal risk is described.