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11: Clozapine

Risk Management and Treatment » Pharmacologic and other Somatic Treatments
11: Clozapine

We suggest clozapine to reduce the risk of suicide attempts for patients with schizophrenia or schizoaffective disorder and either suicidal ideation or a history of suicide attempt(s).

Strength:

Weak for

Category:

ReviewedAmended

Grades and Definitions

Strong for
or "We recommend offering this option …"
Weak for
or "We suggest offering this option …"
No recommendation
or "There is insufficient evidence …"
Weak against
or "We suggest not offering this option …"
Strong against
or "We recommend against offering this option …"

Categories and Definitions

Evidence Reviewed* Recommendation Category* Definition*
Reviewed New-added New recommendation following review of the evidence
New-replaced Recommendation from previous CPG that has been carried over to the updated CPG that has been changed following review of the evidence
Not changed Recommendation from previous CPG that has been carried forward to the updated CPG where the evidence has been reviewed but the recommendation is not changed
Amended Recommendation from the previous CPG that has been carried forward to the updated CPG where the evidence has been reviewed and a minor amendment has been made
Deleted Recommendation from the previous CPG that has been removed based on review of the evidence
Not reviewed Not changed Recommendation from previous CPG that has been carried forward to the updated CPG, but for which the evidence has not been reviewed
Amended Recommendation from the previous CPG that has been carried forward to the updated CPG where the evidence has not been reviewed and a minor amendment has been made
Deleted Recommendation from the previous CPG that has been removed because it was deemed out of scope for the updated CPG
*Adapted from the NICE guideline manual (2012): The guidelines manual. London: National Institute for Health and Care Excellence;2012. and Martinez Garcia L, McFarlane E, Barnes S, Sanabria AJ, Alonso-Coello P, Alderson P. Updated recommendations: An assessment of NICE clinical guidelines. Implement Sci. 2014;9:72.

Recommendation Resources

Clozapine is an atypical antipsychotic medication that has been found to reduce suicidal behaviors in patients diagnosed with schizophrenia or schizoaffective disorder. The quality and consistency of studies on this are highly variable.

Training Resources

This section includes links to training resources about offering clozapine to reduce the risk of suicide attempts for patients with schizophrenia or schizoaffective disorder.

VA National Clozapine Coordinating Center
An invaluable resource for VA clozapine prescribers. NCCC can offer consultation for difficult cases, as well as, assist with logistics concerns related to prescribing within the VA and difficulties with CPRS related to clozapine. Questions can go: vhaclozapine@va.gov.
National Clozapine Coordination Center (NCCC) SharePoint (VA Intranet access required)
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Manuals

This section includes links to implementation manuals or resources about offering clozapine to reduce the risk of suicide attempts for patients with schizophrenia or schizoaffective disorder.

VHA Directive 1108.17: Clozapine Patient Management
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Webinars

This section includes links to webinars that are recommended about offering clozapine to reduce the risk of suicide attempts for patients with schizophrenia or schizoaffective disorder.

CPG Webinar Perceived Barriers and Facilitators of Clozapine Use: A National Survey of Veterans Affairs Prescribers Presented by Drs. Breanna Moody & Courtney Eatmon
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Articles

This section includes links to recommended articles about offering clozapine to reduce the risk of suicide attempts for patients with schizophrenia or schizoaffective disorder.

Alphs, L., Anand, R., Islam, M. Z., Meltzer, H. Y., Kane, J. M., Krishnan, R., Green, A. I., Potkin, S., Chouinard, G., Lindenmayer, J. P., & Kerwin, R. (2004). The international suicide prevention trial (interSePT): rationale and design of a trial comparing the relative ability of clozapine and olanzapine to reduce suicidal behavior in schizophrenia and schizoaffective patients. Schizophrenia bulletin, 30(3), 577-586. https://doi.org/10.1093/oxfordjournals.schbul.a007102
Cho, J., Hayes, R. D., Jewell, A., Kadra, G., Shetty, H., MacCabe, J. H., & Downs, J. (2019). Clozapine and all-cause mortality in treatment-resistant schizophrenia: a historical cohort study. Acta psychiatrica Scandinavica, 139(3). 237–247. https://doi.org/10.1111/acps.12989
Hennen, J., & Baldessarini, R. J. (2005). Suicidal risk during treatment with clozapine: a meta-analysis. Schizophrenia research, 73(2-3). 139–145. https://doi.org/10.1016/j.schres.2004.05.015
Kasckow, J., Felmet, K., & Zisook, S. (2011). Managing suicide risk in patients with schizophrenia. CNS drugs, 25(2). 129–143. https://doi.org/10.2165/11586450-000000000-00000
Meltzer, H. Y., Alphs, L., Green, A. I., Altamura, A. C., Anand, R., Bertoldi, A., Bourgeois, M., Chouinard, G., Islam, M. Z., Kane, J., Krishnan, R., Lindenmayer, J. P., Potkin, S., & International Suicide Prevention Trial Study Group (2003). Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Archives of general psychiatry, 60(1), 82-91. https://doi.org/10.1001/archpsyc.60.1.82
Vermeulen, J. M., van Rooijen, G., van de Kerkhof, M. P. J., Sutterland, A. L., Correll, C. U., & de Haan, L. (2019). Clozapine and Long-Term Mortality Risk in Patients With Schizophrenia: A Systematic Review and Meta-analysis of Studies Lasting 1. -12.5 Years. Schizophrenia bulletin, 45(2). 315–329. https://doi.org/10.1093/schbul/sby052
Wimberley, T., MacCabe, J. H., Laursen, T. M., Sørensen, H. J., Astrup, A., Horsdal, H. T., Gasse, C., & Støvring, H. (2017). Mortality and Self-Harm in Association With Clozapine in Treatment-Resistant Schizophrenia. The American journal of psychiatry, 174(10). 990–998. https://doi.org/10.1176/appi.ajp.2017.16091097
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Podcasts

This section includes links to recommended podcasts about offering clozapine to reduce the risk of suicide attempts for patients with schizophrenia or schizoaffective disorder.

Podcast icon Unpacking Schizophrenia: Preventing Suicides from Consultant 360: Multidisciplinary Medical Information Network Presented by Dr. Robert S. Laitman
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