Should clozapine be available to people with early schizophrenia and suicidal ideation?

To the Editor

Schizophrenia is an enduring and debilitating illness with a lifetime mortality from suicide of 5%. About 10% of patients make a suicide attempt early in the treatment phase (Challis et al., 2013) and many suicides occur early on. Clozapine is the single most effective treatment for schizophrenia in terms of symptom control, suicide prevention, and overall mortality but is rarely used because of the risks of neutropenia, myocarditis, weight gain, hyperlipidaemia and insulin resistance. In Australia and New Zealand clozapine is only indicated after resistance to at least two antipsychotics has been demonstrated. In practice, clozapine is often delayed for months or years. However, in the United States the guidelines for clozapine allow earlier treatment if the patient has suicidal behaviour or recurrent suicidal thoughts (Novartis, 2013).

We believe that it is time to change the prescribing guidelines to allow clozapine prescription to people with first episode psychosis and suicidal thinking. We recently published a meta-analysis of the association between suicidal ideation and suicide among patients with either a schizophrenia spectrum psychosis or a mood disorder (Chapman et al., 2014). In contrast to the disappointing results for patients with mood disorders we found that suicidal ideation is strongly associated with suicide among patients with schizophrenia. Hence, patients with early schizophrenia and suicidal ideation could be rationally treated with clozapine before the emergence of suicidal behaviour.

Clozapine is one of a small number of treatments that have been shown to reduce suicide rates. While clozapine treatment will not suit everyone, patients and their carers deserve the opportunity to weigh the life threatening risks and lifesaving benefits of clozapine.