A 42-year-old female was admitted to the inpatient psychiatry unit due to a severe depressive episode in the course of BD. Before admission, she had quarrelled with her husband, and under the influence of ethanol, she had tried to commit suicide by cutting her wrist.. During hospitalization, she was treated with venlafaxine 375 mg, lamotrigine 200 mg, and quetiapine 200 mg with a small improvement of her depressive symptoms but no effect on her suicidal ideations. The patient stayed at the hospital for 10 days, subsequently withdrawing consent for further hospitalization—claiming her mental state had much improved. The next day, she came to outpatient clinic still presenting active suicidal thoughts and depressive symptoms. She refused to be hospitalized but agreed to take medication at home with the close supervision of her family and frequent ambulatory visits (three times a week). The patient had been diagnosed with BD type I 21 years ago. During her illness, she had three episodes of major depression, two manic episodes, and one mixed episode. She had a low mood and anhedonia, psychomotor retardation, reduced sleep, and active, persistent suicidal thoughts that were the leading cause of her concern at the moment.
She agreed to be treated with clozapine up to 100 mg as an add-on treatment to previous drugs. During the next two weeks, the patient improved significantly, with the most prominent anti-suicidal effect after 10 days of clozapine treatment.
Results
a) Clozapine
Clozapine is an effective anti-suicide agent approved in schizophrenia. Impulsivity and aggressive behavior increase the risk of suicidal acts. Clozapine decreases impulsivity and aggression connected with elevated plasma noradrenalin levels, responsible for the anti-aggressive/anti-suicidal activity of clozapine.
