important to evaluate their effectiveness compared to lithium for prevention of suicide.

Anti-Psychotic Medications

Anti-psychotic medications, including neuroleptics, may also be effective in the reduction of both suicidal behavior and the overall suicide rate when suicidality is seen as a feature of psychosis in schizophrenia. Particularly compelling evidence exists for the atypical anti-psychotic, clozapine.

Meltzer (1999) found that the mortality rate from suicide was reduced by 80 to 85 percent of the expected rate for schizophrenic patients in a population of treatment-resistant schizophrenic patients treated with clozapine after adjusting for the duration of treatment.

Recently, Meltzer and colleagues (2001) reported that in a multi-centered, randomized clinical trial of 980 patients with schizophrenia or schizoaffective disorder, treatment with clozapine when compared to treatment with olanzapine resulted in significantly fewer suicide attempts and a reduced need for additional medications to control suicidality.

Meltzer and Okayli (1995) reported that clozapine in neuroleptic-resistant psychotic patients, when given as continuation or maintenance pharmacotherapy, was associated with markedly less suicidality. They reported that the number of serious suicide attempts decreased significantly and that this decrease was associated with a reduction in depression and hopelessness. Interestingly, they stated that the beneficial effect occurred independently of the response to the psychosis, so it appears to be more attributable to the effect on depression and hopelessness. Both treatment-responsive and treatment-resistant patients were included, but similar results were obtained in the two groups for both prior suicidal behavior and suicidal behavior on treatment. The suicide attempt rate fell from 25 percent prior to treatment to 3.4 percent after clozapine treatment. The lethality of the suicide attempts was also significantly reduced after clozapine treatment.

Walker and colleagues (1997) reported on data from a national registry of clozapine recipients involving 67,072 current and former clozapine users, linking the data to the National Death Index and the Social Security Administration Death Master Files. They identified 396 deaths in 85,399 person-years for patients ages 10–54 years. Mortality was lower during current clozapine use than during periods of nonuse. The mortality from suicide decreased in current clozapine users by comparison with past users. The investigators confirmed that the principal reason for the reduction in deaths was a decrease in the suicide rate. Using the Texas Department of Mental Health and Mental Retardation database, Reid’s research



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