Suicidal Obsessions as Dose Dependent Side-Effect of Clozapine

Area of Science:

• Psychiatry
• Pharmacology

Background:

• Atypical antipsychotics are known to sometimes worsen obsessive-compulsive symptoms.
• However, the induction of ego-dystonic suicidal obsessions by these medications has not been previously documented.

Observation:

• A patient with bipolar disorder developed new-onset ego-dystonic suicidal obsessions.
• These symptoms emerged weeks after their clozapine dosage was increased from 150 mg/day to 300 mg/day.

Findings:

• The patient's suicidal obsessions significantly decreased within days of switching from clozapine to quetiapine and sodium valproate.
• Complete resolution of obsessions occurred 16 days after medication adjustment, with clozapine reduced to 100 mg/day, quetiapine at 600 mg/day, and sodium valproate at 900 mg/day.

Implications:

• This case underscores the importance of distinguishing between genuine suicidal ideation and medication-induced obsessions.
• Consideration of antipsychotic medication changes, particularly to agents with higher antidopaminergic and lower 5HT2 receptor affinity, is suggested.
• The potential role of sodium valproate in managing obsessive-compulsive symptoms warrants further investigation.