CPCP: Clozapine Use for Aggression by Drs. Laura Gibbons and Samuel Shultz

Well, today it was time for a Clinical Problems in Consultation Psychiatry (CPCP), this one on something I occasionally run into, Clozapine used off-label for aggression and personality disorder complicated by self-harm behavior, which sometimes includes deliberate ingestion of foreign bodies. Sometimes, psychiatric consultants see patients in the general hospital who are taking clozapine for these types of problems, and they don’t necessarily have treatment-resistant schizophrenia. Dr. Laura Gibbons and Dr. Samuel Shultz checked the literature on this one.

The off-label indications for clozapine include bipolar disorder, Borderline personality disorder, and aggression among others, and a recent review outlines pertinent guidance [1]. The anti-aggression effects don’t seem to be related to sedation or improvement in psychotic symptoms. Sometimes, the psychosis doesn’t improve but the aggression does.

1.Newman, W. J., MD, and B. M. Newman, MD (2016). “Rediscovering clozapine: Clinically relevant off-label uses.” Current Psychiatry 15(10): 51-61.

The studies include only small numbers of subjects and they’re hard to compare because of differing methodologies. It’s tempting to say there is simply no strong evidence justifying the use of clozapine in these populations, because of the drug’s many potentially dangerous side effects.

But it’s also tough to say we should never make what might seem heroic efforts to treat these fellow humans on the path with us, considering how life-limiting they are.

On the other hand, it’s easy to say it’s also time for another great group picture.

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