Clozapine and rebound psychosis

via The Psychiatrist:

• CORRESPONDENCE

Rebound psychosis following withdrawal of clozapine

1. Dumindu Witharana

1. Amlan Basu

Emergence of a rapid ‘supersensitivity psychosis’ following sudden withdrawal of clozapine has been well documented in the literature (2) ; various studies have attributed rapid relapse following clozapine withdrawal to clozapine induced supersentivity for dopamine, acetylcholine or serotonin receptors (3). Seppala et al (4) found a rapid deterioration in mental state following withdrawal in almost half the patients of a group who had been on long term clozapine treatment and, according to Seeman and Tallerico (3) , the rate of psychotic relapse in patients withdrawn from clozapine is five times higher than that for a traditional antipsychotic such as haloperidol or flupenthixol. Clozapine withdrawal psychosis has also been observed to be severe in symptomatology and in some cases associated with delirium (5).linicians to see patients suffer a severe rebound psychosis as a result of sudden clozapine withdrawal. Emphasis has rightly been placed on preventing a sudden discontinuation of other psychiatric medications with the potential of precipitating a rebound illness (e.g. lithium ) by educating patients. Unfortunately, in our experience, this does not necessarily extend to clozapine.

In our opinion, patients should be made aware of the risks of sudden discontinuation of clozapine treatment, including the possibility of severe symptomatology, at the treatment planning stage with a clear care plan to manage a rebound illness in the event of a sudden discontinuation. From a medicolegal perspective, given that rebound psychosis cannot be considered rare, a clear explanation of the phenomenon during the consent to treatment interview should form a crucial part of obtaining informed consent before prescribing clozapine. (emphasis mine) here

Clozapine is not one of the more commonly prescribed neuroleptic, or "antipsychotic" drugs, but it was the number three cause of drug-induced death from FDA approved drugs from 1998 to 2005.

via JAMA Internal Medicine:

Serious Adverse Drug Events Reported to the Food and Drug Administration, 1998-2005 Thomas J. Moore, AB; Michael R. Cohen, RPh, MS, ScD; Curt D. Furberg, MD, PhD

a couple of excerpts:

"Conclusions  These data show a marked increase in reported deaths and serious injuries associated with drug therapy over the study period. The results highlight the importance of this public health problem and illustrate the need for improved systems to manage the risks of prescription drugs."

read here

via JAMA Psychiatry:

Childhood-Onset SchizophreniaA Double-Blind, Randomized Clozapine-Olanzapine Comparison

an excerpt:

PROCEDURES

"On admission, all medication dosages were tapered during a 1- to 4-week period. This was followed by a medication-free period of up to 3 weeks (mean, 2.7 weeks; SD, 1.2 weeks), as tolerated by the patient. " here

via Medscape:

Current Opinion in Psychiatry

Treatment of Early-onset Schizophrenia

Anand K. Mattai, Julia L. Hill, Rhoshel K. Lenroot

 

Curr Opin Psychiatry. 2010;23(4):304-310. 

"Recent findings Several recent trials support the use of antipsychotics for treatment of schizophrenia in children and adolescents. Clozapine shows greater efficacy in children and adolescents than it has in adults. A large-scale trial comparing a first-generation antipsychotic (molindone) with newer agents did not find significant differences in treatment response, although the newer antipsychotics were associated with more severe weight gain. Data regarding effects of antipsychotics on brain development in children and young adolescents with schizophrenia are sparse, although one report found no difference between effects of clozapine and olanzapine on cortical thickness." here