Our residents and students just presented a patient to me at an inpatient case conference. The man was a veteran in his mid-50s, admitted after a very serious suicide attempt. This was the latest in a series of high-lethality attempts, which have left him seriously scarred. He became psychotic in his early 20s during military service, and over the decades since has had marginal function. He carries the diagnosis of schizoaffective disorder, which his history and my interview supported.
He has taken a raft of antipsychotic medicines—almost all available. He has also taken a host of antidepressants. Conspicuous by its absence was clozapine, which I recommended. Clozapine is unquestionably the best among antipsychotics, and evidence suggests it can attenuate suicidal impulses better than any other in the class. It’s a classic “double-edged sword,” with serious adverse effects and toxicity. But his risks from those is proportionally much less than the very high likelihood he will end his life in the near future.