Clozapine as a treatment option has many strengths. But it also has some weaknesses. This week I had a patient who has been stable on clozapine for ages, but now has a new problem related to this drug.
My patient has a well known problem associated with clozapine that is fortunately rare – obsessional phenomena.
Till date, we do not know what makes some patients on clozapine to develop obsessions and compulsions. Glutamate modulation, serotonergic 5-HT2C hypersensitivity and dopaminergic ‘escape’ after chronic blockade are all suspected but none of these mechanisms are proven to be causal1.
So how can we manage this?
- Clozapine dose reduction is a popular strategy in practice, though this may not be always practical when the patient is still unwell with psychotic symptoms.
- Adding a serotonin reuptake inhibitor such as fluoxetine or sertraline may help, as long as clozapine/nor-clozapine levels are monitored.
- Adding aripiprazole, a 5-HT1A partial agonist, seems to be helpful in some studies.
- Other options include the popular anti-OCD treatment clomipramine as well as glutamatergic modulators such as lamotrigine.
Have you come across clozapine induced obsessions in your practice? What worked for you?
Add your comments below!
- Kim DD, Barr AM, White RF, Honer WG, Procyshyn RM. Clozapine-induced obsessive–compulsive symptoms: mechanisms and treatment. Journal of psychiatry & neuroscience: JPN. 2019 Jan;44(1):71.
Clozapine and New-Onset Obsessions