ORIGINAL RESEARCH

Clozapine Impact on Clinical Outcomes and Aggression in Severely Ill Adolescents With Childhood-Onset Schizophrenia
Lokaranjit Chalasani, MD1, Ravi Kant, MD2, KN Roy Chengappa, MD, FRCPC3

Objectives: To evaluate the impact of clozapine on aggressive behaviour and clinical outcomes in children and adolescents with schizophrenia or schizoaffective disorder.
Methods:  We reviewed the charts of 6 children and adolescents who were admitted consecutively to a long-term care facility for clinical outcomes, including seclusion and restraints incidents prior to and during clozapine treatment. We also present a representative case history.
Results:  We noted clinically significant improvements in social interaction and decreases in the number of violent episodes and homicidal or suicidal thoughts. The global assessment of functioning (GAF) scores improved significantly. Weight gain was significant.
Conclusions:  These cases illustrate the benefits of clozapine treatment in refractory childhood-onset schizophrenia. Outcomes are similar to those described in adults. Even though open data limit conclusions from this study, it is pertinent that there was a clinically significant improvement in aggressive behaviours. This may be particularly important for improved morale of patients, their families, and treating staff. It may also be helpful in discharge to a less restrictive environment.

(Can J Psychiatry 2001;46:965–968)

Key Words:  clozapine, violence, aggression, seclusion, restraint, childhood-onset schizophrenia, schizoaffective


Clozapine has virtually revolutionized the treatment of adults with treatment-refractory schizophrenia. Its role is less well studied in children and adolescents with treatment-refractory schizophrenia, although 2 studies (including a controlled study) indicated clozapine efficacy in these subjects (1,2). Even less appears in literature regarding clozapine impact on aggressive behaviours in children under the age of 16 years. This study assessed a case series of adolescents with childhood-onset schizophrenia who received clozapine for refractory psychosis and who had also exhibited aggressive behaviours.

Methods

We extracted medical chart data from 6 patients consecutively admitted to a long-term care facility for adolescents with persistent and refractory psychotic symptoms. The University of Pittsburgh Institutional Review Board approved this study as exempt from informed consent.

Manuscript received July 2001, revised, and accepted October 2001.
1Research Fellow, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Research Fellow, Special Studies Center, Mayview State Hospital, Pittsburgh, Pennsylvania.
2Clinical Assistant Professor of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Consulting Psychiatrist, Head Injury Clinic, Pittsburgh, Pennsylvania.
3Associate Professor of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Director, Special Studies Center, Mayview State Hospital, Pittsburgh, Pennsylvania.
Address for correspondence:  Dr KNR Chengappa, Special Studies Center, Mayview State Hospital, Western Psychiatric Institute and Clinic 3811 O’Hara Street, Pittsburgh, PA 15213-2593
e-mail: chengappakn@msx.upmc.edu

Data from the original charts were de-identified, assigned a research identity, and entered into a database by a volunteer staff member separate from the investigative team.

Demographic and illness characteristics, as well as concomitant medicine use, were recorded. Further, scores on intelligence tests, diagnoses (DSM-IV criteria [3]), family history, details of clozapine dosage, and side effects were also noted. Any seclusion and restraint events, as well as Global Assessment of Functioning scores (GAF) at admission and discharge, were obtained and recorded. We describe a representative case. Details of all 6 subjects are presented in the tables.

Case

Ms A is a White 17-year-old with a 4-year history of DSM-IV schizophrenia, paranoid type. She has had at least 3 previous hospitalizations because of her unpredictable and violent behaviour. Her family history is significant for major depression (mother) and substance abuse (father). She has no significant medical history.

Her latest admission was due to unpredictable and unprovoked aggressive behaviour toward several of her peers and an assault on her therapist, who suffered a fractured facial bone. She was very aggressive toward her family and threatened to kill her brother.

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