Clozapine as an Effective Antipsychotic in Treatment Resistant Mania: Two Case Reports

Bipolar mood disorder (BD) is a severe debilitating mental disorder, and a number of patients are resistant to standard treatment. We report two clinical cases of treatment resistant mania (TRM) responsive to clozapine. Mrs. A and Mrs. B are two BD patients aged 30-year-old and 34-year-old respectively. They had a similar age of BD onset at 16 years old. They both had five manic episodes at least before they had the TRM. Mrs. A had a history of allergy to haloperidol. She presented a manic episode that was unresponsive to olanzapine 20 mg daily, risperidone 4 mg daily and lithium 1,250 mg daily. Mrs. B had a history of a mania non-responsive to the association of lithium and olanzapine 20 mg daily and a history of severe depression under lithium and haloperidol 30 mg daily. She presented a manic episode resisting the association of lithium 1000 mg daily, carbamazepine 600 mg daily, quetiapine 100 mg daily and chlorpromazine 150 mg daily. They both eventually received clozapine uptitrated gradually to 300 mg daily with lithium (1,000-1,250 mg daily) with satisfactory clinical response within three weeks of starting clozapine. Clozapine seems to be efficacious in TRM. Further randomized clinical trials are needed to strengthen its evidence based indication in TRM.