In a February 2014 medscape.com article titled Clozapine ‘Vastly’ Underutilized for Resistant Schizophrenia, Dr. Stroup points out that:
“Some patients may not want clozapine because of medical risks and frequent blood draws. They may not understand that clozapine’s risks can be managed. But more likely is that patients aren’t made aware of its potential benefits,” he said.
On the other hand, “some doctors don’t offer clozapine because they aren’t comfortable using it or because of the close clinical monitoring and paperwork that clozapine requires,” Dr. Stroup said.
“Unfortunately, this means that instead, they use other treatment strategies that are unproven, for example, combinations of antipsychotics or switching to a different standard antipsychotic.”
There’s no debate – clozapine is unique and in many ways the best antipsychotic available. Yes, it comes with a problematic bundle of possible side effects including metabolic disturbances, Type II diabetes, weight gain, agranulocytosis (a drop in the white blood cells that fight infection) and more. Even with all its issues it has unique properties and helps some individuals when other agents have failed. It is the only agent that has been shown to decrease the risk of suicide!
ACT teams should be serving those with the most severe, most refractory symptoms. I therefore remain baffled when I hear of ACT psychiatrists who emphatically state they “never use clozapine”. I understand being concerned around monitoring its use however the potential benefits to patients are undeniable.
There are a number of outcome measures that should be used when looking at ACT teams fidelity. I advocate the addition of a measure of the number of clients who have had a trial of clozapine.
This blog is not meant to be about plugging the PACTwise database. At the same time, the main reason for the development of the database was to manage information, including allowing me and the nurses on my team to know we always had a handle on the info for those clients on clozapine. If your EMR/EHR doesn’t have the tools to handle this demand that it get them! Then start looking at the patients/clients you serve and seriously consider whether some of them might benefit from a proven effective treatment.
“Unless something changes it is likely that clozapine will continue to be underused. As Stroup and colleagues point out, it is up to our entire health community (clinicians, care systems, policy makers, and consumers) to consider this pattern and implement ways to reverse it,” writes Dr. Sajatovic.
Those doing ACT work are in the change business. Let’s make it happen.