Abstract
BackgroundClozapine treatment may have beneficial effects on behavioural outcomes in psychotic disorders, including violent offending. Although clozapine and other antipsychotics have been linked to lower levels of violent behaviour, these have been primarily in small selected samples, and population-based estimates have been limited and imprecise.MethodsThis study was a within-person cohort study based on linked prescription, hospitalization, and sociodemographic registers. We assessed the effect of clozapine treatment on the rate of violent and non-violent offending in the whole of Sweden, taking account of time-changing sociodemographic characteristics and the combination of violent and non-violent offences within individual convictions.ResultsIn a group of people treated with clozapine for psychotic disorders, violent offences were much less common during treatment than before. Effects on non-violent offences were smaller in magnitude, and lost precision on adjustments. There was a trend for the effects of antipsychotic treatment to increase with increasing age at initiation. Smaller but similar effects were observed for olanzapine. Clozapine rate reductions for violent offending were twice as strong for those with a history of alcohol-use disorders, compared to those without, RR for alcohol use disorders.DiscussionIn patients with psychotic disorders, clozapine treatment is associated with a lower rate of violent offending compared to olanzapine. Clozapine might reduce offending through a direct effect on psychotic symptoms, or indirectly through changes in lifestyle, including use of alcohol.
Highlights
The patients included in RCTs represent a small atypical minority of the entire patient population, as up to 80–90% of patients are excluded because of mental or physical comorbidity, suicidal or antisocial behaviour, or substance abuse
The exposure periods of each individual are compared with the non-exposure periods of the same individual. This far, 3 large observational studies using traditional betweensubject analyses have found that when compared with other oral antipsychotics, clozapine is associated with the best outcome concerning risk of re-hospitalization, and 4 large cohort studies have shown that clozapine is associated with the lowest mortality
We assessed the effect of clozapine treatment on the rate of violent and non-violent offending in the whole of Sweden, taking account of time-changing sociodemographic characteristics and the combination of violent and non-violent offences within individual convictions
Summary
For patients with refractory schizophrenia, clozapine is the drug of first choice. many refractory patients never receive this drug. Methods: In this cluster-randomized trial, 23 Dutch ambulatory care teams were randomized into 2 conditions: (A) coordination of clozapine monitoring by a Nurse Practitioner, versus (B) Treatment As Usual: coordination of clozapine monitoring by the responsible physician (usually a psychiatrist). We followed the teams for 15 months, during which period we counted the numbers of patients who started with clozapine. We assessed the safety of the clozapine monitoring by measuring the number of weekly lab exams performed during the first 18 weeks of treatment and counting serious adverse events (SAE). Clozapine-monitoring by an NP appears to be just as safe as monitoring by a physician These results strongly support the idea that the presence of dedicated staff to arrange and monitor the initiation of clozapine enables the use of this drug
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