Abstract
PurposeClozapine is the most effective intervention for treatment-resistant schizophrenia (TRS). Several studies report ethnic disparities in clozapine treatment. However, few studies restrict analyses to TRS cohorts alone or address confounding by benign ethnic neutropenia. This study investigates ethnic equity in access to clozapine treatment for people with treatment-resistant schizophrenia spectrum disorder.MethodsA retrospective cohort study, using information from 11 years of clinical records (2007–2017) from the South London and Maudsley NHS Trust. We identified a cohort of service-users with TRS using a validated algorithm. We investigated associations between ethnicity and clozapine treatment, adjusting for sociodemographic factors, psychiatric multi-morbidity, substance misuse, neutropenia, and service-use.ResultsAmong 2239 cases of TRS, Black service-users were less likely to be receive clozapine compared with White British service-users after adjusting for confounders (Black African aOR = 0.49, 95% CI [0.33, 0.74], p = 0.001; Black Caribbean aOR = 0.64, 95% CI [0.43, 0.93], p = 0.019; Black British aOR = 0.61, 95% CI [0.41, 0.91], p = 0.016). It was additionally observed that neutropenia was not related to treatment with clozapine. Also, a detention under the Mental Health Act was negatively associated clozapine receipt, suggesting people with TRS who were detained are less likely to be treated with clozapine.ConclusionBlack service-users with TRS were less likely to receive clozapine than White British service-users. Considering the protective effect of treatment with clozapine, these inequities may place Black service-users at higher risk for hospital admissions and mortality.
Highlights
Among people with a common mental disorder, compared to White British people, ethnic minorities are less likely to receive effective treatment [4], less likely to be referred to secondary care by their general practitioner (GP), and more likely to be referred to inpatient or emergence services [5]
Treatment-resistant schizophrenia (TRS) is defined as a failure to respond to two trials of antipsychotics with an adequate dose [9] and affects up to a third of people living with schizophrenia [10]
Other limitations of previous studies include the lack of a cohort of people with TRS [23, 26], or cohorts of only inpatients or outpatients [21, 26]. This study addresses these limitations by investigating ethnic disparities in the prescription of clozapine in a cohort of people with TRS, while adjusting for several potential confounders, including sociodemographic information, psychiatric multi-morbidity, substance misuse, service-use, and neutropenia
Summary
Ethnic minorities received poorer analgesic care [1] and reported worse experiences in maternal and in cancer care [2, 3]. Among people with a common mental disorder, compared to White British people, ethnic minorities are less likely to receive effective treatment [4], less likely to be referred to secondary care by their general practitioner (GP), and more likely to be referred to inpatient or emergence services [5]. A similar pattern in the pathway to care in psychosis is observed, with some ethnic minority groups having lower GP involvement and more compulsory admission [6]. Some studies, including a systematic review, show that Black people are less likely to receive this drug [7, 16, 18–25]. Not all studies report ethnic differences in clozapine prescription [26, 27], and mixed findings are observed even in studies conducted in the same region, such as London [16, 21, 26, 27]
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