Abstract
Purpose: To our knowledge, no study has examined in a structured way the extent of underprescription of clozapine in ambulatory patients with Non-Affective Psychotic Disorder (NAPD). In the Netherlands, psychiatric care for such patients is provided by Flexible Assertive Community Treatment (FACT) teams and by early intervention teams. In 20 FACT teams and 3 early intervention teams we assessed the proportion of patients who: use clozapine (type 1 patients), previously used this drug (type 2), have an unfulfilled indication for this drug, by type of indication (type 3), or were at least markedly psychotic, but had not yet received two adequate treatments with other antipsychotic drugs (type 4). We expected to find major differences between teams. To rule out that these differences are caused by differences in severity of psychopathology, we also calculated the proportions of patients who use clozapine given an indication at any time (number of type 1 patients divided by the sum of type 1, 2, and 3 patients).Materials and methods: The nurse practitioner of each team identified the patients already on clozapine. Next, using a highly-structured decision tree, the nurse practitioner and psychiatrist assessed whether the remaining patients had an indication for this drug. Indications were treatment-resistant positive symptoms, tardive dyskinesia, aggression and suicidality. The severity of positive symptoms was determined using the Clinical Global Impression-Schizophrenia Scale (CGI-SCH).Results: In the participating FACT-teams 2,286 NAPD patients were assessed. The range among teams in proportions was: type 1: 8.8–34.7% (mean: 23.0%), type 2: 0–8.2% (mean: 3.5%), type 3: 1.7–15.6% (mean: 6.9%), type 4: 1.8–16.3% (mean: 8.6%). The range in proportions of patients using this drug given an indication was 49.0–90.9% (mean: 68.8%). These figures were lower in early intervention teams.Conclusions: The proportion of patients in FACT-teams who have an unfulfilled indication for clozapine is 6.9%. There were considerable differences between teams with respect to this proportion. Almost a third of the outpatients had at any time an indication for clozapine. If one takes type 4 patients into account, this proportion may be higher.Registration number: NTR5135 http://www.trialregister.nl/trialreg/index.asp
Highlights
Despite the general idea that clozapine is underutilized, little research has been done into the extent of this problem
This study reports the results of baseline measurements preceding a randomized controlled trial to assess the safety of the deployment of nurse practitioners to start patients on clozapine
In 94.8% of these patients treatment-resistant positive symptoms were the reason for the clozapine indication
Summary
Despite the general idea that clozapine is underutilized, little research has been done into the extent of this problem. The main indication for this drug according to guidelines is treatmentresistant schizophrenia, the prevalence of which has been estimated at about 20–30% [1], but exact numbers are unknown. This uncertainty is caused by a scarcity of pertinent studies, and by the absence (until recently) of consensus on criteria to define treatment-resistant schizophrenia [2]. A Danish register-based study among outpatients with a diagnosis of schizophrenia found a prevalence of 24.7 or 48.2% [4], depending on the definition of a proxy for treatment-resistant schizophrenia: [1] at least two different periods of antipsychotic use and one hospitalization within 18 months and [2] patients treated with polypharmacy for at least 90 days. No information on adherence and symptom severity was available, which precludes an exact assessment of treatment-resistant schizophrenia
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