The Clozapine Clinic: A Model of Integrated Care

Abstract

Introduction: A significant proportion of individuals with psychotic illness are either refractory to, or intolerant of, standard antipsychotic pharmacotherapy. There is currently only one medication available with proven effectiveness in this population. Clozapine while providing a superior response rate requires significant physical health care monitoring both before and during treatment. The medication requires weekly hematologic monitoring and intensive metabolic screening. Methods: A site was selected for establishment of a new Clozapine Clinic to provide services for individuals with treatment refractory psychotic symptoms or individuals with medication side effects deemed to be related to standard antipsychotic medications. Individuals were selected without predetermined exclusion criteria such as age or physical comorbidity. Patients were accepted into the Clozapine Clinic with a combination of physical health and mental health assessments. The Clozapine Clinic was fortunately located in close proximity to a County Primary Care Clinic and County Tertiary Care Hospital, both of which were helpful in obtaining baseline physical health assessments and diagnostic tests and concurrent hematologic and metabolic laboratory monitoring Results: A new Clozapine Medication Support service line was established using a collaborative care model with existing County facilities. At total of 10 new and established individuals were enrolled into the Clozapine Clinic, with weekly, biweekly and monthly psychiatric and physical health monitoring. The Clozapine Clinic continues to receive referrals for individuals in need of complex care with this unique psychopharmacologic agent. Conclusions: Clozapine pharmacotherapy for treatment resistant psychotic symptoms provides a model for integrated care in this population. Using a collaborative relationship and employing integrated care principles as the model, the complex care of new and established Clozapine patients was provided at an existing County Mental Health Clinic. Weekly hematologic and metabolic monitoring was achieved by partnering with the affiliated hospital laboratory in order to provide rapid, same day results. A dedicated Clozapine Clinic Nurse was employed to provide the coordination of physical health assessments, psychiatric evaluations and laboratory monitoring. In less than a year, the Clozapine Clinic services at this clinical site were expanded to approximately 10 individuals, with additional individuals awaiting entry. Clozapine pharmacotherapy for treatment refractory psychiatric illness is vastly underutilized in large part due to the complexity in coordination of physical health and mental health needs. This underutilization leads to high levels of morbidity and mortality in the psychiatric population. Implications for Integrated Care Practice: Since a significant percentage of patients with chronic psychotic illness are either intolerant or refractory to standard antipsychotic medications, Clozapine remains the only effective agent available. However, with its significant need for monitoring of physical health side effects, integrated care models of treatment provide the most cost effective, efficient and comprehensive model for addressing the whole person health care needs of this special population. Integrated Care models represent the solution to the underutilization of Clozapine pharmacotherapy in treatment resistant populations.