Patients' and primary carers' views on clozapine treatment for schizophrenia: A cross-sectional study in Qatar

Determinants of patient satisfaction in clozapine users: results from the Clozapine International Consortium (CLOZIN)

Clozapine is highly effective for treatment-resistant schizophrenia but is underutilized due to patient and clinician-related concerns. Little is known about the general level of patient satisfaction with clozapine and determinants thereof. We therefore explored determinants of patient satisfaction with clozapine in individuals diagnosed with schizophrenia spectrum disorders (SSDs). Cross-sectional data from 480 clozapine users were used to examine demographic and clinical factors, including symptom severity, treatment response, and adverse drug reactions (ADRs). Patient satisfaction was self-rated on a scale of 1 to 10. Results showed a mean satisfaction score of 7.4 (SD = 1.9), with significant associations between satisfaction and treatment response (B = 0.42, R² = 0.19, p = 3.9 × 10⁻¹⁸), symptom severity (B = 0.10, R² = 0.05, p = 2.06 × 10-9), occurrence of ADRs (B = -0.16, R² = 0.06, p = 3.2 × 10-5), and recreational drug use (B = -1.32, R² = 0.05, p = 2.09 × 10-4). Hypersalivation and prolonged sleep duration were the only ADRs linked to lower satisfaction (B = -0.72, R² = 0.06, p = 3.5 × 10-5 and B = -0.57, R² = 0.04, p = 1.4 × 10-3, respectively). Despite concerns about ADRs, treatment effectiveness showed a stronger association with patient satisfaction among clozapine users than the occurrence of ADRs. In conclusion, our findings suggest that strategies aimed at bolstering clozapine's effectiveness may help counter worldwide underprescription rates of clozapine in patients with SSDs.

The impacts of antipsychotic medications on eating-related outcomes: A mixed methods systematic review

BACKGROUND

Almost all antipsychotics are associated with weight gain. Given the gravity of this side-effect and its consequences, it is imperative to understand the mechanisms involved. One mechanism that could contribute to this side effect is the impact of antipsychotics on eating-related outcomes.

OBJECTIVE

We aimed to synthesise the available quantitative research on the effects of first- and second-generation antipsychotics on eating-related outcomes, and qualitative research exploring people's experiences with these medications in relation to appetite and eating behaviours (PROSPERO protocol CRD42022340211).

METHODS

We searched Medline, PsycInfo, and Web of Science from inception to 9 May 2024. Quantitative data were synthesised without meta-analysis using vote counting based on direction of effect. Qualitative data were synthesised using thematic synthesis.

RESULTS

Searches identified 8,746 citations yielding 61 separate studies; 55 quantitative and 6 qualitative, published 1982-2024. Using GRADE, our assessment of the quantitative review findings ranged from low to very low-level certainty. Given the lack of direct evidence from high-quality placebo-controlled trials, it is pertinent to interpret the quantitative findings with caution. Using GRADE-CERQual, our assessment of the qualitative review findings ranged from low to very low-level certainty; these findings suggest that the relationship between antipsychotics and food intake is influenced by an interplay of individual, interpersonal and external factors, the most significant of which is food environment.

LIMITATIONS

The internal validity of this review was affected by the serious limitations of the included quantitative studies and the paucity of qualitative evidence.

STRENGTHS

We used GRADE and GRADE-CERQual frameworks to enhance the transparency of our judgement of the certainty of the evidence. Lived experience perspectives were incorporated in different stages of the review to enhance its relevance and practical implications.

CONCLUSIONS

There is insufficient evidence from well-conducted studies to determine the effect of antipsychotics on eating-related outcomes.

What is the current scope of research assessing patients' and clinicians' perspectives on clozapine treatment? A comprehensive scoping review

OBJECTIVES

Clozapine is continuously underused. The existing systematic reviews addressing barriers to clozapine prescribing primarily focus on clinical staff's attitudes and perceived barriers to prescribing. However, a preliminary literature search revealed additional literature on the subject not previously included in systematic reviews, including literature on patient perspectives. A scoping review is warranted to map the scope of primary studies on patients' and/or clinicians' perspectives on clozapine treatment and to identify gaps in research.

DESIGN

A scoping review was designed and reported in accordance with established guidelines for scoping reviews.

DATA SOURCES

The electronic databases Cochrane Library, CINAHL, Web of Science, PsycINFO, MEDLINE, EMBASE, Google Scholar and two grey literature databases were searched. Furthermore, citation tracking of selected studies was undertaken.

ELIGIBILITY CRITERIA

We included primary, empirical studies reporting clinicians' and/or patients' perspectives on clozapine treatment. No limitation was set for the year of publication or type of primary study.

DATA EXTRACTION AND SYNTHESIS

Two researchers independently screened for studies, extracted the data and coded the content. Findings were summarised visually and narratively.

RESULTS

146 studies were included. Most studies reported on patients' or clinicians' perspectives on active clozapine treatment or on clinicians' perspectives on barriers to clozapine initiation in general. Three gaps in research were identified: (1) clozapine-eligible, yet clozapine-naïve, patients' attitudes towards clozapine commencement, (2) clinicians' reasons for clozapine withholding and perceived facilitators of clozapine treatment in specific patient-cases and (3) patient and clinician perspectives on clozapine discontinuation, continuation and rechallenge in specific patient cases.

CONCLUSIONS

Research on clozapine perspectives tends to repeat itself. Future studies addressing the identified gaps in evidence could provide the insights needed to optimise clozapine utilisation.

Patient and caregivers perspective about clozapine: A systematic review

BACKGROUND

Clozapine is a gold standard treatment for treatment-resistant schizophrenia. However, the patients' and caregivers' perception and their experience with clozapine has remained much less explored.

AIM

To review the available literature on the patients' and caregivers' attitudes, perceptions, and experiences with clozapine.

METHODOLOGY

27 original research and review articles published in PubMed-indexed journals till March 2023 in the English language, exploring the patient and/or caregiver/family member's experience with using clozapine, were included.

RESULTS

30-80 %of patients and 92-100 % of caregivers were found to have a positive attitude towards clozapine in terms of its impact on psychopathology, cognitive and social functioning of the patient, and caregiving needs. Most patients and caregivers also found that the positive effects of clozapine outweighed the side effects and distress related to repeated blood testing. However, a lack of satisfaction was noted among both patients and caregivers regarding the knowledge provided to them regarding clozapine, especially regarding its common adverse effects. Discontinuation of clozapine was found to be more commonly done by the patients' accord rather than clinicians, and the perceived side effects like hypersalivation and excessive sedation emerge as important factors that lead to discontinuation rather than the need for repeated blood testing.

CONCLUSIONS

Overall, patients and their caregivers share a positive attitude towards clozapine and perceive it to be an effective and beneficial drug, but more effort needs to be directed by the clinical teams to educate the users of clozapine regarding its complete side effect profile and provide continuous guidance about dealing with the emerging side effects throughout treatment.

Experience with and attitude toward clozapine use among patients receiving clozapine on long term and their caregivers

Background

Despite clozapine being the gold standard for treating patients suffering from treatment-resistant schizophrenia, the experience and attitude of patients receiving clozapine for a long duration and their caregivers have not been evaluated, especially in India and other low-middle-income countries. Also, no standardized scale has been validated for such assessment.

Objective

This study aimed to evaluate the perception regarding clozapine among patients and their caregivers. We also attempted to evaluate the factor structure of the scale for such assessment.

Methods

A total of 172 consenting patients who have been receiving clozapine for ≥1 year and their caregivers were evaluated on self-designed questionnaires (patient and caregiver versions containing 44 and 47 items, respectively) to assess various aspects of their experiences about clozapine use.

Results

A majority (70-80%) of patients and caregivers reported improvement in psychotic symptoms, mood symptoms, and overall functioning with starting of clozapine. However, about 40% of the patients reported cognitive side effects, and 20-25% reported disabling side effects like lethargy, forgetfulness and decreased attention, and distress related to blood testing after starting of clozapine. Factor analysis of the questionnaires yielded five- and seven-factor models for the experience and attitude of the patients and the caregivers, respectively. The positive experiences were associated clinical and functional improvement, lower disability, and improvement in functioning as well as the self-reported perceived improvement by the patient and caregiver.

Conclusion

This study suggests that patients tend to have an overall positive experience and attitude about using clozapine. The caregivers also report the beneficial effect on the caregiving. A good level of agreement was seen between the experience of patients, caregivers, and clinician-rated improvement in the psychopathology and functioning.