Iranian psychiatrists' attitude towards clozapine use for patients with treatment-resistant schizophrenia: a nationwide survey

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.

Psychiatrists' views on clozapine prescribing in Ireland

INTRODUCTION

Despite proven effectiveness in refractory schizophrenia, clozapine remains underutilised, and it is important to understand potential reasons for this. This study's aim was to examine in a National sample of Consultant Psychiatrists their knowledge of, attitudes and perceived barriers to clozapine use.

METHODS

A novel questionnaire was designed and distributed by email to 275 Consultant Psychiatrists in Republic of Ireland.

RESULTS

Twenty-eight percent (n = 77) completed the survey, with 55% of respondents practicing for 15 or more years. Clinicians expressed confidence in managing clozapine treatment and side effects and were well aware of clozapine's clinical effectiveness and guideline-based use. A majority indicated insufficient experience managing rechallenge and half expressed insufficient experience managing adverse events. Perceived patient factors were highlighted as barriers with 69% of respondents reporting patients' concern about effectiveness and 50% regarding tolerability. Sixty-four percent (n = 40) indicated that a specialised/tertiary clozapine service would facilitate initiation, with 57% (n = 36) reporting less frequent blood monitoring would aid clozapine prescribing. A majority identified that access to dedicated staff (81%, n = 51) and dedicated day hospital services (84%, n = 53) would facilitate community initiation.

CONCLUSION

Consultants are familiar with clozapine use and related guidelines. Dedicated staff and facilities for clozapine use is one identified structural change to enhance clozapine prescribing in Ireland. Tertiary service or clinical advice service would assist in clozapine rechallenge cases or in managing significant adverse events. More structured patient education regarding clozapine effectiveness and professional development programmes focused on managing side effects and rechallenge may promote clozapine use.

Managing treatment resistance in schizophrenia: A joint study in Hong Kong and Singapore

OBJECTIVE

This study surveyed clinicians in psychiatry in Hong Kong and Singapore to understand their familiarity and prescribing practices in treatment-resistant schizophrenia (TRS) and clozapine-resistant schizophrenia (CRS).

MATERIALS AND METHODS

All clinicians in psychiatry in both regions were invited through email to participate in an anonymous online survey. The survey collected information on the participants' characteristics, their familiarity and experience with clozapine use, and their treatment practices in TRS and CRS. Data collection took place between September 2019 and February 2020 in Hong Kong and December 2018 and March 2019 in Singapore.

RESULTS

261 clinicians responded to the survey, with response rates of 19% (105 out of 556 participants) in Hong Kong and 50% (156 out of 309 participants) in Singapore. The majority of respondents (99.0% in Hong Kong; 87.9% in Singapore) were familiar with treatment guidelines for TRS. However, approximately half (54.2% in Hong Kong; 41.7% in Singapore) delayed the prescription of clozapine when indicated. In terms of alternatives to clozapine, approximately half or more of the clinicians in both regions would use high dose antipsychotics, long-acting injectable antipsychotics, antipsychotic polypharmacy, while the adjuvant use of mood stabilizers and electroconvulsive therapy differed between the two regions. In those with CRS, between 10 and 20% of the respondents added adjuvant mood stabilizers or antipsychotics, and 3-10% would use an antidepressant.

CONCLUSION

Clozapine delays occur in spite of clinicians' familiarity with treatment guidelines. More research is needed to guide the use of augmentation strategies and the search for effective treatments beyond clozapine.