The safety and efficacy of clozapine in severe treatment-resistant schizophrenic patients in the UK. Clozapine Study Group

A systematic chart review of pharmacological interventions in patients with clozapine-induced hypersalivation

OBJECTIVES

To investigate the efficacy and tolerability of medications, such as mouthwash use of 1 % atropine sulfate and tropicamide drops, oral amitriptyline and amisulpride used for clozapine-induced hypersalivation (CIH).

METHODS

The medical charts of inpatients with psychotic disorders between 2010 and 2022 were reviewed retrospectively. We detected 161 patients with eligible data who received or commenced clozapine. Primary outcome was defined as the percentage change in the diameter of a wet patch on the pillow (DWP) for improvements in CIH.

RESULTS

The frequency of CIH was 42 % (n = 68). The first step medications for CIH were tropicamide drops (49 %), atropine drops (43 %) and amitriptyline (3 %). After the first step, the median DWP significantly decreased by -33 %. During the index hospitalization, in 18 patients with persistent CIH, the median DWP significantly decreased by -42 % with the second step medications which also included amisulpride. There were no reported serious adverse events. The change in DWP was significantly correlated with the duration of clozapine treatment (r = 306) and clozapine serum level at discharge (r = 0.294). A linear regression model showed a link between the change in DWP and reduced Positive and Negative Syndrome Scale scores.

CONCLUSIONS

Our findings emphasize that mouthwash use of atropine or tropicamide drops has a satisfying and tolerable effect in treating CIH. Switching medications for CIH seems to be effective when CIH persists despite a first step agent. Controlled follow-up studies are needed to understand the relationship between CIH, clozapine serum levels, illness severity, and functioning.

Cost of the Illness of Treatment-Resistant Schizophrenia: A Mirror Image Study Comparing Clozapine With Other Antipsychotics

PURPOSE/BACKGROUND

This study aimed to evaluate and compare the cost of illness in patients with treatment-resistant schizophrenia (TRS) during 3 months before starting clozapine and for the initial 3 months of treatment with clozapine.

METHODS/PROCEDURES

Fifty-two patients with TRS were evaluated for the cost of illness (direct, indirect, and provider cost) by using a structured questionnaire for the period of 3 months before starting clozapine and then at the end of the 3 months of clozapine therapy.

FINDINGS/RESULTS

Total treatment cost for the period of 3 months before starting clozapine was Indian rupees (INR) 40,372 (560.72 US dollars), and the total treatment cost for the first 3 months of clozapine therapy was INR 40,553 (563.23 US dollars). At both the assessments, indirect cost formed the main bulk of the total cost, with no significant difference in the indirect cost. The total direct treatment cost reduced from INR 13,931.6 (193.49 US dollars) to INR 8756 (121.61 US dollars), and the difference between the 2 assessments was statistically significant, with an advantage for clozapine. Overall, after starting clozapine, the total direct cost reduced from 34.5% to 21.6%, and the total indirect cost reduced from 54.3% to 40.2%. After starting clozapine, total provider cost increased from 11.2% to 38.2% of the totalcost.

IMPLICATIONS/CONCLUSIONS

Treatment with clozapine is not associated with a significant increase in the overall treatment cost, in the short term. However, there is a significant reduction in direct treatment costs.

Effectiveness of clozapine on quality of life and functioning in patients with treatment-resistant schizophrenia

BACKGROUND

Although it is well known that treatment with clozapine is associated with improvement in core symptoms of schizophrenia, little information is available about its impact on other outcome variables. Accordingly, this study aimed to evaluate the short term (3 months) effectiveness of clozapine in patients with treatment-resistant schizophrenia (TRS) in terms of quality of life, disability, and level of functioning.

METHODS

This naturalistic follow-up study evaluated 52 participants at the baseline and three months (±1 week) after initiation of clozapine (prospective assessment) on Positive and Negative Syndrome Scale for schizophrenia, Calgary Depression Scale for Schizophrenia, Yale-Brown Obsessive-Compulsive Scale Checklist and Scale, Clinical Global Impression (CGI) scale, Beck Cognitive Insight Scale (BCIS), Scale to Assess Unawareness of Mental Disorders (SUMD), Social Occupational Functioning Scale - SOFS, Functioning Assessment Short Test (FAST), Indian Disability Evaluation and Assessment Scale (IDEAS), World Health Organisation Quality Of Life-BREF (WHOQOL-BREF) and Self-report Quality of Life Measure for people with schizophrenia.

RESULTS

Treatment with clozapine led to significant improvement in the quality of life, functioning, and disability; reduction in psychopathology (positive, negative, general psychology, depression), the severity of illness, compulsive behavior, and improvement in insight including cognitive insight.

CONCLUSIONS

Treatment with clozapine leads to improvement in core symptoms of schizophrenia and is also associated with significant improvement in the quality of life, functioning, and disability.

The use of clozapine in South Manchester

We describe a survey examining the use of clozapine in South Manchester since 1990. The aims were to determine the patient characteristics, type of illness, response to treatment and recording of this information. The case-notes of the first 25 patients to receive clozapine between 1990 and 1992 were audited. Guidelines about who should receive this drug and what objective assessments should be performed were agreed by the consultant group. The audit demonstrated that 24 patients suffered from chronic schizophrenia which had failed to respond to conventional neuroleptics. Routine mental state examinations were regularly performed but objective assessments using standardised rating scales were employed infrequently. Sixteen out of 25 improved on clozapine but at the end of 1992 only ten subjects were still receiving this drug. The majority had been discontinued because of side effects.

Discontinuation of clozapine: a 15-year naturalistic retrospective study of 320 patients

OBJECTIVE

Clozapine is underutilized in the management of treatment-resistant schizophrenia. To understand contributing factors, we analyzed the frequency and causes of clozapine discontinuations that occurred over a 15-year period in a clinical setting.

METHOD

Data were extracted from computerized records and from mandatory termination reports for discontinuation events 1993-2007. The reasons for termination were analyzed.

RESULTS

Over half of the patients (n = 183/320; 57%) had at least one discontinuation (median time 609 days). The two most common causes for discontinuation were non-adherence (35%) and side-effects (28%). Hematological side-effects accounted for 45% of all side-effect associated discontinuations; most such patients remained eligible for clozapine treatment, and a significant fraction remained on clozapine after rechallenge. Central nervous system side-effects accounted for 35% of side-effect induced discontinuations. General factors significantly associated with discontinuation were African American race, older age at initiation of clozapine and less improvement in psychiatric symptoms.

CONCLUSION

In addition to anticipating and addressing causes of non-adherence, psychiatrists should consider clozapine rechallenge in eligible patients and implement measures to mitigate clozapine-associated sedation, seizures, and other side-effects. Future studies should particularly address why African American and older patients may be more likely to discontinue clozapine.

Use of clozapine in a mental handicap hospital — report of the first 17 patients

Objectives: To examine the process and outcome of use of clozapine in patients with mental handicap, with particular reference to selection of patients, response to treatment, adverse effects and withdrawal from treatment.

Methods: The case notes and medication charts of all patients commenced on clozapine between January 1991 and December 1994 were examined.

Results: Seventeen patients had been commenced on clozapine, the majority in the mild and moderate range of handicap. Fifteen had ICD-9 diagnosis of schizophrenia and all were refractory to conventional neuroleptics. Improvement was marked in 47% and substantial in 76%, with a mean daily dose of 453.8(sd = 238.5)mg and a range of 200mg-900mg. Reduction of aggressive behaviour was an important indicator of improvement. Five patients were withdrawn but only one related to side effects. Four patients had a past history of epilepsy and six others either developed seizures or EEG changes on treatment.

Conclusion: Clozapine use has been associated with considerable benefit in patients with mild and moderate handicap wh o have schizophrenia. In this population aggression responded well but a high prevalence of drug-induced epilepsy was evident.

Drooling in children

Although drooling may occur in healthy children under two years of age, it is commonly observed in neurologically impaired children and carries a considerable social stigma. Drooling can be socially embarrassing, and at times may cause serious medical complications. Drooling may result from the hypersecretion of saliva or, more commonly, the impairment of swallowing. Most of the causes of drooling can be diagnosed from a history and physical examination of the patient. Laboratory investigations are usually unnecessary. Treatment should be directed at the underlying cause whenever possible. No active management is necessary for patients who have little functional and psychological impairment from their objectively mild or intermittent drooling. Treatment options for moderate and severe drooling include physiotherapy, behavioural or biofeedback modification, pharmacotherapy and surgery.

Clozapine versus typical neuroleptic medication for schizophrenia

BACKGROUND

Long-term drug treatment of schizophrenia with typical antipsychotics has limitations: 25 to 33% of patients have illnesses that are treatment-resistant. Clozapine is an antipsychotic drug, which is claimed to have superior efficacy and to cause fewer motor adverse effects than typical drugs for people with treatment-resistant illnesses. Clozapine carries a significant risk of serious blood disorders, which necessitates mandatory weekly blood monitoring at least during the first months of treatment.

OBJECTIVES

To evaluate the effects of clozapine compared with typical antipsychotic drugs in people with schizophrenia.

SEARCH STRATEGY

For the current update of this review (March 2006) we searched the Cochrane Schizophrenia Group Trials Register.

SELECTION CRITERIA

All relevant randomised clinical trials (RCTs).

DATA COLLECTION AND ANALYSIS

We extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed-effect model. We calculated numbers needed to treat/harm (NNT/NNH) where appropriate. For continuous data, we calculated weighted mean differences (WMD) again based on a fixed-effect model.

MAIN RESULTS

We have included 42 trials (3950 participants) in this review. Twenty-eight of the included studies are less than 13 weeks in duration, and, overall, trials were at significant risk of bias. We found no significant difference in the effects of clozapine and typical neuroleptic drugs for broad outcomes such as mortality, ability to work or suitability for discharge at the end of the study. Clinical improvements were seen more frequently in those taking clozapine (n=1119, 14 RCTs, RR 0.72 CI 0.7 to 0.8, NNT 6 CI 5 to 8). Also, participants given clozapine had fewer relapses than those on typical antipsychotic drugs (n=1303, RR 0.62 CI 0.5 to 0.8, NNT 21 CI 15 to 49). BPRS scores showed a greater reduction of symptoms in clozapine-treated patients, (n=1145, 16 RCTs, WMD -4.22 CI -5.4 to -3.1), although the data were heterogeneous (Chi(2) 0.0001, I(2) 66%). Short-term data from the SANS negative symptom scores favoured clozapine (n=196, 5 RCTs, WMD -5.92 CI -7.8 to -4.1). We found clozapine to be more acceptable in long-term treatment than conventional antipsychotic drugs (n=982, 16 RCTs, RR 0.60 CI 0.5 to 0.7, NNT 15 CI 12 to 20). Blood problems occurred more frequently in participants receiving clozapine (3.2%) compared with those given typical antipsychotics (0%) (n=1031, 13 RCTs, RR 7.09 CI 2.0 to 25.6). Clozapine participants experienced more drowsiness, hypersalivation, or temperature increase, than those given conventional neuroleptics. However, clozapine patients experienced fewer motor adverse effects (n=1433, 18 RCTs, RR 0.58 CI 0.5 to 0.7, NNT 5 CI 4 to 6).The clinical effects of clozapine were more pronounced in participants resistant to typical neuroleptics in terms of clinical improvement (n=370, 4 RCTs, RR 0.71 CI 0.6 to 0.8, NNT 4 CI 3 to 6) and symptom reduction. Thirty-four per cent of treatment-resistant participants had a clinical improvement with clozapine treatment.

AUTHORS' CONCLUSIONS

Clozapine may be more effective in reducing symptoms of schizophrenia, producing clinically meaningful improvements and postponing relapse, than typical antipsychotic drugs - but data are weak and prone to bias. Participants were more satisfied with clozapine treatment than with typical neuroleptic treatment. The clinical effect of clozapine, however, is, at least in the short term, not reflected in measures of global functioning such as ability to leave the hospital and maintain an occupation. The short-term benefits of clozapine have to be weighed against the risk of adverse effects. Within the context of trials, the potentially dangerous white blood cell decline seems to be more frequent in children and adolescents and in the elderly than in young adults or people of middle-age.The existing trials have largely neglected to assess the views of participants and their families on clozapine. More community-based long-term randomised trials are needed to evaluate the efficacy of clozapine on global and social functioning as trials in special groups such as people with learning disabilities.

Prevalence and nature of side effects during clozapine maintenance treatment and the relationship with clozapine dose and plasma concentration

Clozapine is associated with non-neurological side effects that can be subjectively unpleasant and/or clinically serious. We sought to: (i) assess the nature and prevalence of side effects experienced by patients receiving maintenance treatment with clozapine and (ii) explore the relationship between clozapine plasma concentration and side effect burden. Patients were receiving clozapine maintenance treatment. Open questioning followed by systematic enquiry using the Antipsychotic Non-neurological Side Effects Rating Scale were used to assess side effects. Trough plasma clozapine and norclozapine concentrations were measured. One hundred and three patients participated. On open questioning, 61 patients reported a total of 117 side effects, whereas systematic enquiry identified an additional 649 side effects, with each patient reporting at least one. Clozapine plasma concentrations were significantly but weakly correlated with total Antipsychotic Non-neurological Side Effects Rating Scale score (Pearson correlation=0.29, P<0.004). Patients with a plasma clozapine concentration >0.25 mg/l were significantly more likely to have moderate/severe side effects than patients with lower plasma concentrations (63/76 vs. 12/23, chi=9.07, d.f.=1, P<0.01). The side-effect burden associated with maintenance clozapine treatment is high and the true extent can only be ascertained by systematic inquiry. The use of target plasma concentrations below those used for acute treatment should be explored as a strategy for minimizing side effects.

Managing side-effects to the optimum: valuing a client's experience

Despite the recent emergence of psychosocial interventions and other forms of practical treatments, antipsychotic medication remains the cornerstone of treatment for schizophrenia, as it is recognized to be effective in reducing relapse rates. Nevertheless, the side-effects of psychotropic medication make adherence to treatment regimens difficult for many clients and, until recently, little has been done by mental health nurses to consistently monitor or manage these symptoms. This report describes how the integration of knowledge and clinical skills in psychopharmacology optimized one client's concordance with medication. It reports on 'John's' treatment experience with medication and addresses the role that mental health nurses can play in appraising pharmaceutical effects, and assessing and working with side-effects, using a medication-management multidisciplinary team approach.

Simultaneous determination of clozapine and its N-desmethyl and N-oxide metabolites in plasma by liquid chromatography/electrospray tandem mass spectrometry and its application to plasma level monitoring in schizophrenic patients

A liquid chromatography tandem mass spectrometry (LC-MS-MS) assay method for the simultaneous determination of clozapine and its N-desmethyl (norclozapine) and N-oxide metabolites in human plasma is described. The compounds were extracted from plasma by a single step liquid-liquid extraction procedure and analyzed using a high performance liquid chromatography electrospray tandem mass spectrometer system. The compounds were eluted isocratically on a C-18 column, ionized using positive ion atmospheric pressure electrospray ionization method by a TurboIonspray source and analyzed using multiple reaction monitoring mode. The ion transitions monitored were m/z 327 --> m/z 270 for clozapine, m/z 313 --> m/z 192 for norclozapine, m/z 343 --> m/z 256 for clozapine-N-oxide and m/z 421--> m/z 201 for internal standard. The standard curves of clozapine, norclozapine and clozapine-N-oxide were linear over the range of 1 ng/ml to 1000 ng/ml when 0.5 ml of plasma was used for the analysis (r(2) >0.998). Three pooled plasma samples collected from patients who were treated with clozapine were used as long-term quality control samples to check the validity of spiked standard curve samples made at various times. The intra- and inter-assay variations for the spiked standard curve and quality control samples were less than 14%. These variations for the long-term patient quality control samples were less than 11%. The LC-MS-MS assay for simultaneous determination of clozapine, norclozapine and clozapine-N-oxide reported here is highly specific, sensitive, accurate and rapid. This method is currently being used for the plasma level monitoring of clozapine and its N-desmethyl and N-oxide metabolites in patients treated with clozapine. The plasma levels of clozapine, norclozapine and clozapine-N-oxide varied widely within and among patients. The data revealed that the norclozapine and clozapine N-oxide metabolites were present at about 58%+/-14% and 17%+/-6% of clozapine concentrations in plasma, respectively.

Refractory schizophrenia and atypical antipsychotics

Treatment resistant or refractory schizophrenia is a difficult to define condition of largely unknown prevalence. For 10 years, clozapine has been the standard treatment in this condition and is recognized unequivocally as being effective. However, clozapine is sometimes poorly tolerated and has the potential for severe toxicity. Partly as a result of this, other atypicals have recently been evaluated as treatments for refractory schizophrenia. In order to evaluate the evidence base relating to the drug treatment of refractory schizophrenia, we developed a refractoriness rating based on previous work. Using this rating, we assessed all trials of atypicals in schizophrenia unresponsive to at least one drug. Overall, clozapine was consistently shown to be effective in refractory schizophrenia, even when stringently defined. Data relating to olanzapine and risperidone are equivocal at best, and there is some evidence to suggest that they are less effective than clozapine. There is essentially no cogent evidence to support the use of any other atypical in refractory schizophrenia. Clozapine remains the drug of choice in this condition.

A survey of clozapine prescribing for inpatients in a tertiary psychiatric hospital

Objectives: To audit the prescribing of clozapine for inpatients at a large, specialist psychiatric hospital.

Method: The clinical standards used were agreed by the authors after reference to the clozapine data sheet and British National Formulary (BNF). Prescribing practices for forty-six patients were audited.

Results: In this population of difficult to manage, treatment-resistant schizophrenic patients, prescribing and case note documentation needed improvement. Although almost all of these patients had had an adequate trial of clozapine monotherapy, over a quarter were currently receiving clozapine augmented with another antipsychotic. Plasma clozapine monitoring was used only once in a patient who had failed to respond adequately to clozapine.

Conclusions: Clinicians should fully document the patient's consent to treatment, the clinical response to treatment and the reasons for any deviation in clinical practice from that recommended by the data sheet and national formulary. Plasma clozapine monitoring should be used to optimise therapy and clinical rating scales should be used to evaluate outcome. Until the clinical effectiveness of clozapine augmentation strategies is proven, their use should be restricted to cases where evidence-based therapies have failed.

Clozapine-induced hypersalivation

OBJECTIVE

To review underlying pathophysiology and possible treatments for clozapine-induced hypersalivation.

DATA SOURCES

Primary literature was accessed through MEDLINE (1966-May 1999). Key search terms included clozapine, hypersalivation, sialorrhea, and treatment.

DATA SYNTHESIS

Hypersalivation occurs in up to 54% of patients receiving clozapine. An evaluation of studies and case reports focusing on management of clozapine-induced hypersalivation was conducted.

CONCLUSIONS

It is unclear whether clozapine increases salivation through its muscarinic M4 receptor activation and/or blockade of alpha2-adrenoceptors, or by causing a distortion in swallowing reflex. Treatment options include chewing gum, reducing the dosage of clozapine, or prescribing pharmacologic agents such as anticholinergics or alpha2-adrenoceptor agonists.

Tolerability of atypical antipsychotics

Atypical antipsychotics are expected to be better tolerated than older antipsychotics because of their lower propensity to cause certain adverse effects. All atypical drugs have been shown to cause fewer acute extrapyramidal symptoms (EPS) than a standard typical agent (usually haloperidol) and some (clozapine, sertindole and quetiapine) appear to cause these effects no more often than placebo. In the longer term, clozapine, olanzapine and (less robustly) other atypical antipsychotics are thought to cause less tardive dyskinesia than typical antipsychotics. Problems caused by hyperprolactinaemia occur less often with some atypical antipsychotics than with typical drugs although risperidone and amisulpride appear to have no advantages in this respect. Other adverse effects may occur as frequently with some atypical antipsychotics as with some typical drugs. Clozapine, risperidone and quetiapine are known to cause postural hypotension; clozapine, olanzapine and quetiapine are clearly sedative; and anticholinergic effects are commonly seen with clozapine, and, much less frequently, with olanzapine. Some adverse effects are more frequent with atypical drugs. Idiosyncratic effects seem particularly troublesome with clozapine and, to a lesser extent, sertindole, olanzapine and zotepine. Bodyweight gain is probably more problematic with atypical antipsychotics than with typical drugs. Overall tolerability, as judged by withdrawals from therapy, is not clearly proven to be better with atypical drugs, although some individual trials do indicate an advantage with atypical agents. Differences in tolerability between individual atypical antipsychotics have not been clearly shown. The tolerability profile of atypical drugs certainly benefits from a lower incidence of acute EPS effects, along with less certain or less uniform benefits in symptomatic hyperprolactinaemia or tardive dyskinesia. Other, perhaps more trivial, adverse effects militate against their good tolerability, and effects such as bodyweight gain may severely reduce tolerability. Without clear advantages in tolerability in patient groups used in trials, drug choice in regard to adverse effects should continue to be on a patient to patient basis.

Clozapine versus typical neuroleptic medication for schizophrenia

BACKGROUND

Long-term drug treatment of schizophrenia with conventional antipsychotics has limitations: 25-33% of patients have illnesses that are treatment-resistant. Clozapine is an atypical antipsychotic drug, which is claimed to have superior efficacy and to cause fewer motor adverse effects than typical drugs for people with treatment-resistant illnesses. Clozapine carries a significant risk of serious blood disorders, which necessitates mandatory weekly blood monitoring at least during the first months of treatment.

OBJECTIVES

To evaluate the effects of clozapine for schizophrenia in comparison to typical antipsychotic drugs.

SEARCH STRATEGY

Publications in all languages were searched from the following databases: Biological Abstracts (1982-1999), The Cochrane Library CENTRAL (Issue 2, 1999), Cochrane Schizophrenia Group's Specialised Register (1999), EMbase (1980-1999), ISI Citation Index, LILACS (1982-1999), MEDLINE (1966-1999), and PsycLIT (1974-1999). Reference list screening of included papers was performed. Authors of recent trials and the manufacturer of clozapine contacted.

SELECTION CRITERIA

All randomised controlled trials comparing clozapine with typical antipsychotic drugs were included by independent assessment by at least two reviewers.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by at least two reviewers. Authors of trials published since 1980 were contacted for additional and missing data. Odds ratios (OR) and 95% confidence intervals (CI) of homogeneous dichotomous data were calculated with the Peto method. A random effects model was used for heterogeneous dichotomous data. Where possible the numbers needed to treat (NNT) or needed to harm (NNH) were also calculated. Weighted or standardised means were calculated for continuous data.

MAIN RESULTS

Currently the review includes 31 studies, 26 of which are less than 13 weeks in duration. These studies include 2589 participants, most of whom were men (74%). The average age was 38 years. There was no difference in the effects of clozapine and typical neuroleptic drugs for broad outcomes such as mortality, ability to work or suitability for discharge at end of the study. Clinical improvement was seen more frequently in those taking clozapine (random effects OR 0.4 CI 0.2-0.6, NNT 6) both in the short and the long term. Also, in the short term, participants on clozapine had fewer relapses than those on typical antipsychotic drugs (OR 0.6 CI 0.4-0.8, NNT 20 CI 17-38), and this may be true for long-term treatment as well. Symptom assessment scales showed a greater reduction of symptoms in clozapine-treated patients. Clozapine treatment was more acceptable than low-potency antipsychotics such as chlorpromazine (OR 0.6 CI 0.4-0.9) but did not differ from acceptability of high-potency neuroleptics such as haloperidol (random effects OR 0.8 CI 0.4-1.5). Clozapine was more acceptable in long-term treatment than conventional antipsychotic drugs (random effects OR 0.4 CI 0.2-0.7, NNT 6 CI 3-111). Patients were more satisfied with clozapine treatment (OR 0.5 CI 0.3-0.8, NNT 12 CI 7-37), but they experienced more hypersalivation, temperature increase, and drowsiness than those given conventional neuroleptics. However, clozapine patients experience fewer motor side effects and less dry mouth. The clinical efficacy of clozapine was more pronounced in participants resistant to typical neuroleptics in terms of clinical improvement (random effects OR 0.2 CI 0.1-0.5, NNT 5 CI 4-7) and symptom reduction. Thirty-two percent of treatment resistant people had a clinical improvement with clozapine treatment.

REVIEWER'S CONCLUSIONS

This systematic review confirms that clozapine is convincingly more effective than typical antipsychotic drugs in reducing symptoms of schizophrenia, producing clinically meaningful improvements and postponing relapse. Patients were more satisfied with clozapine treatment than with typical neuroleptic treatment. (ABSTRACT TRUNCATED

Switching from therapy with typical antipsychotic agents to risperidone: long-term impact on patient outcome

This paper reports the results of a retrospective, open-label study in 31 schizophrenic patients who had been switched from therapy with a typical antipsychotic agent to risperidone, a novel antipsychotic agent, in the course of their treatment in an outpatient/community program. The study was based on both a review of all 31 patients' charts and a structured interview of 26 of the patients. The change to risperidone had been made because of lack of efficacy or intolerance to typical antipsychotic agents after a mean of 3.5 years of therapy. Patients had been maintained on risperidone for a mean of 1.7 years at the time of the review. The impact of switching to risperidone was assessed by comparing clinical variables for the patients with their own historic control data. The current levels of symptoms, side effects, and social functioning were also assessed by means of the Interview for Retrospective Assessment of Onset of Schizophrenia and rating scales. Seventy-one percent and 81% of the patients exhibited a positive response, as measured by a 30% reduction in psychotic and disorganization syndromes, respectively. After the switch, significant declines were noted in service utilization; the level of psychotic, disorganization, and negative symptom dimensions; and the use of anticholinergic drugs (P < 0.01 for all). Assessments conducted at the time of the review revealed a low level of psychotic (mean, 3.5) and disorganization (mean, 3.0) symptoms, a moderate level of negative symptoms (mean, 19.5), and a low level of extrapyramidal symptoms (total mean parkinsonism score, 6.0). No significant changes were seen in the level of employment or in living conditions. Results of this study suggest that a switch to risperidone therapy because of the inefficacy of typical antipsychotic agents or patients' inability to tolerate them may lead to sustained and significant improvement in a substantial proportion of patients with schizophrenia.

Clozapine versus typical antipsychotics. A retro- and prospective study of extrapyramidal side effects

Schizophrenic patients in long-term neuroleptic monotherapy with clozapine (n = 100) and perphenazine, flupenthixol or zuclopentixol (controls, n = 100) were evaluated for extrapyramidal side effects (EPS) (blind) as well as other side effects and mental condition (non-blind). In both groups the patients had received neuroleptic treatment for a total of 14 years (median) and the present antipsychotic (clozapine or control drug) for 5 years. Thus the clozapine-treated patients had previously received traditional neuroleptics for 9 years (median). The study was both retrospective (0.3-19 years for clozapine, 0.3-24 years for control drug, by means of chart information) and prospective (1 year, with video-controlled evaluation of EPS). There was a significantly lower prevalence of tardive dyskinesia (TD) in clozapine treated patients than control patients, although prior to this treatment there were more TD patients in the clozapine group (P < 0.05). This lower level of TD in the clozapine group was related to a lower induction of new cases (P < 0.001) and a tendency towards greater disappearance of TD in the clozapine than in the control group (P = 0.07). Clozapine treated patients without TD had started clozapine and ceased traditional neuroleptics at an earlier age than those with TD. Parkinsonian signs were seen in 33% of the clozapine patients versus 61% of the control patients, mainly as hypokinesia; tremor in 3% versus 11% and rigidity in 0 versus 19%. Psychic akathisia was found in 14% versus 40% and motor akathisia in 7% versus 29% of the patients, all differences significantly in favor of clozapine. Clozapine treated patients also had less neuroleptic-induced emotional indifference and depression, but more autonomic side effects than controls.

Effectiveness of clozapine in hospitalised people with chronic neuroleptic-resistant schizophrenia

BACKGROUND

Clozapine's effectiveness in reducing symptoms and facilitating discharge among patients with chronic schizophrenia who were resistant to neuroleptics was studied.

METHOD

All 169 such patients in a public psychiatric hospital were given clozapine. BPRS ratings (0-5 scale) were completed before treatment and 21 months later. Patients were followed for about 2.5 years.

RESULTS

Clozapine was discontinued in 37.8% of cases due to non-compliance, non-response, or side-effects. At follow-up 41% of clozapine recipients and 25.9% of the drop-outs were discharged and remained so, and 33% of recipients and 24.1% of drop-outs were being prepared for discharge. Longer treatment was associated with more improvement. Decline in average BPRS total scores of recipients was significantly more than drop-outs (32.7, s.d. 16.8 v. 12.1, s.d. 14.1, d.f. = 155, t = 7.5, P = 0.000).

CONCLUSIONS

Clozapine appears to be effective for treating some chronic neuroleptic nonresponding schizophrenic patients.

Clozapine treatment of schizophrenia: implications for forensic psychiatry

Clozapine, a new antipsychotic medication, is now the first-line treatment for neuroleptic refractory schizophrenia. Preliminary observations on its efficacy in treating schizophrenic patients with co-morbid substance abuse and, particularly, schizophrenic patients with persistent aggressive behaviour suggests that clozapine may provide a useful treatment option in forensic patient populations. Potential applications of clozapine and management considerations that are relevant to the forensic setting are discussed.