Current status of clozapine in the United States

Unemployment, homelessness, and other societal outcomes in patients with schizophrenia: a real-world retrospective cohort study of the United States Veterans Health Administration database : Societal burden of schizophrenia among US veterans

BACKGROUND

The burden associated with schizophrenia is substantial. Impacts on the individual, healthcare system, and society may be particularly striking within the veteran population due to the presence of physical and mental health comorbidities. Disease burden is also influenced by a complex interplay between social determinants of health and health disparities. The objective of the current study was to compare non-healthcare societal outcomes between veterans with and without schizophrenia in the United States Veterans Health Administration (VHA).

METHODS

A retrospective cohort study was conducted using the VHA database (01/2013-09/2019; study period). Veterans with schizophrenia (≥2 diagnoses of ICD-9295.xx, ICD-10 F20.x, F21, and/or F25.x during the study period) were identified; the index date was the earliest observed schizophrenia diagnosis. Veterans with schizophrenia were propensity score-matched to those without schizophrenia using baseline characteristics. A 12-month baseline and variable follow-up period were applied. The frequency of unemployment, divorce, incarceration, premature death, and homelessness were compared between the matched cohorts using standardized mean difference (SMD). Risk of unemployment and homelessness were estimated using logistic regression models.

RESULTS

A total of 102,207 veterans remained in each cohort after matching (91% male; 61% White [per AMA]; median age, 59 years). Among veterans with schizophrenia, 42% had a substance use disorder and 30% had mental health-related comorbidities, compared with 25 and 15%, respectively, of veterans without schizophrenia. Veterans with schizophrenia were more likely to experience unemployment (69% vs. 41%; SMD: 0.81), divorce (35% vs. 28%; SMD: 0.67), homelessness (28% vs. 7%; SMD: 0.57), incarceration (0.4% vs. 0.1%; SMD: 0.47), and premature death (14% vs. 12%; SMD < 0.1) than veterans without schizophrenia. After further adjustments, the risk of unemployment and of homelessness were 5.4 and 4.5 times higher among veterans with versus without schizophrenia. Other predictors of unemployment included Black [per AMA] race and history of substance use disorder; for homelessness, younger age (18-34 years) and history of mental health-related comorbidities were additional predictors.

CONCLUSION

A greater likelihood of adverse societal outcomes was observed among veterans with versus without schizophrenia. Given their elevated risk for unemployment and homelessness, veterans with schizophrenia should be a focus of targeted, multifactorial interventions to reduce disease burden.

Comparison of clozapine monitoring and adverse event management in a psychiatrist-only and a clinical pharmacist-psychiatrist collaborative clinic

Introduction

In an effort to establish clinical support for providers prescribing clozapine and to help reverse the national decline in clozapine utilization, a clinical pharmacist began seeing half the clozapine clinic patients, preceding the psychiatrist, at this facility in July 2017. The other half of the clozapine clinic patients continued being seen by the psychiatrist only. The purpose was to determine the impact of the pharmacist on clozapine management and identify barriers to clozapine use to potentially increase its utilization.

Methods

Baseline data (clozapine dose, number of antipsychotics and other psychotropics, A1c, lipids, pulse, body mass index, weight, blood pressure, and number of medications for adverse effects) were collected via chart review from the first clinic visit and each follow-up visit. A provider survey was used to identify barriers and solutions to prescribing clozapine.

Results

There were no statistically significant differences from baseline in patient outcomes between the collaborative and psychiatrist-only group. In the prepharmacist to postpharmacist analysis, there was a decrease in number of antipsychotics (−0.27 ± 0.65), number of other psychotropics (−0.18 ± 0.41), A1c (−0.04% ± 0.25%), clozapine dose (−7.96 mg ± 19.58 mg), and total cholesterol (−15.73 mg/dL ± 42.31 mg/dL). There were more pharmacologic (71 vs 19) and nonpharmacologic (154 vs 3) interventions documented in the collaborative group compared to the psychiatrist-only group. Eleven providers (69%) completed the survey. Providers' perception of patient refusal of monitoring was the barrier that received the most responses (54%). A pharmacist seeing every clozapine clinic patient was the solution that received the most responses (90%).

Discussion

Trends were seen for decreasing the number of antipsychotics, other psychotropics, A1c, and total cholesterol as well as an increased number of nonpharmacologic and pharmacologic interventions documented in the collaborative group. Providers identified that pharmacists seeing every clozapine clinic patient would be a solution to clozapine underutilization, which demonstrates the perceived value of pharmacist involvement.

Relative toxicity of mood stabilisers and antipsychotics: case fatality and fatal toxicity associated with self-poisoning

BACKGROUND

Bipolar and other psychiatric disorders are associated with considerably increased risk of suicidal behaviour, which may include self-poisoning with medication used to treat the disorder. Therefore, choice of medication for treatment should include consideration of toxicity, especially for patients at risk. The aim of this study was to estimate the relative toxicity of specific drugs within two drug categories, antipsychotics and mood stabilizers, using large-scale databases to provide evidence that could assist clinicians in making decisions about prescribing, especially for patients at risk of suicidal behaviour.

METHOD

Two indices were used to assess relative toxicity of mood stabilisers and antipsychotics: case fatality (the ratio between rates of fatal and non-fatal self-poisoning) and fatal toxicity (the ratio between rates of fatal self-poisoning and prescription). Mood stabilisers assessed included lithium [reference], sodium valproate, carbamazepine, and lamotrigine, while antipsychotics included chlorpromazine [reference], clozapine, olanzapine, quetiapine and risperidone. Fatal self-poisoning (suicide) data were provided by the Office for National Statistics (ONS), non-fatal self-poisoning data by the Multicentre Study of Self-harm in England, and information on prescriptions by the Clinical Practice Research Datalink. The primary analysis focussed on deaths due to a single drug. Cases where the drug of interest was listed as the likely primary toxic agent in multiple drug overdoses were also analysed. The study period was 2005-2012.

RESULTS

There appeared to be little difference in toxicity between the mood stabilisers, except that based on case fatality where multiple drug poisonings were considered, carbamazepine was over twice as likely to result in death relative to lithium (OR 2.37 95% CI 1.16-4.85). Of the antipsychotics, clozapine was approximately18 times more likely to result in death when taken in overdose than chlorpromazine (single drug case fatality: OR 18.53 95% CI 8.69-39.52). Otherwise, only risperidone differed from chlorpromazine, being less toxic (OR 0.06 95% CI 0.01-0.47).

CONCLUSIONS

There was little difference in toxicity of the individual mood stabilisers. Clozapine was far more toxic than the other antipsychotics. The findings are relevant to prescribing policy, especially for patients at particular risk of suicidal behaviour.