ORIGINAL CONTRIBUTION
Clozapine Use in a Cohort of First-Episode Psychosis
Roisin Doyle, MSc,* Caragh Behan, MRCPsych,* Donal O'Keeffe, MSc,* Sarah Masterson, BA,*
Anthony Kinsella, MSc,* Aine Kelly, PhD,† Ann Sheridan, PhD,‡ Dolores Keating, MSc,§
Caroline Hynes, MSc,§ Kevin Madigan, MSc,||#
Elizabeth Lawlor, MSc,*|| and Mary Clarke, MD, FRCPI, FRCPsych*||**
Abstract:
Purpose/Background: For approximately one third of individuals
treated for psychosis or schizophrenia, antipsychotic medications will have
little or no therapeutic benefit. Clozapine remains the sole medication ap-
proved for treatment-resistant schizophrenia, and studies have demon-
strated its superior efficacy in reducing psychotic symptoms.
Methods/Procedures: Data were collected from the medical records of
people who originally presented with a first-episode psychosis between
1995 and 1999 (N = 171). Data were obtained from first presentation up
to December 31, 2013 or until the patient was discharged or transferred. In-
formation on service use and physical health was gathered using a data col-
lection template designed specifically for this audit.
Findings/Results: Twenty-eight (16.3%) of the cohort were prescribed
clozapine. Data were available for 24 individuals. Of this clozapine sub-
sample, the mean age at baseline was 23.11 (SD = 4.58); 82.14% (n = 23)
were male; and 82.14% (n = 23) had a baseline diagnosis of schizophrenia.
The mean time to first trial of clozapine was 6.7 years. The mean number
of antipsychotics prescribed before clozapine trial was 4.85. After the ini-
tiation of clozapine, the mean number of hospital admissions reduced from
6.04 per year to 0.88 per year.
Implications/Conclusions: Nearly 1 in 5 of the original cohort was
considered to have a suboptimal response to trials of antipsychotic medication.
The use of clozapine for treatment-resistant schizophrenia is underutilized, and
better understanding of the barriers to prescribing clozapine is necessary
given the implications for patient's quality of life and hospital admission
rates. Physical health data further emphasizes the importance of physical
health monitoring in this vulnerable population.
Key Words: Clozapine, First-episode psychosis, Psychosis
(J Clin Psychopharmacol 2017;37: 00–00)
A ntipsychotic medication continues to be the predominant
treatment for psychosis and schizophrenia; however, approx-
imately a third of individuals prescribed such medications will
have little or no therapeutic benefit. Those who have a diagnosis
of schizophrenia but who do not respond to 2 trials of antipsy-
chotic medications are considered to have a “treatment resistant”
form of the illness, with a trajectory of enduring difficulties and
recurring hospital admissions.1–3
From the *Dublin and East Treatment and Early Care Team (DETECT) Ser-
vices, Blackrock; †Research Department, Saint John of God Hospitaller Minis-
tries, Stillorgan, County Dublin; ‡School of Nursing Midwifery and Health
Systems, University College Dublin, Belfield, Dublin; §Pharmacy Department, Saint
John of God Hospital, Stillorgan, County Dublin; ||Saint John of God Community
Mental Health Services, Stillorgan, County Dublin; #School of Postgraduate Studies,
Royal College of Surgeons in Ireland, Dublin; and **School of Medicine and Med-
ical Science, University College Dublin, Belfield, Dublin, Ireland.
Received December 19, 2016; accepted after revision April 25, 2017.
Reprints: Roisin Doyle, MSc, DETECT, Avila House, Block 5, Blackrock
Business Park, Blackrock, County Dublin (e‐mail: roisin.doyle@sjog.ie).
Grant HRA_HSR/2013.409 awarded by the Health Research Board of Ireland.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0271-0749
DOI: 10.1097/JCP.0000000000000734
Journal of Clinical Psychopharmacology • Volume 37, Number 5, October 2017
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Clozapine has been widely available for decades and remains
the sole medication with approval for treatment-resistant schizo-
phrenia.4 Studies have demonstrated its superior efficacy in reduc-
ing psychotic symptoms in schizophrenia and treatment-resistant
schizophrenia.5,6 A recent meta-analysis by Leucht et al6 assessed
the efficacy and tolerability of 15 antipsychotic drugs in the treatment
of schizophrenia and ranked clozapine as the most effective drug.
Whereas clozapine is highly effective, its use has been restricted be-
cause of safety concerns regarding the risk of agranulocytosis.7 Fur-
thermore, it can be associated with significant metabolic effects.8
The UK National Institute for Health and Care Excellence
(NICE) recommends the use of clozapine for treatment-resistant
schizophrenia. The current guidelines state that clozapine should
be offered after 2 adequate 4- to 6-week trials of 2 different anti-
psychotics, 1 of which must be an atypical.9,10 However, despite
these guidelines, studies from the United States, Canada, New
Zealand, and Australia have shown that barriers continue to exist
for clozapine utilization.4,11,12 It is important to note that a certain
percentage of those with psychosis will not respond to clozapine
monotherapy and often will receive augmentation with another
medication. Currently, limited eveidence exists for the effective-
ness of any one agent or another.13
The aim of this study is to describe the pattern of clozapine
utilization in an epidemiological cohort of first-episode psychosis.
The objectives were, first, to determine the extent to which pre-
scribing of clozapine followed NICE guidelines; second, to out-
line the metabolic adverse effects associated with clozapine;
third, to describe which medications were used for clozapine aug-
mentation; and lastly, if clozapine was effective in terms of reduc-
ing hospital readmissions.
MATERIALS AND METHODS
Ethical approval was granted for the project from the ethics
committee of the service.
Study Sample
The study consisted of patients who presented with a first ep-
isode of psychosis between 1995 and 1999, as either an inpatient
or outpatient to a community-based mental health service catch-
ment area with a population of 165,000 at the time.
Data Collection
Data collection was completed by a senior psychiatrist. Data
were compiled from paper charts and electronic records of both in-
patient and outpatient from the time of first presentation until the
end of December 2013 or until the individual was transferred to
another service or discharged from the service. Information on
service use and physical health was gathered using a data col-
lection template that had been designed specifically for this
study and then entered into an Excel data base with predetermined
response options.
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Doyle et al Journal of Clinical Psychopharmacology • Volume 37, Number 5, October 2017
The data collected included patient demographic information
(gender, age) and primary baseline diagnosis (Structured Clinical
Interview for DSM-IV (SCID) determined); patterns of health ser-
vice and resource use including psychiatric admissions history
and hospital days; social and functional information (relationship
status, occupational activity, living arrangements and education);
and psychotropic medication including number and type of psy-
chotropic medication, monitoring of psychotropic medications,
and monitoring of adverse effects of psychotropic medication using
physical health parameters and investigations including documen-
tation of blood pressure, weight, waist circumference, body mass
index (BMI), electrocardiography, blood parameters, and imag-
ing. For those patients who were prescribed clozapine, the date
of clozapine initiation was recorded. The number of antipsychotic
treatments was defined as the number of different antipsychotics
prescribed regularly at a therapeutic dose for a minimum of
6 weeks. All forms of identification were removed before data
entry, and each participant was given a new unique identifying
code. The primary outcome measure was delay in initiation of
clozapine prescription; secondary outcomes were readmissions
and bed day utilization post–clozapine initiation.
Data were analyzed using IBM SPSS Statistics version 21.
Discrete variables were compared between groups using χ2 tests.
We examined the presence of a significant difference in age by
group using the Mann-Whitney U test.
RESULTS
A total of 171 individuals were included in the study. The
characteristics of the sample have been described in detail else-
where,14 but briefly, 57.9% of the cohort (n = 171) were male;
the mean age at baseline of the entire sample was 29 years; the
most prevalent SCID diagnosis of the entire first episode psycho-
sis sample was schizophrenia, 48.5% (n = 83); 80.1% (n = 137)
were living with family, and 9.4% (n = 16) were living alone at
the time of presentation; and 31.6% (n = 54) were unemployed.
Differences Between Clozapine and
Non-Clozapine Groups
Of the entire first episode psychosis sample, a total of
28 participants (16.3%) were prescribed clozapine. Demographic
differences between those prescribed clozapine (n = 28) or not
prescribed clozapine (n = 142) are shown in Table 1. A χ2 test
(with Yates continuity correction) indicated that males (n = 23)
were more likely to be prescribed clozapine than females (n = 5)
[χ2 (1, n = 171) = 6.9, P = 0.008, φ = .21 (small/medium effect
size)]. Those prescribed clozapine were more likely to be younger
(mean, 23.11; SD, 4.5) than the non-clozapine group (mean,
30.31; SD, 12.6) (z = −2.6, P = 0.008). Significant differences
were also found in terms of employment status [χ2 (1,
n = 170) = 16.5, P = 0.011, φ = .31].
Diagnosis was approaching significance level [χ2 (1,
n = 171) = 18.17, P = 0.052, φ = .32]. The most prevalent diagno-
sis of the clozapine subsample was schizophrenia (82%); it was also
the most prevalent diagnosis of the non-clozapine group (44.8%).
No significant differences were found between the clozapine
and non-clozapine groups in terms of marital status, living status,
accommodation, or educational level.
Clozapine Utilization
We had baseline information for n = 28 of those prescribed
clozapine. Of the clozapine subsample (n = 28), 2 individuals
did not sustain stabilization on clozapine and a further 2 individ-
uals had a significant amount of missing data; therefore, we only
had follow-up information for n = 24 of the clozapine subsample
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and the results presented refer to this 24. The mean time to first
trial of clozapine was 6.7 years (SD,3.5; range,1–14). Please see
Figure 1 displaying years from baseline to trial of clozapine. The
mean number of antipsychotics trialled before clozapine was
4.85 (SD,2.26; range, 1–11).
Clozapine Dose
The average dose of clozapine prescribed to individual's at
time of clozapine initiation was 359.38 mg (SD, 83.99) and, at
end time of audit (December 2013 or when an individual was
discharged or disengaged from service), was 347.92 mg (SD,
113.71). The lowest dose prescribed was 175 mg, and the highest
dose was 575 mg.
Adverse Effects
Twenty-one (87.5%) of 24 of patients had documented ad-
verse effects associated with clozapine. Thirteen (54.1%) experi-
enced weight gain; 12 (50%) reported experiencing drooling; 9
individuals (37.5%) experienced sedation; 8 (33.3%) reported
constipation as an adverse effect; and 7 reported other adverse
effects (29.1%).
Augmentation
Eleven participants (46%) had their clozapine prescription
augmented with another medication (Table 2), including mood
stabilizers and both first- and second-generation antipsychotics.
Nine individuals were prescribed 1 medication for augmentation
with clozapine, and 2 were prescribed 3 medications for augmentation.
In total, 8 individuals had their clozapine augmented with
another antipsychotic medication, 4 individuals were prescribed
first-generation antipsychotic medication, and 4 individuals with
second-generation antipsychotic medications. Two individuals
(18%) out of the 11 were augmented with another medication in
the same year as clozapine initiation.
Sodium Valproate
Five individuals were prescribed sodium valproate. Two indi-
viduals were prescribed sodium valproate before clozapine initia-
tion. One individual had their clozapine prescribed with sodium
valproate in the same year as clozapine initiation. Four individuals
were prescribed sodium valproate after clozapine initiation rang-
ing from 1 to 3 years post–commencing clozapine.
Physical Health
Hypertension
Six individuals (25%) were documented to have a blood pres-
sure reading in the high range (a reading greater than 140/90) at
some point post–clozapine initiation, with a further 3 individuals
(12.5%) documented in the pre–high range (120/80–140/90).
Weight
We had height and weight recordings for 23 individuals.
Body mass index calculations were as follows: 17.3% (n = 4) were
considered to be in the normal range (18.5–24.5); 30.4% (n = 7)
were considered to be in the overweight range with a body mass
index greater than 25; and 52.1% (n = 12) were considered to be
in the obese category with a body mass index greater than 30.
Bloods
Sixteen individuals (66%) were documented as having high
cholesterol post–clozapine initiation with 11 individuals (45.8%)
having high triglyceride readings documented post-clozapine.
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Journal of Clinical Psychopharmacology • Volume 37, Number 5, October 2017 Clozapine in First-Episode Psychosis

TABLE 1. Socio Demographics and Differences Between TABLE 1. (Continued)

Clozapine and Non-Clozapine Groups
SCID diagnosis
Prescribed Non-Clozapine Bipolar, manic, 0 (0) 18 (12.6) χ2
Statistics Clozapine (%) Group (%) Differences mood congruent (10) = 18.179
Bipolar, manic, 2 (7.1) 6 (4.2) P = 0.052
Gender
mood incongruent
Male 23 (82.1) 76 (53.1) χ2
Major depression, 0 (0) 8 (5.6) n = 171
(1) = 6.9
mood congruent
Female 5 (17.9) 67 (46.9) P = 0.008*
Major depression, 0 (0) 2 (1.4)
Total 28 142 n = 171 mood incongruent
Age Schizophrenia 23 (82.1) 64 (44.8)
Mean 23.11 30.31 Z = −2.635 Schizophreniform, 0 (0) 11 (7.7)
Standard deviation 4.58 12.65 P = 0.008* good prognosis
n = 171 Schizophreniform, 1 (3.6) 2 (1.4)
Marital status without good
Never married 28 (100) 117 (82.4) χ2 prognosis
(4) = 5.78 Delusional disorder 1 (3.6) 12 (8.4)
Married once 0 (0) 15 (10.6) P = 0.216 Psychotic disorder 0 (0) 4 (2.8)
Divorced 0 (0) 8 (5.6) n = 170 NOS
Divorced-remarried 0 (0) 1 (0.7) Drug-induced 1 (3.6) 11 (7.7)
psychosis
Widowed 0 (0) 1 (0.7)
Organic 0 (0) 5 (3.5)
Total 28 142
Total 28 143
Living status
Living alone 3 (10.7) 13 (9.2) χ2
(1) = 0.67
Living with people 25 (89.3) 129 (90.8) P = 0.796 Four individuals (16.6%) were noted to have high low-density li-
poprotein levels, and 1 individual (4.1%) have low low-density li-
28 142 n = 170
poprotein levels. One individual (4.1%) had high high-density
Accommodation lipoprotein levels, and 3 individuals (12.5%) had low high-
Family home 24 (85.7) 113 (79.6) χ2 density lipoprotein levels.
(3) = 6.927 Four individuals (16.6%) had high alanine transaminase
Shared 1 (3.6) 18 (12.7) P = 0.074 levels noted. Three individuals (12.5%) were documented to have
Alone 2 (7.1) 11 (7.7) n = 170 high γ-glutamyl transpeptidase.
No fixed abode 1 (3.6) 0 (0) One individual was documented to have been diagnosed with
Total 28 142 an axillary vein thrombosis post-clozapine.
How far in school Five (20%) of the cohort were noted to have diabetes (type
Grade 6 or less 1 (3.65) 6 (4.2) χ2 II), 4 individuals (16.6%) were documented post-clozapine, and
(6) = 5.033 1 individual (4.1%) was documented to have been diagnosed with
Grade 7–12, 11 (39.3) 44 (31.0) P = 0.540 diabetes pre–clozapine initiation. One individual was documented
no graduation to have hypothyroidism.
Graduated 9 (32.1) 41 (28.9) n = 170 No individual within the cohort was documented to have nor-
high school mal results in all 4 areas (blood pressure, weight range, blood sugar,
Part college 1 (3.6) 19 (13.4) and cholesterol).
Graduated 0 (0) 5 (3.5)
2-year college Bed Utilization Post-Clozapine
Graduated 3 (10.7) 20 (14.1) The mean number of hospital admissions reduced from 6.04
4-year college per year to 0.88 per year, after the initiation of clozapine [Wilcoxon
Still student 3 (10.7) 7 (4.9) signed ranks test (z = −4.05, P = <0.00)]. The mean number of days
Total 28 142 in hospital reduced from 257.8 to 42.6 (z = −3.89, P = <0.00),
Employment status once clozapine had commenced.
Full-time 3 (10.7) 60 (42.0) χ2
employment (6) = 16.562 DISCUSSION
Part-time employment 3 (10.7) 9 (6.3) P = 0.011* This study has described clozapine use in an epidemiological
Unemployed 12 (42.9) 42 (29) n = 170 cohort of patients with first-episode psychosis from first presenta-
Student 9 (32.1) 20 (14.0) tion over a 20-year period.
Work placement 1 (3.6) 1 (0.7) The main finding of this study was that 16% of the sample
Housewife/ 0 (0) 7 (4.9) reviewed was prescribed clozapine. This is lower than the ex-
homemaker pected rate, given that approximately 1 in every 3 patients will
Retired 0 (0) 4 (2.8) be anticipated to have a treatment-resistant form of the schizo-
Total 28 142 phrenia.11,15,16 One possible explanation is the fact that the sample
included both inpatients and outpatients and, at the time of the
study, clinicians may have been reluctant to prescribe clozapine

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Doyle et al Journal of Clinical Psychopharmacology • Volume 37, Number 5, October 2017

clozapine initiation).3,11,17,18 In an examination of adherence to

FIGURE 1. Y axis (count) represents the number of people
prescribed clozapine; x axis represents duration in years. For
example, 3 individuals (count) were prescribed clozapine in their
third year from baseline presentation, 4 individuals in their fourth
year from baseline etc.
to outpatients in community settings. A further possibility was
that clinical guidelines recommending the use of clozapine for
those with treatment resistance did not come into effect until
2002. Thus, clinicians may have had limited experience of cloza-
pine and its effectiveness in this group prepublication of the guide-
lines and this may have impacted on this particular cohort
presenting from 1995 to 1999.
The mean time to trial of clozapine was 6.7 years. This raises
the possibility of a delay to clozapine initiation. We did not record
the reason for initiating clozapine; however, it is possible that
some may have been prescribed clozapine because of treatment in-
tolerance rather than true resistance, although the percentage pre-
scribed would mitigate against this as an explanation. Furthermore,
it is plausible that patients may have developed resistance to neuro-
leptic medication a few years after onset, thus, artificially inflating
the delay to clozapine initiation. Nonetheless, the fact that, before
clozapine initiation, patients received on average almost 5 different
antipsychotic treatment episodes makes this explanation less likely.
Treatment delays in initiating clozapine in routine clinical
practice have been reported in the United States, United Kingdom
(delay of 5 and 4 years post–second trial of antipsychotic), and
New Zealand (duration of untreated illness of 9 years before
NICE guidelines published in 2002, the South London and
Maudsley group found delays of 5 years in their 2002 study and
found a mean delay of 4 years in a more recent study, which au-
thors note as still quite a substantial delay.11 Studies have reported
multiple factors for the delay in prescribing clozapine. A survey
conducted with 243 psychiatrists in the UK12 investigated the
underuse and delayed use of clozapine in clinical practice and
identified that, while the majority (75%) of those surveyed had re-
ceived good training (good exposure in using clozapine as a
trainee) and had clozapine-dedicated (systematic monitoring of
those on clozapine) service (56%), 40.5% preferred to use several
other antipsychotics before considering clozapine. Reasons for
clozapine underutilization included concerns about adverse ef-
fects, patients not wanting to have blood tests, and lack of experience
or knowledge. The authors also identified knowledge deficiency in
certain aspects of clozapine use; for example, a third of respondents
did not know that the risk of agranulocytosis changes with time,
42.7% did not think that clozapine can reduce substance use,
while 20% were not aware of its benefit in reducing suicidal
risk.12 Patient-related factors such as refusing blood monitoring
have also been found to impact on the underutilization of cloza-
pine in clinical practice. Despite this, the vast majority of service
users once on clozapine report that the advantages outweigh
its disadvantages.11,16,19,20
The most common adverse effect reported here was weight
gain, which was reported by 54% as an adverse effect, although
82% were actually documented to be in the overweight category.
In addition, in the same sample, more than 50% were classified
in the BMI obese category with a BMI greater than 30. This is
an important finding given the increasing concern regarding the
physical health of those with serious mental illnesses.21,22 Sixty-
three percent of people with schizophrenia are overweight in com-
parison with 39% of the general population with a finding of an
average weight gain of 30 pounds in one 10-year cohort study.23
Most patients experience weight gain in the first 6 to 12 months;
however, in some individuals, the weight gain is continous without
reaching a plateau.24 More than 40% of the cohort had blood pres-
sure readings in the high blood pressure range (<140/90), and
75% of the cohort had high cholesterol readings post−clozapine
initiation. Our findings further highlight the value of the system-
atic physical health monitoring of those with schizophrenia.8,25
A third of those on clozapine had their clozapine medication
augmented with a second antipsychotic medication. Results of
meta-analyses by Taylor and Smith (2009) incorporating 10 stud-
ies of antipsychotic augmentation of clozapine lasting from 6 to
12 weeks found only weak evidence of therapeutic benefit, and

TABLE 2. Medications Used for Augmentation

Medication Type Number %

Lamotrigine Mood stabilizer and anticonvulsant 1 4.2
Sulpiride First-generation antipsychotic 1 4.2
Olanzapine Second-generation antipsychotic 2 8.3
Risperidone Second-generation antipsychotic 1 4.2
Sodium valproate Mood stabilizer and anticonvulsant 5 20.8
Amisulpride Second-generation antipsychotic 2 8.3
Flupenthixol First-generation antipsychotic 1 4.2
Prochlorperazine First-generation antipsychotic 1 4.2
Med group First-generation antipsychotic 4 16.6
Second-generation antipsychotic 4 16.6
Mood stabilizer 6 25

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Journal of Clinical Psychopharmacology • Volume 37, Number 5, October 2017
authors concluded by questioning the value of antipsychotic aug-
mentation of clozapine in clinical practice.26 This is of particular
relevance considering the risk of adverse effects, in a group with
increased risk of physical health comorbidities.
Many of the adverse effects are dose dependent, and the av-
erage dose of clozapine prescribed to individuals at time of cloza-
pine initiation was 359.38 mg and, at end time of audit (December
2013 or when an individual was discharged or disengaged from
service), was 347.92 mg. A maintenance dose of 300 to 600 mg
per day is usually required for efficacy, and the average dose that
individuals received in our audit falls within these parameters.7
There was a significant reduction in the number of hospital
admissions and hospital days within the clozapine subsample,
once clozapine had been commenced. This resulted in an overall
reduction of days in hospital from 257 to 46. This marked reduc-
tion in hospital admissions may be indicative of the severity of the
illness. The reduction in admissions is in line with findings from
the study in the United States, which found that initiating clozapine
was more effective than a standard antipsychotic in terms of risk
of admissions.4 The significant reduction in hospital admissions
also has implications from a health economics perspective, with
the majority of published health economic studies indicating that
clozapine is cost saving when used for treatment-resistant schizo-
phrenia, and this saving is predominantly a direct reduction in
hospitalizations.2 However, this must be offset against the increased
costs of monitoring in the community and the long-term costs of
increased health risks.
The findings of this study should be considered with the
following limitations. Although the study data were collected
over a 20-year time period, prescribing guidelines changed dur-
ing this time, which also may have influenced practice. Given
these changes in prescribing guidelines and the shift toward com-
munity integrated services, the direct comparison of days spent
in hospital pre−clozapine and post−clozapine initiation com-
pared with days in hospital over the 20-year period is a limitation
of the study.
Secondly, all data were collected retrospectively from in-
formation in the participant's individual clinical file; therefore,
researchers were reliant on the accuracy and quality of clini-
cian's records. Furthermore, we were unable to control for con-
founding variables in our analyses such as adherence to treatment
pre−clozapine initiation, adverse effects due to other antipsy-
chotic medications, and clozapine levels. These factors may
have influenced outcomes with clozapine treatment (eg, hospi-
tal admission rates).
Unfortunately, information on individual clozapine levels
was not available. Considering that the most useful strategy in
nonresponse is increasing the plasma level higher than 350 ng/mL
(Schulte et al., 2003), the average dose of clozapine given may
indicate under treatment in some patients, and this is consid-
ered a limitation of the study.27 Evidence for augmentation
strategies, when there has only been partial response to clozapine
despite dose optimization, is growing but remains insufficient.26
A recent systematic review paper noted that the most commonly
suggested strategy is to combine clozapine with a second antipsy-
chotic taking additional adverse effects profile into consideration.
Lamotrigine is also considered by some to have sufficient evidence
to recommend its use as a clozapine augmentation strategy.28
Given the small number of this study (n = 24), the adverse ef-
fects reported lead to large confidence intervals and should be
interpreted with caution.
The relatively low dose of clozapine prescribed and the lack
of information on clozapine levels mean that we cannot out rule
inadequate treatment in some patients as a cause of nonresponse,
and this is considered a limitation of the study.
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Clozapine in First-Episode Psychosis
• Nearly 1 in 5 of the original cohort was considered to have a
suboptimal response to trials of antipsychotic medication.
• The use of clozapine for treatment-resistant schizophrenia is
underutilized, and better understanding of this is necessary
given the implications for patient's quality of life and hospital
admission rates.
• Given the delays and number of antipsychotic intervention be-
fore commencing clozapine, the findings of this study suggest
that barriers to treatment with clozapine exist. The scope of this
study did not encompass investigating reasons for underutiliza-
tion of and/or delay in prescribing clozapine within the service.
Reasons for delays are likely to been influenced by multiple
factors and warrant further study within this service. It is
likely that similar barriers outlined above in the UK survey
exist in our service.12
• Greater than half of the cohort had a BMI above 30, which clas-
sifies them in the obese category; greater than 40% had high
blood pressure readings, and greater than 75% high cholesterol
readings post−clozapine initiation, further emphasizing the im-
portance of physical health monitoring in this vulnerable population.
AUTHOR DISCLOSURE INFORMATION
The authors declare no conflicts of interest.
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