Speaker: Best practices needed for clozapine implementation in persistent psychosis

Mental health professionals can implement specific practices in routine clinical care to effectively prescribe clozapine for treatment-resistant schizophrenia, according to a presenter at the American Psychiatric Nurses Annual Conference.

“Treatment-resistant schizophrenia is a significant public health problem that causes incredible suffering of individuals,” Robert Cotes, MD, associate professor at Emory University School of Medicine in Atlanta, said during the presentation. “It costs the United States $34 billion in direct medical costs, and individuals with treatment-resistant schizophrenia have high rates of suicidal ideation, smoking and substance abuse. Among those with schizophrenia, it's possible that between 20% to 30% of individuals have treatment-resistant schizophrenia.”

Currently, clozapine is the only FDA-approved medication for treatment-resistant schizophrenia, with 4.8% of those with schizophrenia in the U.S. prescribed the agent. However, according to Cotes, many clinicians do not have necessary clinical competencies for prescribing clozapine, and many organizations lack proper supports for its effective implementation. APA guidelines recommend “minimal or no response to two trials of antipsychotic medication” prior to clozapine prescribing. Further recommendations include its use among patients with schizophrenia who have a remaining risk for suicide attempt, suicide or aggressive behavior despite other treatments.

Cotes highlighted a systematic approach to addressing treatment-resistant schizophrenia published in 2019 that recommended consideration of five “c’s”: correct diagnosis, comorbidities, compliance, concentration of antipsychotics and continuous psychosocial stressors.

Successful care and staffing models for use of clozapine may come in the form of a multidisciplinary clinic, which can incorporate psychiatrists or psychiatric-mental health nurse practitioners, nurses, pharmacists and case managers, according to Cotes. In this model, prescriptions can be dispensed via one or multiple prescribers, typically with a psychiatrist serving as medical director. Virtual teams are also an option, and these may include a psychiatrist or psychiatrist-mental health nurse practitioner prescriber, pharmacist or involvement with a laboratory.

Laboratories, pharmacies, patients and their families all play a role in easing the burden of clozapine, according to Cotes. Regarding families, mental health professionals can ask patients who they consider to be a source of support and then secure releases of information. This designated individual can be invited into a session to learn the benefits and challenges of clozapine therapy, what they can expect and keep watch for and how they can be supportive of the patient receiving clozapine.

Potential adverse events that should be monitored for related to clozapine use include myocarditis, seizures, weight gain, sedation, tachycardia, hypotension, constipation, sialorrhea or drooling and insulin resistance and diabetes.

“I really want to uncouple the notion that persistent psychosis means that someone is in a hopeless situation,” Cotes said. “I firmly believe in the recovery model, and I really think that people can do well and ultimately achieve the goals that they want to have.”