Clozapine for treatment resistance in early psychosis: a survey of UK clinicians’ training, knowledge and confidence

Abstract

Background: Clozapine is the only medication licenced for patients with psychosis that is resistant to conventional antipsychotic treatment. However, despite its effectiveness, it remains widely underutilised. One contributory factor for this may be clinicians’ lack of confidence around the management of clozapine. Objective: We conducted a survey of clinicians working in Early Intervention in Psychosis (EIP) services to determine their training needs for clozapine management in EIP services. Methods: An electronic survey was made available to all clinicians working in EIP services in England. The survey assessed confidence and training needs regarding managing clozapine in patients with treatment-resistant psychosis. Quantitative data were analysed using total mean scores and the Mann–Whitney U test. Results: In all, 192 (27%) of approximately 700 clinicians from 35 EIP services completed the survey. Approximately half (54%) had not received training on treatment with clozapine. Experience of training was higher in prescribers than non-prescribers, and among medical than non-medical clinicians. Previous training was associated with significantly higher confidence in offering clozapine and managing treatment-resistant psychosis ( p < 0.001). Confidence levels with managing treatment-resistant psychosis and clozapine were relatively high (mean = 4 out of 5, SD = 1). Respondents were most confident about monitoring mental health response to treatment (mean = 5, SD = 1). Participants were least confident about how to discontinue clozapine treatment safely (mean = 3, SD = 1). Conclusion: Most clinicians working in EIP have not received training on the use of clozapine. This may account, in part, for the underutilisation of clozapine in EIP services. The provision of training in the identification of treatment-resistant psychosis and the use of clozapine will likely improve the detection and management of treatment resistance in the early phase of psychosis.

What are the barriers and facilitators of clozapine use in early psychosis? A survey of UK early intervention clinicians

“…Reducing the perceived cumbersome nature of clozapine monitoring by minimising the degree of physical health monitoring (whilst maintaining safety standards) through evidence-based guidelines alongside use of POC testing could reduce barriers to clozapine use, improve patient satisfaction and overall increase clozapine utilisation 40 . Our data highlights the potential benefit of ensuring professionals working within EIP services have the opportunity to develop their skills, knowledge and confidence in managing and prescribing clozapine treatment through education and training interventions, such as through e-learning 20 . This may also increase clinician confidence when communicating with patients and their families and caregivers around clozapine treatment, however studies are required to confirm this.…”

“…Nevertheless, there is currently no consistent approach to the training of clinicians for clozapine management. The implementation of training and learning from experienced clozapine prescribers are likely to increase clinician confidence 11 , 20 , 22 , 30 . Consistent with the broader literature, addressing clinician attitudes towards clozapine was considered an important facilitator by EIP clinicians 11 .…”

“…An online survey was developed by a multidisciplinary team consisting of psychiatrists, pharmacists, psychologists and occupational therapists following guidelines for designing electronic survey designs 19 and has previously been described 20 . In brief, the survey comprised of 15 items divided into three areas: respondent demographics (7 items) ( e.g.…”

What is the extent of research assessing patients’ and clinicians’ perspectives on clozapine treatment? – a comprehensive scoping review

“…No other published studies within the identified underprioritized areas were found. Instead, eight additional studies on general clinician perspectives on clozapine treatment [203][204][205][206][207][208][209][210] , three additional studies on clozapinepatients' (and their clinicians') attitudes towards their ongoing treatment 40 211 212 , and three additional studies on case-note derived reasons for clozapine cessation or withholding [213][214][215] appeared, ratifying the repetitive behavior of current research and the importance of disseminating these results in order to direct future research towards more meaningful and less well-described areas.…”

Mediation and Longitudinal Analysis to interpret the association between clozapine pharmacokinetics, pharmacogenomics, and absolute neutrophil count

“…Regular blood monitoring is a requirement of clozapine prescription both in the UK and in many other countries to reduce the risks of progression from low neutrophil count to formal agranulocytosis 14 . Nevertheless, despite the superiority of clozapine for managing treatment-resistant schizophrenia in comparison to standard first-line antipsychotics, concerns about ADR risk and monitoring requirements are primary contributors to this drug being underutilised worldwide 15 . For this reason, identifying factors that are predictive of low neutrophil counts in an otherwise healthy sample of clozapine users could help clinicians to improve clozapine use while supporting patient safety and wellbeing.…”