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Clozapine prescribing in adolescent psychiatry: survey of prescribing practice in in-patient units

  • Giovanni Cirulli (a1)
Abstract
Aims and Method

Clozapine is an effective drug in treatment-resistant schizophrenia, but it seems to be prescribed for few patients under the age of 18 years. This study reports a survey of consultant psychiatrists working in adolescent units in the UK, looking at their use of clozapine and experience with it.

Results

Out of 83 clinicians, 59 responded (71%). More than 40% of respondents do not use clozapine, and those who do may not always be following best practice recommendations. Reasons for not using clozapine, beliefs about its effectiveness and problems encountered in its use are described.

Clinical Implications

Clozapine may not always be made available to young people with treatment-resistant schizophrenia. There is a need for more education, guidance and debate on clozapine use in child and adolescent psychiatry.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Clozapine prescribing in adolescent psychiatry: survey of prescribing practice in in-patient units

  • Giovanni Cirulli (a1)
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eLetters

Omission or commission?

Adrian Blaj, Specialist Registrar in Psychiatry, MRCPsych
02 November 2005

Sir: There is already a significant body of accumulated clinical evidence highlighting the unique status of clozapine and its excellent benefits in treatment resistant schizophrenia. It is a common knowledge that in their Cochrane systematic review, Whalbeck et al (The Cochrane Database of Systematic Reviews Issue 4, 2005), concluded that clozapine is'convincingly more effective than typical antipsychotic drugs in reducing symptoms of schizophrenia, producing clinically meaningful improvements and postponing relapse' and that 'the effects of clozapine in comparison to conventional neuroleptics in hospitalised adults is now well established and the conduct of further hospital-based short-term trials would be a waste of resources', effectively making clozapine a gold standard treatment for schizophrenia.

Cirulli (Oct 2005) tells us that according to the Clozaril Patient Monitoring Service there were just 88 patients under the age of 18 on the UK register treated with clozapine (out of about 21 000 on the register in April 2004) - that represents a dismal 0.42%. On the other hand, various authors agree that there is a considerable delay in diagnosing schizophrenia in the adolescent population; the delay in treatment appearsto be clearly associated with poor response and sharp decline in functioning the longer the psychosis remains untreated.

It would logically follow that by applying the gold standard treatment earlier, it would be possible not only to be beneficial and worthwhile for the patients, but also cost-effective in the long run. Moving the goalposts further, would it be a question of being unethical bydepriving the patients of a proven effective treatment on the account of restricting the licence for clozapine to treatment resistant schizophrenia? Especially in the context of Byrne et al (rapid response letter) giving a 'mean maximum theoretical delay' in using clozapine of 60months.
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Conflict of interest: None Declared

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Clozapine prescribing in adolescent psychiatry

Adhiraj Joglekar, Specialist Registrar
31 October 2005

Cirulli (2005) has highlighted a significant deficit in care provision for adolescents suffering from treatment resistant psychosis. The author is right in cautioning readers from generalising the finding toall consultant adolescent psychiatrists. It is not clear if all the 83 consultants to whom the questionnaire was sent worked in adolescent in-patient units. The child & adolescent mental health services are organised such that, often clinicians working in the community do not workwithin in-patient settings. This and lack of assertive outreach or home treatment teams may significantly affect early consideration of Clozapine.Further, across UK, adolescent services cater for different age groups, some up to 17 while others until 19. Consultants working with adolescents up to 17 may not get a suitable opportunity to institute Clozapine.

Cirulli G 2005 Clozapine prescribing in adolescent psychiatry: surveyof prescribing practice in in-patient units. original papers Psychiatric Bulletin 29, 377-38
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Conflict of interest: None Declared

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Clozapine for children and adolescents

Patrick J Byrne, Consultant Psychiatrist
12 October 2005

Sir: Cirulli (2005) has made an important contribution to clarifying prescribing patterns with Clozapine among psychiatrists in inpatient adolescent units but more needs to be done. Although child psychiatrists may be slow in prescribing Clozapine for treatment resistant psychosis, there is little evidence that adult psychiatrists conform closely to the NICE 2002 recommendations also. In a recent study (Taylor DM et al 2003) examined the patterns of antipsychotic prescribing by psychiatrists in adult patients eventually prescribed Clozapine. The mean duration of illness was 15.1 years and subjects had undergone a mean of 9.2 (range, 2-35) episodes of antipsychotic prescription before clozapine was first used. This gave a mean maximum theoretical delay in using Clozapine of 60 months (range, 0-11.1 years).

In the Bethlem Adolescent Unit we have completed a pilot clozapine case audit of 10 adolescent TRS subjects aged 13-18 admitted to a specialist service, which showed that the mean number of antipsychotics used before clozapine was 3.7 and the mean total time to treatment with clozapine was 23 months. Although these differences may be largely a result of the greater duration of illness in adult patients, they may alsoreflect practice in a specialist service with some expertise in the use ofClozapine and its untoward effects. We would predict that delay in use of Clozapine in juvenile onset patients with TRS is widespread in the UK and Eire. A national survey of all child and adolescent patients registered for treatment with Clozapine would be a helpful next step.

Cirulli G 2005 Clozapine prescribing in adolescent psychiatry: surveyof prescribing practice in in-patient units. original papers Psychiatric Bulletin 29, 377-38

National Institute for Clinical Excellence (2002) Summary: Guidance on the Use of Newer (Atypical) Antipsychotic Drugs for the Treatment of Schizophrenia. London: NICE (http://www.nice.org.uk/pdf/43_Antipsychotics_summary.pdf).

Taylor D., Young C., and Paton, C. 2003 Prior antipsychotic prescribing in patients currently receiving clozapine: A case note review.Journal of Clinical Psychiatry, Jan 2003, vol. 64, no. 1, p. 30-34,
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Conflict of interest: None Declared

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Better late than Never.

Yasir Abbasi, SHO in Adolescent Psychiatry
10 October 2005

I read with interest the article by Giovanni Cirulli regarding the use of Clozapine in adolescent psychiatry.

We recently commenced a 17 year old female patient on clozapine. She was diagnosed with her first psychotic episode in March 2003 and after a second opinion in November 2004 the diagnosis was confirmed to be paranoidschizophrenia. Although it was advised in November 2004 to initiate clozapine if there was no response from two antipsychotics, it took nearlya year and the use of all the current atypical antipsychotics before we decided to use clozapine.

But to add more anxiety to our apprehension, she has had two known side effects from it within a month of treatment. The first being severe postural hypotension after which the medication had to be stopped and re-started two day later from the lowest dose again. And most recently she encountered nocturnal enuresis, which seems to be controlled on desmopressin now.

Regardless of these side effects, she seems to be recuperating with her mental state improving and diminishing psychotic symptoms, thus clozapine being used to good effect.
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