Prescribing restrictions for expensive psychiatric drugs

Sir: Drug expenditure has, historically, accounted for only a small percentage of the total cost of caring for patients with schizophrenia. One suggested figure is 3% (Davis & Drummond, 1990). This differs markedly with the relative costs in other therapeutic areas where the drugs budget accounts for approximately 10% of the total cost of patient care. Clozapine is a prime example of a relatively new drug for the treatment of schizophrenia which may alter the disproportionately low prescribing costs for this condition. Its use, therefore, has high cost implications for the field of psychiatry. Pharmacoeconomic studies have suggested that, although the acquisition cost of clozapine is high in comparison with other neuroleptics, the clinical benefits of the drug may confer medium to long-term economic benefits in patients with treatment resistant schizophrenia (Fitton & Benfield, 1993). However, in the current economic climate, concerns have been expressed regarding the prescribing of expensive drugs and whether the use of these drugs is being restricted for purely economic reasons. In response to these concerns a telephone survey of 20 hospitals in the United Kingdom was performed in May 1994. The hospitals were randomly selected. Using an open semi-structured questionnaire the hospitals' use of clozapine and any

Sir: Drug expenditure has, historically, accounted for only a small percentage of the total cost of caring for patients with schizophrenia. One suggested figure is 3% (Davis & Drummond, 1990). This differs markedly with the relative costs in other therapeutic areas where the drugs budget accounts for approximately 10% of the total cost of patient care. Clozapine is a prime example of a relatively new drug for the treatment of schizophrenia which may alter the disproportionately low prescribing costs for this condition. Its use, therefore, has high cost implications for the field of psychiatry. Pharmacoeconomic studies have suggested that, although the acquisition cost of clozapine is high in comparison with other neuroleptics, the clinical benefits of the drug may confer medium to long-term economic benefits in patients with treatment resistant schizophrenia (Fitton & Benfield, 1993). However, in the current economic climate, concerns have been expressed regarding the prescribing of expensive drugs and whether the use of these drugs is being restricted for purely economic reasons.
In response to these concerns a telephone survey of 20 hospitals in the United Kingdom was performed in May 1994. The hospitals were randomly selected. Using an open semi-structured questionnaire the hospitals' use of clozapine and any restrictions placed on its use were determined from pharmacists working closely with the mental health unit.
The number of patients prescribed clozapine at each hospital ranged from one to approximately 100 (median 15-20 patients). It was found that at 11 hospitals the use of clozapine was reported to be on consultant request as per data sheet requirements. Six hospitals had written guidelines for the use of clozapine in operation with a further three units in the process of developing guidelines. An assessment of the patient's resistance to standard neuroleptics was a prime requirement of the guidelines. This was achieved by a medication history prepared by either the medical team or pharmacist. A second opinion of the patient's diagnosis was a requirement at one hospital. Predictors of response to clozapine were included in the guidelines. Therapeutic trials of varying lengths (18 weeks to one year) were recommended, after which an assessment of the benefits gained from the drug was to be performed using a variety of rating scales. Prescribing of clozapine on discharge of the patient into the community remained under the care of the consultant at all of the hospitals contacted. Four of the pharmacists contacted were aware that extra funding had been obtained for the use of clozapine at their hospital.
Interestingly, a number of pharmacists thought that the increased drug expenditure through the use of clozapine had been contained by the recent appreciable decrease in bed numbers at their hospital.
In conclusion, guidelines for the use of clozapine were found to be in operation at a number of units. However, these did not appear to be for purely economic reasons but with the aim of targeting the use of clozapine to those patients who would most benefit from its use. Limiting the use of clozapine on the grounds of cost alone would appear, from this survey, to be unusual. It is appreciated that only a random sample of hospitals were included in this survey; however, no economic limitations on the use of clozapine were found.
If your prescribing of clozapine is being limited for purely economic reasons -is this ethical?

ECT machines: identical, but different
Sir: As an extension of our audit of ECT in three Liverpool hospitals we evaluated patient case-note data from one of the hospitals over 12 months, July to December 1992 (period 1), and January to July 1993 (period 2) when the ECT clinic inherited an Ectron Duopulse Series (E2) machine from the local district general hospital. For reasons unknown the inherited machine was used in preference to the existing clinic machine, an apparently identical E2.
Fit length was not recorded in 42% of first stimulations in period 1 (n=87) and 28% in Correspondence