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LETTER TO EDITOR  
Year : 2011  |  Volume : 53  |  Issue : 3  |  Page : 274-275
Clozapine: A friend estranged?


Department of Psychiatry, National Institute of Mental Health & Neurosciences, Bangalore, Karnataka, India

Click here for correspondence address and email

Date of Web Publication29-Oct-2011
 

How to cite this article:
Agarwal SM, Rao NP, Venkatsubramanian G. Clozapine: A friend estranged?. Indian J Psychiatry 2011;53:274-5

How to cite this URL:
Agarwal SM, Rao NP, Venkatsubramanian G. Clozapine: A friend estranged?. Indian J Psychiatry [serial online] 2011 [cited 2014 Nov 24];53:274-5. Available from: http://www.indianjpsychiatry.org/text.asp?2011/53/3/274/86825


Sir,

Fact one: clozapine has proven superiority in partial or non-responsive schizophrenia and is the only evidence-based medication for treatment resistant schizophrenia. [1] Fact two: the incidence of the most feared side effect - Agranulocytosis, is as low as 0.38% and falls to 0.08% after 1 year of treatment. [2] Fact three: Clozapine has been shown to reduce suicidal behavior in comparison with Olanzapine. [3] Fact four: Only 14% of all patients who deserve clozapine are prescribed clozapine. [4]

In the face of these facts, the continuing under utilization of clozapine is difficult to explain and numerous patients undergo multiple trials of other antipsychotics and live more than a decade with disability before clozapine is considered. One, therefore, needs to look beyond drug and response characteristics to make sense of these inconsistencies. The attitude of psychiatrists toward clozapine may be of special relevance.

A recent study on the attitudes of practicing psychiatrists towards clozapine [5] brings up surprising results with 64% psychiatrists opting to combine two antipsychotics rather than opt for clozapine, in spite of several treatment guidelines clearly recommending otherwise. Clozapine's use obviously mandates strict blood monitoring, and is accompanied by side effects quite unique to this drug, which may perhaps be seen as barriers against its more frequent use by psychiatrists. Alongside, there is perhaps an element of therapeutic nihilism that creeps in if clozapine is viewed as the last resort medication-the proverbial panic button. However, an interesting study comparing the attitudes of patients and prescribers toward clozapine [6] revealed that patients were happier and more satisfied with clozapine and were less troubled by the repeated blood tests and side effects than their prescribers believed them to be.

A recent article [2] elegantly investigated clozapine's current status and if it can be promoted to become a second line medication for schizophrenia. The authors recommend that clozapine should be considered at the same stage as other atypical antipsychotics, and not as a "special" drug for resistant cases. A necessary prerequisite for that to happen would be the removal of the associated misperceptions with clozapine and a gradual and thorough 'demystification' of the drug, so that clinicians would be much more comfortable using it. The risk of agranulocytosis though real, needs to be put in perspective. Carbamazepine, another commonly used drug in patients with psychiatric disorders, has a 1-2% risk of life-threatening hematological complications like aplastic anemia and agranulocytosis.

Thus, studies are needed to explore the role of clozapine as a second line agent vis-a-vis other antipsychotics to guide rational and effective use of all available antipsychotics. Schizophrenia is a difficult condition to manage, its natural course pockmarked with multiple relapses, incomplete recovery and limited therapeutic options. It would perhaps do us good not to estrange the occasional friend we chance upon.

 
   References Top

1.Kane JM, Correll CU. Past and present progress in the pharmacologic treatment of schizophrenia. J Clin Psychiatry 2010;71:1115-24.  Back to cited text no. 1
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2.Agid O, Foussias G, Singh S, Remington G. Where to position clozapine: Re-examining the evidence. Can J Psychiatry 2010;55:677-84.  Back to cited text no. 2
[PUBMED]    
3.Meltzer HY, Bastani B, Kwon KY, Ramirez LF, Burnett S, Sharpe J. A prospective study of clozapine in treatment-resistant schizophrenic patients. I. Preliminary report. Psychopharmacology (Berl) 1989;99:S68-72.  Back to cited text no. 3
    
4.Stroup TS, Lieberman JA, McEvoy JP, Davis SM, Swartz MS, Keefe RS, et al. Results of phase 3 of the CATIE schizophrenia trial. Schizophr Res 2009;107:1-12.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Nielsen J, Dahm M, Lublin H, Taylor D. Psychiatrists' attitude towards and knowledge of clozapine treatment. J Psychopharmacol 2010;24:965-71.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Hodge K, Jespersen S. Side-effects and treatment with clozapine: A comparison between the views of consumers and their clinicians. Int J Ment Health Nurs 2008;17:2-8.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Naren Prahlada Rao
Department of Psychiatry, National Institute of Mental Health & Neurosciences, Bangalore, Karnataka
India
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DOI: 10.4103/0019-5545.86825

PMID: 22135452

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