Notes on where I am with the clozapine thing

After two trials of antipsychotics clozapine can be tried. It is a broad spectrum antipsychotic working on a range of neurotransmitter sites. It's intended and theorised action is on D-receptors. I would guess that a broad spectrum medication would also affect other areas of the body and brain. There is the problem of agranulocytosis and the risk of his has been reduced by haemotological monitoring. If levels of granulocytes and other immune system cells drops too low the clozapine is stopped and they shouldn't be put on it again. It is highly valued by the psychiatric profession because it treats when nothing else will and has the most potent effect of the suicide rate. Its use is also widening.

When the manufacturers introduced it they didn't know about the damage it could do to the body's immune system and there were a few fatalities. They voluntarily withdrew it however because of its capability to treat schizophrenia it was reintroduced. Even with the blood level monitoring there have been deaths attributed to clozapine-induced agranulocytosis and the secondary infections. I can't remember if the blood level monitoring covers clozapine-induced neuropenia (a milder version of agranulocytosis from what I understand) however this is still a condition that reduces the body's immuno-response so any infection has more chance of harming the body. There is a hypothetical possibility that granulocyte levels can drop precipitously between the periodical blood level checks and this is a risk factor.

Clozapine doesn't reduce the suicide rate through the same neurobiological pathways as have been studied for depression. I haven't found suitable qualtitive research into the experience of taking clozapine. I can make an educated guess that it is through the induction of apathy, avolition or a sort of stoned haze. In the research into experiences by the manufacturers it was mentioned that it does have an effect of dulling psychosis.

Agranulocytosis is not the only condition caused by clozapine. There is a long list. There is evidence that many people may be dying much earlier than they should though on average the reduction in completed suicides means it will continue to be used.

Based on the current psychiatric understanding of severe mental illness (which is changing to be a more socially-orientated model) there is no alternative to clozapine. There is no alternative to antipsychotic medication.

Research into alternatives happens in the fringes of mental health. The research into alternatives isn't generally accepted in mainstream psychiatry. New journals like Psychosis are publishing studies on alternative approaches. However the studies used by NICE and are part of their evidence reviews are mainstream psychiatry.

There are few if any alternatives to hospitalisation and/or antipsychotic medication for psychosis and schizophrenia in the UK though early intervention services that were part of the New Horizons strategy may be a step forward in this area.

High doses of quetapine may, perhaps, be an alternative before clozapine use because it is the same type of chemical however my neurochemistry knowledge is virtually non-existant.

I know there's an alternative to pharmcotherapy or at least a way to get people off clozapine and onto a safer antipsychotic. My belief is that there is a solution such that the maximum number of people can be taken off clozapine and the least number of people put on it.

-- treating the suicide rate is important and also very difficult. More research into that.
-- there are other factors in the action of antipsychotics beyond the chemical cosh element however there are also non-pharmocological ways to achieve some of the gains of antipsychotics, for example by brain training to try and overcome the cognitive deficits and keep the brain sharp
-- I need the figures on mortality
-- there's little chance but I want to try clozapine
-- I need to find a high quality qualitiative study - perhaps someone's done one in America?
-- I need to understand more about what people really go through because that's where the solution will come from
-- I need a good, long list of things that work for some people with schizophrenia and psychosis
-- I need to keep thinking outside the box because this is a really difficult problem to solve
-- if it is the action as chemical cosh which is why clozapine is effective then...I'm not sure what to do.