Clozapine

This drug was the first of a new generation of antipsychotics: the
atypical or second generation neuroleptic. It was voluntarily removed
from service because of the dangers it posed but was introduced because
of psychiatrists' belief in its ability to treat schizophrenia.

The value psychiatry to places on clozapine is high today even with the
development of third generation anitpsychotics, pharmacogentics,
psychological therapies for psychosis, alternate treatment paradigms for
first episode psychosis and the advance of the psychosocial model (which
I'm afraid may not have penetrated far into the general medical
profession's understanding of mental health).

It was withdrawn because of the deaths it caused shortly after it's
introduction. Clozapine causes agranulocytosis which is a condition
where the immune system becomes depleted to the point where ordinary
infections can kill the patient. Regular monitoring of agranulocyte
levels in the blood are done for the first six months of use since it
was reintroduced. The drug is still killing people though these deaths
are compensated for by the fewer completed suicides and increased
average life expectancy.

There is the important question of quality of life. Antipsychotics make
people fat and clozapine is the worst. It may also have the strongest
effect as the "chemical cosh" or 'chemical straight jacket' as I like to
call it. The problem is I don't know what it's like and I'm not very
good at finding the information on what it feels like. I'm will to try
it though. I've been on very high levels of antipsychotics before but
nothing like clozapine and from what I've read of it's neurobiological
effects it should be very different to the other antipsychotics I've tried.

The NICE clinical guidelines for schizophrenia and 'best' practice is
for the use of clozapine after the trial of just two other antipsychotic
medications. There is evidence that patients aren't made fully aware of
the risk or partially aware of the risk to life. The weight gain alone
is something many would find intolerable along with the risk to life and
the other strong side effects that contribute to poor quality of life.

I've spent a long time considering what to do about the problem of
clozapine because the simple fact is the evidence shows it is capable of
treating the suicide rate very effectively - more than any other
treatment for schizophrenia. Schizophrenia is associated with a very
high lifetime completed suicide rate - 10%. In fact based on that logic
it could be used to treat borderline personality disorder (BPD) which
has a lifetime completed suicide rate of up to 20%.

In BPD there is a treatment hope. Dialectical behavioural therapy (DBT)
has shown positive results from the evidence I have seen and heard about
however I have not read a meta-analysis or systematic review of high
quality trials.
DBT is an expensive therapy. Whereas the NICE recommendations of
schizophrenia currently only recommend 16 sessions of CBT for
schizophrenia a full course of DBT can take a year. It also involves a
second therapist to counsel the first therapist because of the difficult
work involved. The higher cost is mitigated by the cost of saving a life.

I don't know much about DBT but the hope it provides for people who have
such a high risk of death, as well as the poor quality of life and life
outcomes, and in schizophrenia that may be one of the most depressing
things for a person with the diagnosis: the lack of hope. I think that
happens in a lot of suicides.

Psychosocial treatments and interventions offer a better hope for
quality of life and, in my opinion, a better chance to treat the suicide
rate of all people with a diagnosis of schizophrenia. Helping is better
the drugs. Quality of life is better. There's far fewer side effects.
There's also the opportunity to reduce the other ways antipsychotic
medications cause illness and contribute to the reduced life expectancy
of people with a diagnosis of schizophrenia.

Schziophrenia and other severe mental illnesses are typified by a lack
of ability to treat, i.e. medicine doesn't know what to do. Simpler
problems like common mental disorders treated by more sophistcated drugs
and simpler psychological therapies are important. The area where
progress is most needed is in the treatment and recovery of people with
severe mental illnesses.

(
There is also a need for a change in society. The change is partially
emobodied by the antistigma movement for all mentall ill health however
the broad group of psychotic disorders in Western society, especially in
Britain, are deserving of more attention. That's something far deeper
and not something I'll explain here.
)

Psychiatrists don't have the opportunity to try other psychological
therapies because the NHS and NICE favour CBT because it is the best
according to the evidence and because Lord Layard said it was cost
effective.

It's common sense to realise that different things work for different
people. Mental health isn't as an advanced a science as physics. The
science of mental health is like knowing a coin lands heads up about 50%
of the time. It is far from knowing what will happen the next time you
toss a coin. Physics can do that though if and the same equation also
works for pancakes and explains why toast falls butter side down (for
standard sized toast from standard height tables).

So the evidence in mental health and the science is still quite poor. In
the abscene of good science what is left is guesswork and good
judgement. It is down to clinicians who are working with limited
resources to make decisions based on need, and those decisions are based
on what the local trust is able to provide and what the extra funding
from the government allows for (e.g. the IAPT program for CBT).

Everyone deserves the best mental healthcare but there isn't the money
for it, especially in a cash strapped economy. There is no greater need
for the best mental healthcare, the sort of mental healthcare that
focuses on quality of life and longevity without resorting to a
chemically induced solution, and one that shortens life and makes it
worse - so much so that many people taking antipsychotics would rather
not be on them.

That's really what this rant or ramble or whatever you'd like to call
this effort is all about. The extension of a the opportunity of trial
and error in treatment using non-pharmocological means after the trial
of two antipsychotics along with the use of clozpaine (or before if
possible) is an opportunity to help these sorry few who have to live on
the worst drug in mental health.

There is a vitally important aspect though: the power balance between
psychiatrist or other mental health professional and 'patient'. This
opportunity created by the free reign to assist the patient by any means
necessary must come from patient and professional. What that means is
that the patient needs freedom and independence to make their decisions.
These must be informed. I can not place a greater onus on this.

However I'm pretty drunk and stoned now. It's Saturday night. I'm
probably officially a loser now. The point was about clozapine and the
hope for an alternative to a drug that, if they had an alternative,
would be banned.