Clozapine and treatment of schizophrenia

Outside psychiatry few people know what clozapine is. Within
psychiatry it is a highly valued treatment. It is the only drug named in
the NICE schizophrenia guidelines because of this percieved value.

The perception of value comes from three evidence-based things: it's
effectiveness measured with measures of the psychopathology of
schizophrfenia, the highest ability to treat suicidal behaviours and
it's superiority to all other antipsychotics. It's beloved for more than
that though and this element is about the psychology of doctors.

In the developed world schizophrenia has a poor prognosis - the worst of
all the major mental illnesses. It can lead to a therapeutic nihilism
that leads to extreme and ineffective treatments that risk the lives of
people with a diagnosis of schizophrenia. A diagnosis has been likened
to a diagnosis of cancer. Clozapine was the first of a new generation of
antipsychotic, the rest of which have improved patient quality of life
through fewer side effects.

The early studies showed very promising results and it was only the
unexpected problem of agranulocytosis that caused it to be withdrawn. It
was a mriacle - a new pharmocological treatment that, according to the
studies at the time, was very effective at treating something doctors
had found impossible to treat. It's why the psychiatric profession got
it back with mandatory blood level monitoring for the first six months
of use.

Clozapine is effective at a neurochemical level because it is like s
sawn off shotgun and works on lots of neurotransmitter sites whereas the
latest generation of antipsychotics are effectively sniper rifles. In my
opinion the neurochemical shotgun causes a lot of collateral damage,
though no new antipsychotic has been developed that's as effecvtive but
more selective in it's approach.

The evidence shows that people still die from agranulocytosis and a
small percentage develop a milder version called neutropenia. There are
other neurological problems. The list includes seizures, heart problems
and other documented risks. There's evidence that a lot of people who
are taking clozapine are dying much earlier than they should. Several
new stories were published highlighting this problem. Other research is
showing the negative effect on life expectancy of antipsychotics used
for conditions other than schizophrenia, for example the deaths in the
management of dementia. These risks have not been studied but there's
evidence that there needs to be a re-evaluation of the evidence-base for
the use of clozapine, alternatives for treatment-resistant schizophrenia
looked into and more care made available for people with treatment
resistant schizophrenia.

Of course many patients would prefer not to be taking clozapine. The
side effects are most likely the worst of all the antipsychotics. There
has been no independent research into the experiences and preferences of
UK clozapine patients. NICE's process does not involve high levels of
patient involvement. No organisation has chosen to be the voice for the
people dying on clozapine.