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Silva E, Legge S, Casetta C, Whiskey E, Oloyede E, Gee S. Understanding clozapine-related blood dyscrasias. Developments, genetics, ethnicity and disparity: it's a CIN. BJPsych Bull 2024:1-6. [PMID: 38828731 DOI: 10.1192/bjb.2024.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
Clozapine remains the gold standard intervention for treatment-resistant schizophrenia; however, it remains underused, especially for some minority groups. A significant impediment is concern about propensity to neutropenia. The aim of this article is to provide an update on current knowledge relating to: the pattern and incidence of severe blood dyscrasias; the effectiveness of current monitoring regimes in reducing harm; the mechanisms of and the distinctions between clozapine-induced neutropenia and agranulocytosis; benign ethnic neutropenia; and changes to the monitoring thresholds in the USA and other international variations. These all have implications for the practical use of clozapine; specifically, how barriers to initiating, maintaining and restarting clozapine can be understood and in many cases overcome, especially for patients from minority groups, potentially with simpler approaches than the use of lithium or G-CSF.
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Affiliation(s)
| | | | - Cecilia Casetta
- South London and Maudsley NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Eromona Whiskey
- South London and Maudsley NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Ebenezer Oloyede
- South London and Maudsley NHS Foundation Trust, London, UK
- University of Oxford, Oxford, UK
| | - Siobhan Gee
- South London and Maudsley NHS Foundation Trust, London, UK
- King's College London, London, UK
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Sarpal DK, Cole ES, Gannon JM, Li J, Adair DK, Chengappa KNR, Donohue JM. Variation of Clozapine Use for Treatment of Schizophrenia: Evidence from Pennsylvania Medicaid and Dually Eligible Enrollees. Community Ment Health J 2024; 60:743-753. [PMID: 38294579 DOI: 10.1007/s10597-023-01226-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/26/2023] [Indexed: 02/01/2024]
Abstract
While clozapine is the most effective antipsychotic treatment for treatment-resistant schizophrenia, it remains underutilized across the United States, warranting a more comprehensive understanding of variation in use at the county level, as well as characterization of existing prescribing patterns. Here, we examined both Medicaid and Medicare databases to (1) characterize temporal and geographic variation in clozapine prescribing and, (2) identify patient-level characteristics associated with clozapine use. We included Medicaid and Fee for Service Medicare data in the state of Pennsylvania from January 1, 2013, through December 31, 2019. We focused on individuals with continuous enrollment, schizophrenia diagnosis, and multiple antipsychotic trials. Geographic variation was examined across counties of Pennsylvania. Regression models were constructed to determine demographic and clinical characteristics associated with clozapine use. Out of 8,255 individuals who may benefit from clozapine, 642 received treatment. We observed high medication burden, overall, including multiple antipsychotic trials. We also identified variation in clozapine use across regions in Pennsylvania with a disproportionate number of prescribers in urban areas and several counties with no identified clozapine prescribers. Finally, demographic, and clinical determinants of clozapine use were observed including less use in people identified as non-Hispanic Black, Hispanic, or with a substance use disorder. In addition, greater medical comorbidity was associated with increased clozapine use. Our work leveraged both Medicaid and Medicare data to characterize and surveil clozapine prescribing. Our findings support efforts monitor disparities and opportunities for the optimization of clozapine within municipalities to enhance clinical outcomes.
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Affiliation(s)
- Deepak K Sarpal
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Evan S Cole
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jessica M Gannon
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jie Li
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dale K Adair
- Office of Mental Health and Substance Abuse Services, Pennsylvania Department of Human Services, Harrisburg, PA, USA
| | - K N Roy Chengappa
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Julie M Donohue
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
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Barry S, Jarskog LF, Xia K, Torpunuri RS, Wu X, Zeng X. Racial Disparities in Clozapine Prescription Patterns Among Patients With Schizophrenia. Psychiatr Serv 2024:appips20230226. [PMID: 38500451 DOI: 10.1176/appi.ps.20230226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
OBJECTIVE Previous research has suggested that demographic factors affect the likelihood of a patient with schizophrenia receiving a clozapine prescription. The authors aimed to determine the impact of race, social determinants of health, gender, rurality, and care patterns on clozapine prescription rates. METHODS This cross-sectional observational study used structured electronic health records data from 3,160 adult patients diagnosed as having schizophrenia between October 1, 2015, and November 30, 2021, in a multifacility health system. The social vulnerability index (SVI) was used to quantify social determinants of health. Descriptive data analysis, logistic regression, and sensitivity analysis were conducted to identify differences between patients with schizophrenia who received a clozapine prescription and those who received antipsychotic medications other than clozapine. RESULTS Overall, 401 patients with schizophrenia were given a clozapine prescription during the study period, and 2,456 received antipsychotics other than clozapine. Results of the logistic regression indicated that White race (OR=1.71, compared with Black race), community minority status and language SVI score (OR=2.97), and increased treatment duration (OR=1.36) were significantly associated with a higher likelihood of clozapine prescription; gender, rurality, age at first diagnosis, and ethnicity did not influence the likelihood of receiving clozapine. CONCLUSIONS Black patients with schizophrenia had a lower likelihood of receiving a clozapine prescription compared with White patients, even after analyses accounted for demographic variables, social determinants of health, and care access patterns. Given the effectiveness of clozapine in managing treatment-resistant schizophrenia, it is crucial for future research to better understand the factors contributing to this treatment disparity.
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Affiliation(s)
- Spenser Barry
- Department of Psychology, University of North Carolina Wilmington, Wilmington (Barry); Carolina Health Informatics Program (Torpunuri) and Department of Biostatistics (Wu), University of North Carolina at Chapel Hill, Chapel Hill; North Carolina Psychiatric Research Center (Jarskog, Zeng) and Mental Health Informatics and Analytics Core (Xia, Zeng), Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill
| | - L Fredrik Jarskog
- Department of Psychology, University of North Carolina Wilmington, Wilmington (Barry); Carolina Health Informatics Program (Torpunuri) and Department of Biostatistics (Wu), University of North Carolina at Chapel Hill, Chapel Hill; North Carolina Psychiatric Research Center (Jarskog, Zeng) and Mental Health Informatics and Analytics Core (Xia, Zeng), Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill
| | - Kai Xia
- Department of Psychology, University of North Carolina Wilmington, Wilmington (Barry); Carolina Health Informatics Program (Torpunuri) and Department of Biostatistics (Wu), University of North Carolina at Chapel Hill, Chapel Hill; North Carolina Psychiatric Research Center (Jarskog, Zeng) and Mental Health Informatics and Analytics Core (Xia, Zeng), Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill
| | - Rohit Simha Torpunuri
- Department of Psychology, University of North Carolina Wilmington, Wilmington (Barry); Carolina Health Informatics Program (Torpunuri) and Department of Biostatistics (Wu), University of North Carolina at Chapel Hill, Chapel Hill; North Carolina Psychiatric Research Center (Jarskog, Zeng) and Mental Health Informatics and Analytics Core (Xia, Zeng), Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill
| | - Xiaoyu Wu
- Department of Psychology, University of North Carolina Wilmington, Wilmington (Barry); Carolina Health Informatics Program (Torpunuri) and Department of Biostatistics (Wu), University of North Carolina at Chapel Hill, Chapel Hill; North Carolina Psychiatric Research Center (Jarskog, Zeng) and Mental Health Informatics and Analytics Core (Xia, Zeng), Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill
| | - Xiaoming Zeng
- Department of Psychology, University of North Carolina Wilmington, Wilmington (Barry); Carolina Health Informatics Program (Torpunuri) and Department of Biostatistics (Wu), University of North Carolina at Chapel Hill, Chapel Hill; North Carolina Psychiatric Research Center (Jarskog, Zeng) and Mental Health Informatics and Analytics Core (Xia, Zeng), Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill
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Wang T, Codling D, Bhugra D, Msosa Y, Broadbent M, Patel R, Roberts A, McGuire P, Stewart R, Dobson R, Harland R. Unraveling ethnic disparities in antipsychotic prescribing among patients with psychosis: A retrospective cohort study based on electronic clinical records. Schizophr Res 2023; 260:168-179. [PMID: 37669576 PMCID: PMC10881407 DOI: 10.1016/j.schres.2023.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/11/2023] [Accepted: 08/27/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Previous studies have shown mixed evidence on ethnic disparities in antipsychotic prescribing among patients with psychosis in the UK, partly due to small sample sizes. This study aimed to examine the current state of antipsychotic prescription with respect to patient ethnicity among the entire population known to a large UK mental health trust with non-affective psychosis, adjusting for multiple potential risk factors. METHODS This retrospective cohort study included all patients (N = 19,291) who were aged 18 years or over at their first diagnoses of non-affective psychosis (identified with the ICD-10 codes of F20-F29) recorded in electronic health records (EHRs) at the South London and Maudsley NHS Trust until March 2021. The most recently recorded antipsychotic treatments and patient attributes were extracted from EHRs, including both structured fields and free-text fields processed using natural language processing applications. Multivariable logistic regression models were used to calculate the odds ratios (OR) for antipsychotic prescription according to patient ethnicity, adjusted for multiple potential contributing factors, including demographic (age and gender), clinical (diagnoses, duration of illness, service use and history of cannabis use), socioeconomic factors (level of deprivation and own-group ethnic density in the area of residence) and temporal changes in clinical guidelines (date of prescription). RESULTS The cohort consisted of 43.10 % White, 8.31 % Asian, 40.80 % Black, 2.64 % Mixed, and 5.14 % of patients from Other ethnicity. Among them, 92.62 % had recorded antipsychotic receipt, where 24.05 % for depot antipsychotics and 81.72 % for second-generation antipsychotic (SGA) medications. Most ethnic minority groups were not significantly different from White patients in receiving any antipsychotic. Among those receiving antipsychotic prescribing, Black patients were more likely to be prescribed depot (adjusted OR 1.29, 95 % confidence interval (CI) 1.14-1.47), but less likely to receive SGA (adjusted OR 0.85, 95 % CI 0.74-0.97), olanzapine (OR 0.82, 95 % CI 0.73-0.92) and clozapine (adjusted OR 0.71, 95 % CI 0.6-0.85) than White patients. All the ethnic minority groups were less likely to be prescribed olanzapine than the White group. CONCLUSIONS Black patients with psychosis had a distinct pattern in antipsychotic prescription, with less use of SGA, including olanzapine and clozapine, but more use of depot antipsychotics, even when adjusting for the effects of multiple demographic, clinical and socioeconomic factors. Further research is required to understand the sources of these ethnic disparities and eliminate care inequalities.
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Affiliation(s)
- Tao Wang
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom.
| | - David Codling
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom; South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom
| | - Dinesh Bhugra
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom
| | - Yamiko Msosa
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom
| | - Matthew Broadbent
- South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom
| | - Rashmi Patel
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom; South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom
| | - Angus Roberts
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom; South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom
| | - Philip McGuire
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom; Oxford Health, Oxford Health NHS Foundation Trust, Oxford, United Kingdom
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom; South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom
| | - Richard Dobson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London SE5 8AF, United Kingdom; South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom; Institute of Health Informatics, University College London, Euston Road, London NW1 2DA, United Kingdom; Health Data Research UK London, University College London, Euston Road, London NW1 2DA, United Kingdom
| | - Robert Harland
- South London and Maudsley National Health Service (NHS) Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom
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Freitas DF, Walker S, Nyikavaranda P, Downs J, Patel R, Khondoker M, Bhui K, Hayes RD. Ethnic inequalities in involuntary admission under the Mental Health Act: an exploration of mediation effects of clinical care prior to the first admission. Br J Psychiatry 2023; 222:27-36. [PMID: 36281471 PMCID: PMC10250681 DOI: 10.1192/bjp.2022.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/26/2022] [Accepted: 08/05/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Studies show ethnic inequalities in rates of involuntary admission and types of clinical care (such as psychological therapies). However, few studies have investigated if there is a relationship between clinical care practices and ethnic inequalities in involuntary admission. AIMS This study investigated the impact of ethnicity and clinical care on involuntary admission and the potential mediation effects of prior clinical care. METHOD In this retrospective cohort study, we used data from the electronic records of the South London and Maudsley NHS Foundation Trust and identified patients with a first hospital admission between January 2008 and May 2021. Logistic regression and mediation analyses were used to investigate the association between ethnicity and involuntary admission, and whether clinical care, in the 12 months preceding admission, mediates the association. RESULTS Compared with White British people, higher odds of involuntary admission were observed among 10 of 14 minority ethnic groups; with more than twice the odds observed among people of Asian Chinese, of Asian Bangladeshi and of any Black background. There were some ethnic differences in clinical care prior to admission, but these had a minimal impact on the inequalities in involuntary admission. More out-patient appointments and home treatment were associated with higher odds of involuntary admission, whereas psychological therapies and having a care plan were associated with reduced odds of involuntary admission. CONCLUSIONS Ethnic inequalities in involuntary admission persist after accounting for potential mediating effects of several types and frequencies of clinical care. Promoting access to psychological therapies and ensuring that care plans are in place may reduce involuntary admissions.
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Affiliation(s)
- Daniela Fonseca Freitas
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK and Department of Psychiatry, University of Oxford, UK
| | - Susan Walker
- Division of Psychiatry, University College London, UK and Great Ormond Street Institute of Child Health, University College London, UK
| | - Patrick Nyikavaranda
- Department of Primary Care & Public Health, Brighton & Sussex Medical School, University of Sussex, UK
| | - Johnny Downs
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK and South London and Maudsley NHS Foundation Trust, UK
| | - Rashmi Patel
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK and South London and Maudsley NHS Foundation Trust, UK
| | | | - Kamaldeep Bhui
- Department of Psychiatry, University of Oxford, UK and Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Richard D. Hayes
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
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Abstract
AIMS Clozapine is licensed for treatment-resistant psychosis and remains underutilised. This may berelated to the stringent haematological monitoring requirements that are mandatory in most countries. We aimed to compare guidelines internationally and develop a novel Stringency Index. We hypothesised that the most stringent countries would have increased healthcare costs and reduced prescription rates. METHOD We conducted a literature review and survey of guidelines internationally. Guideline identification involved a literature review and consultation with clinical academics. We focused on the haematological monitoring parameters, frequency and thresholds for discontinuation and rechallenge after suspected clozapine-induced neutropenia. In addition, indicators reflecting monitoring guideline stringency were scored and visualised using a choropleth map. We developed a Stringency Index with an international panel of clozapine experts, through a modified-Delphi-survey. The Stringency Index was compared to health expenditure per-capita and clozapine prescription per 100 000 persons. RESULTS One hundred twocountries were included, from Europe (n = 35), Asia (n = 24), Africa (n = 20), South America (n = 11), North America (n = 7) and Oceania and Australia (n = 5). Guidelines differed in frequency of haematological monitoring and discontinuation thresholds. Overall, 5% of included countries had explicit guidelines for clozapine-rechallenge and 40% explicitly prohibited clozapine-rechallenge. Furthermore, 7% of included countries had modified discontinuation thresholds for benign ethnic neutropenia. None of the guidelines specified how long haematological monitoring should continue. The most stringent guidelines were in Europe, and the least stringent were in Africa and South America. There was a positive association (r = 0.43, p < 0.001) between a country's Stringency Index and healthcare expenditure per capita. CONCLUSIONS Recommendations on how haematological function should be monitored in patients treated with clozapine vary considerably between countries. It would be useful to standardise guidelines on haematological monitoring worldwide.
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Gee S, Almeida V, Hughes A, McMullen I, Taylor D. Reasons for admission to a general medical hospital for patients taking clozapine. Ther Adv Psychopharmacol 2022; 12:20451253221136753. [PMID: 36582490 PMCID: PMC9793060 DOI: 10.1177/20451253221136753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/12/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Clozapine is associated with a diverse range of side effects. In addition, patients prescribed clozapine commonly suffer with medical comorbidities. OBJECTIVES This study aimed to characterise patients prescribed clozapine who required medical admission, understand reasons for admission, identify areas for interventions to prevent future admission and describe clozapine management during the inpatient stay. DESIGN We conducted a retrospective analysis of patients prescribed clozapine who were admitted to a general medical hospital in a 12-month period. METHOD Data were collected using electronic drug charts and notes. RESULTS In total, 114 clozapine patients were hospitalised. Twenty-eight patients (25%) were admitted because of infection, 12 (11%) were elective admissions and 12 (11%) had gastrointestinal problems. Most patients admitted were Black (54%) and half were female. Few changes were made to clozapine dosing on admission or during the inpatient stay. Most patients had been taking clozapine for many years at the point of admission, the majority were able to continue taking it for the duration of their medical treatment and were discharged on the same dose they were taking prior to admission. Clozapine plasma concentrations were not consistently measured with only 18 (16%) patients having one or more plasma concentrations determined during their admission. The median clozapine plasma concentration on admission was 0.48 mg/L (nor-clozapine 0.21 mg/L), with a range of 0.09 to 3.9 mg/L. Three patients were admitted to the intensive care unit during their admission; all were discharged on clozapine. Four patients died; one from lung adenocarcinoma, one bowel obstruction, one cardiac arrest and one chest sepsis. In total, 27 patients (23%) had their clozapine stopped on admission, 6 (22% of this group) unintentionally. CONCLUSIONS Our study found that the most common reason for admission for patients taking clozapine was infection. Plasma concentrations were not measured routinely despite clozapine having a narrow therapeutic index and enhanced potential for toxicity in the medically unwell patient.
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Affiliation(s)
- Siobhan Gee
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Vasco Almeida
- Department of Psychological Medicine, King's College Hospital, London, UK
| | - Adam Hughes
- Department of Psychological Medicine, King's College Hospital, London, UK
| | - Isabel McMullen
- Department of Psychological Medicine, King's College Hospital, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK.,Faculty of Life Sciences & Medicine, King's College London, London, UK
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