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Taylor D, Vallianatou K, Gandhi S, Casetta C, Howes O, MacCabe J. Severe neutropenia unrelated to clozapine in patients receiving clozapine. J Psychopharmacol 2024; 38:624-635. [PMID: 39041349 DOI: 10.1177/02698811241262767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
BACKGROUND Clozapine is known to cause agranulocytosis. Mandatory monitoring schemes are aimed at reducing the risk of agranulocytosis and of the consequences of agranulocytosis. All cases of agranulocytosis occurring in people prescribed clozapine are assumed to be caused by clozapine. METHODS In a previous study, we examined a cohort of patients listed on our hospital database as having had clozapine-induced agranulocytosis and applied specific criteria to identify those with confirmed clozapine-related, life-threatening agranulocytosis. In this study, we examine the cases not meeting these specific criteria. RESULTS In the original study, 9 of 23 cases met the criteria for clozapine-induced, life-threatening agranulocytosis. Of the 13 remaining cases for whom data were available, 5 were probably caused by clozapine but were not life-threatening. Three cases were the result of concomitant cancer chemotherapy. Three were anomalous results probably related to measurement error. For the remaining two cases, the cause was not identified. CONCLUSION Not all cases of agranulocytosis occurring in people taking clozapine are caused by clozapine. The widely used threshold criterion-based diagnosis overestimates the risk of agranulocytosis. True clozapine-related agranulocytosis is best identified by pattern-based criteria: rapid fall in neutrophil counts over around 2 weeks to below 0.5 × 109/L for two consecutive days (unless clozapine is stopped very early or granulocyte colony stimulating factor is given) where other possible causes (benign ethnic neutropenia, cancer chemotherapy) can be ruled out.
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Affiliation(s)
- David Taylor
- Institute of Pharmaceutical Science, King's College London, London, UK
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Kalliopi Vallianatou
- Institute of Pharmaceutical Science, King's College London, London, UK
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Shreyans Gandhi
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Cecilia Casetta
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- National Psychosis Unit, South London and Maudsley NHS Foundation Trust, Beckenham, Kent, UK
| | - Oliver Howes
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Institute of Clinical Sciences (ICS), Faculty of Medicine, Imperial College London, London, UK
| | - James MacCabe
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- National Psychosis Unit, South London and Maudsley NHS Foundation Trust, Beckenham, Kent, UK
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Oloyede E, Dzahini O, Abolou Z, Gee S, Whiskey E, Malhotra D, Hussain M, Osborne I, Casetta C, McGuire P, MacCabe JH, Taylor D. Clinical impact of reducing the frequency of clozapine monitoring: controlled mirror-image cohort study. Br J Psychiatry 2023:1-7. [PMID: 37092691 PMCID: PMC10391318 DOI: 10.1192/bjp.2023.44] [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: 04/25/2023]
Abstract
BACKGROUND To minimise infection during COVID-19, the clozapine haematological monitoring interval was extended from 4-weekly to 12-weekly intervals in South London and Maudsley NHS Foundation Trust. AIMS To investigate the impact of this temporary policy change on clinical and safety outcomes. METHOD All patients who received clozapine treatment with extended (12-weekly) monitoring in a large London National Health Service trust were included in a 1-year mirror-image study. A comparison group was selected with standard monitoring. The proportion of participants with mild to severe neutropenia and the proportion of participants attending the emergency department for clozapine-induced severe neutropenia treatment during the follow-up period were compared. Psychiatric hospital admission rates, clozapine dose and concomitant psychotropic medication in the 1 year before and the 1 year after extended monitoring were compared. All-cause clozapine discontinuation at 1-year follow-up was examined. RESULTS Of 569 participants, 459 received clozapine with extended monitoring and 110 controls continued as normal. The total person-years were 458 in the intervention group and 109 in the control group, with a median follow-up time of 1 year in both groups. During follow-up, two participants (0.4%) recorded mild to moderate neutropenia in the intervention group and one (0.9%) in the control group. There was no difference in the incidence of haematological events between the two groups (IRR = 0.48, 95% CI 0.02-28.15, P = 0.29). All neutropenia cases in the intervention group were mild, co-occurring during COVID-19 infection. The median number of admissions per patient during the pre-mirror period remained unchanged (0, IQR = 0) during the post-mirror period. There was one death in the control group, secondary to COVID-19 infection. CONCLUSIONS There was no evidence that the incidence of severe neutropenia was increased in those receiving extended monitoring.
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Affiliation(s)
- Ebenezer Oloyede
- South London and Maudsley NHS Foundation Trust, London, UK; and Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK
| | - Olubanke Dzahini
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
| | - Zadro Abolou
- Barnet, Enfield and Haringey Mental Health Trust, London, UK
| | - Siobhan Gee
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
| | - Eromona Whiskey
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
| | | | - Masuma Hussain
- South West London and St George's Mental Health NHS Trust, London, UK
| | - Ian Osborne
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
| | - Cecilia Casetta
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Philip McGuire
- Barnet, Enfield and Haringey Mental Health Trust, London, UK
| | - James H MacCabe
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - David Taylor
- South London and Maudsley NHS Foundation Trust, London, UK; and Institute of Pharmaceutical Science, King's College London, London, UK
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Jakobsen MI, Schaug JP, Nielsen J, Simonsen E. Antipsychotic prescribing practices for outpatients with schizophrenia and reasons for non-clozapine treatment - Data from a Danish quality assessment audit. Nord J Psychiatry 2023:1-10. [PMID: 36651766 DOI: 10.1080/08039488.2022.2160878] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Clozapine is the gold standard for treating treatment-resistant schizophrenia (TRS) although widely underutilised. Both organisational, patient- and clinician related reasons for the underutilisation have been reported, however, the clinical impact of either in real-world settings is not fully elucidated. AIM This audit aimed to evaluate the local antipsychotic (AP) prescribing practices for outpatients with schizophrenia and to assess the spectrum and prevalence of journalised reasons for non-clozapine treatment amongst eligible outpatients. METHODS Data on demographics, current and former AP treatments, as well as documented reasons for non-clozapine treatment, was extracted through chart audit. RESULTS Of the 668 affiliated outpatients with schizophrenia, 43% were treated with AP polytherapy (APP) and 19.6% with clozapine. The most prevalent reason for clozapine discontinuation was related to side effects whereas the most prevalent reason for refusal or omission of clozapine treatment was related to the associated monitoring regimen. CONCLUSIONS This audit showed that APP prescribing is a highly prevalent practice in our services when treating outpatients with schizophrenia and that clozapine is underutilised in a 'last resort' manner. The blood-monitoring regimen associated with clozapine treatment was found to be an important factor in the underutilisation. It seemed, however, that the monitoring constituted a barrier for different reasons, requiring different approaches to remedy. Future studies, directly involving both patients and clinicians in the identification and management of the most clinically relevant barriers and their corresponding facilitators, are warranted.
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Affiliation(s)
- Michelle I Jakobsen
- The Mental Health Services East, Region Zealand Psychiatry, Roskilde, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Julie P Schaug
- Psychiatric Research Unit, Centre for Evidence-Based Psychiatry, Region Zealand Psychiatry, Slagelse, Denmark
| | - Jimmi Nielsen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Psychiatric Centre Glostrup, The Mental Health Services in the Capital Region of Denmark, Glostrup, Denmark
| | - Erik Simonsen
- The Mental Health Services East, Region Zealand Psychiatry, Roskilde, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Oloyede E, Blackman G, Whiskey E, Bachmann C, Dzahini O, Shergill S, Taylor D, McGuire P, MacCabe J. Clozapine haematological monitoring for neutropenia: a global perspective. Epidemiol Psychiatr Sci 2022; 31:e83. [PMID: 36426600 PMCID: PMC9714212 DOI: 10.1017/s204579602200066x] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/27/2022] Open
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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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Graham Blackman
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Eromona Whiskey
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College, London 5th Floor, Franklin-Wilkins Building 150 Stamford Street, LondonSE1 9NH, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Christian Bachmann
- Department of Child and Adolescent Psychiatry, Universitätsklinikum Ulm, Steinhövelstr. 5, 89075, Ulm, Germany
- Department of Child and Adolescent Psychiatry, Medical University of Vienna, Vienna, Austria
| | - Olubanke Dzahini
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Sukhi Shergill
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College, London 5th Floor, Franklin-Wilkins Building 150 Stamford Street, LondonSE1 9NH, UK
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - James MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
- NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
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5
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Oloyede E, Whiskey E, Casetta C, Dzahini O, Dunnett D, Gandhi S, Gaughran F, Shergill S, McGuire P, MacCabe JH, Taylor D. Relaxation of the criteria for entry to the UK Clozapine Central Non-Rechallenge Database: a modelling study. Lancet Psychiatry 2022; 9:636-644. [PMID: 35772414 DOI: 10.1016/s2215-0366(22)00188-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/22/2022] [Accepted: 05/04/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Clozapine is uniquely effective in treatment-resistant psychosis. In the UK, patients must discontinue clozapine indefinitely if they are placed on the Central Non-Rechallenge Database (CNRD) after their haematological parameters fall below particular thresholds. Under exceptional circumstances, patients can be rechallenged on clozapine under an off-licence agreement. In the USA in 2015, restrictive practice was discontinued to allow greater flexibility for clozapine maintenance. The absolute neutrophil count leading to treatment interruption was lowered from less than 1·5 × 109/L to less than 1·0 × 109/L and platelet and white cell count monitoring were ceased. We aimed to investigate the implications of a similar policy change on clozapine use in the UK. METHODS This was a modelling study of all patients registered on the UK CNRD. First, we determined the proportion of patients placed on the database in the UK who would have had to discontinue clozapine treatment under the US Food and Drug Administration (FDA) criteria. Second, we compared the haematological characteristics of patients who did or did not meet FDA criteria for discontinuing clozapine, including the time to registration from clozapine initiation and the proportion of cases of severe neutropenia at registration. Third, we investigated the success rates of clozapine re-challenge for patients that had been placed on the CNRD. Successful rechallenge was defined as no recurrence of CNRD registration. FINDINGS Between May 2, 2002 and March 1, 2021, 3731 patients were placed on the CNRD, with a mean age of 47 years (SD 15), including 1420 (38%) women and 2311 (62%) men, of whom 3089 (83%) were White, 360 (10%) were Black, 190 (5%) were Asian, and 92 (2%) were classified as other. 566 (15%) of 3731 patients met the equivalent criteria for clozapine discontinuation under the FDA guidelines. The median time to CNRD registration from clozapine initiation was 1·6 years (IQR 0·2-4·9). Data for 519 rechallenged patients were examined; 419 (81%) were successful. Clozapine rechallenge success rates were broadly similar between individuals who did not meet the US CNRD registration criteria (36 [78%] of 46) and those who did meet the criteria (383 [81%] of 473). INTERPRETATION Implementing the revised FDA monitoring criteria in the UK would substantially reduce clozapine discontinuation for haematological reasons, which would greatly improve the mental health outcomes of these patients without having a major effect on their physical health. FUNDING None.
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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - Eromona Whiskey
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK; National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Pharmaceutical Science, King's College, London, UK
| | - Cecilia Casetta
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Olubanke Dzahini
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Pharmaceutical Science, King's College, London, UK
| | - Danielle Dunnett
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Shreyans Gandhi
- Kings College Hospital London NHS Foundation Trust, London, UK
| | - Fiona Gaughran
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - Sukhi Shergill
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James H MacCabe
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Pharmaceutical Science, King's College, London, UK
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Blackman G, Oloyede E, Horowitz M, Harland R, Taylor D, MacCabe J, McGuire P. Reducing the Risk of Withdrawal Symptoms and Relapse Following Clozapine Discontinuation-Is It Feasible to Develop Evidence-Based Guidelines? Schizophr Bull 2021; 48:176-189. [PMID: 34651184 PMCID: PMC8781383 DOI: 10.1093/schbul/sbab103] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Clozapine is the only antipsychotic that is effective in treatment-resistant schizophrenia. However, in certain clinical situations, such as the emergence of serious adverse effects, it is necessary to discontinue clozapine. Stopping clozapine treatment poses a particular challenge due to the risk of psychotic relapse, as well as the development of withdrawal symptoms. Despite these challenges for the clinician, there is currently no formal guidance on how to safely to discontinue clozapine. We assessed the feasibility of developing evidence-based recommendations for (1) minimizing the risk of withdrawal symptoms, (2) managing withdrawal phenomena, and (3) commencing alternatives treatment when clozapine is discontinued. We then evaluated the recommendations against the Appraisal of Guidelines for Research and Evaluation (AGREE) II criteria. We produced 19 recommendations. The majority of these recommendation were evidence-based, although the strength of some recommendations was limited by a reliance of studies of medium to low quality. We discuss next steps in the refinement and validation of an evidence-based guideline for stopping clozapine and identify key outstanding questions.
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Affiliation(s)
- Graham Blackman
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,Psychosis Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK,To whom correspondence should be addressed; Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK; tel: 44-20-7848-5228, fax: 44-20-7848-0976, e-mail:
| | - Ebenezer Oloyede
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,Psychosis Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK,Institute of Pharmaceutical Science, King’s College London, London, UK
| | - Mark Horowitz
- Division of Psychiatry, University College London, London, UK,North East London NHS Foundation Trust, London, UK
| | - Robert Harland
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,Psychosis Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK
| | - David Taylor
- Institute of Pharmaceutical Science, King’s College London, London, UK
| | - James MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,Psychosis Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK,Psychosis Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK
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Oloyede E, Casetta C, Dzahini O, Segev A, Gaughran F, Shergill S, Mijovic A, Helthuis M, Whiskey E, MacCabe JH, Taylor D. There Is Life After the UK Clozapine Central Non-Rechallenge Database. Schizophr Bull 2021; 47:1088-1098. [PMID: 33543755 PMCID: PMC8266568 DOI: 10.1093/schbul/sbab006] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS In the United Kingdom, patients on clozapine whose hematological parameters fall below certain thresholds are placed on the Central Non-Rechallenge Database (CNRD), meaning that they cannot be prescribed clozapine again except under exceptional circumstances. This practice was discontinued in the United States in 2015 by expanding the hematological monitoring guidelines, allowing more patients to receive clozapine. Our objective was to investigate the implications this policy change would have on clozapine utilization in the United Kingdom. METHODS This was an observational, retrospective analysis of patients registered on the CNRD in a large mental health trust. The first objective was to compare the number of patients placed on the CNRD under the United Kingdom and the US Food and Drug Administration (FDA) criteria. The second objective was to explore the hematological and clinical outcomes of CNRD patients. The third objective was to investigate the hematological outcomes of patients rechallenged on clozapine after nonrechallengeable status. RESULTS One hundred and fifteen patients were placed on CNRD from 2002 to 2019, of whom 7 (6%) met the equivalent criteria for clozapine discontinuation under the FDA guidelines. Clinical outcomes, as measured by the Clinical Global Impression-Severity scale, were worse 3 months after clozapine cessation than on clozapine (t = -7.4862; P < .001). Sixty-two (54%) patients placed on CNRD were rechallenged. Fifty-nine of those (95%) were successfully rechallenged; 3 patients were placed back on CNRD, only one of which would have had to stop clozapine again under FDA criteria. CONCLUSION Implementation of the updated FDA's monitoring criteria in the United Kingdom would significantly reduce clozapine discontinuation due to hematological reasons. The evidence suggests an urgent need for revising the UK clozapine monitoring guidelines to improve outcomes in treatment-resistant schizophrenia.
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Affiliation(s)
- Ebenezer Oloyede
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Cecilia Casetta
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Olubanke Dzahini
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King’s College, London, UK
| | - Aviv Segev
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Fiona Gaughran
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Sukhi Shergill
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
| | - Alek Mijovic
- Kings College Hospital NHS Foundation Trust, London, UK
| | | | - Eromona Whiskey
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
- NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - James Hunter MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- National Psychosis Service, South London and Maudsley NHS Foundation Trust, London, UK
- NIHR Biomedical Research Centre for Mental Health South London and Maudsley NHS, London, UK
| | - David Taylor
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King’s College, London, UK
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8
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Verma M, Grover S, Chakrabarti S, Dua D. Attitude towards and experience with clozapine of patients and their caregivers after three months of starting of clozapine. Nord J Psychiatry 2021; 75:336-343. [PMID: 33372832 DOI: 10.1080/08039488.2020.1857832] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM To evaluate the patients' perceptions of clozapine and that of their family caregivers about the positive and negative effects of clozapine. METHODOLOGY 52 patients and their family caregivers were assessed for their perception of the positive and negative effects of clozapine by using a self-designed questionnaire. RESULTS About half (53.8%) of the patients were not distressed of frequent blood testing. At least two-thirds of the patients acknowledged a reduction in psychopathology, achieving clinical stability, improvement in the behavior of others towards them, improvement in their behavior towards others, improvement in regularity in medication intake, agreed that their clinical state will worsen if clozapine is stopped, and reported overall satisfaction/happiness with the intake of clozapine. In general, caregivers also reported similar perceptions. In terms of caregiver outcomes, about two-third to three-fourth of the caregivers reported a reduction in caregiving needs, personal caregiver distress and tension, caregiver burden and time spent in caregiving. About half of the caregivers reported a reduction in the cost of treatment, since the starting of clozapine. CONCLUSIONS To conclude, the present study suggests that a significant proportion of patients receiving clozapine for three months and their relatives report positive perception and experience with the molecule.
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Affiliation(s)
- Meha Verma
- Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sandeep Grover
- Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Subho Chakrabarti
- Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Devakshi Dua
- Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Laforgue EJ, Istvan M, Guerlais M, Chaslerie A, Artarit P, Vallot G, Jolliet P, Grall-Bronnec M, Victorri-Vigneau C. What about regular hematological monitoring during clozapine treatment? A compliance analysis using the French health insurance database. Expert Opin Drug Saf 2021; 20:1247-1256. [PMID: 34085879 DOI: 10.1080/14740338.2021.1939304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The inherent risk of agranulocytosis associated with clozapine requires the realization of weekly white blood cell monitoring (WBCM) during the 18 first weeks of treatment. The aim of this study was to assess the compliance with WBCM during clozapine initiation for schizophrenia and Parkinson's disease (PD) subjects. RESEARCH DESIGN AND METHOD The analysis was conducted using SNDS data on a cohort of new users of clozapine in 2018. We analyzed all reimbursements for WBCM from 2 weeks before the index date to 18 weeks after (optimal monitoring during hospitalization was assumed). The primary outcome was the proportion of good realization of WBCM according to different thresholds of completion (70%; 80%; 90%). Descriptive and comparative analyses with chi-squared test or Student's t-test were performed. RESULTS Two hundred and ninety-six subjects were included. Rates of patients with WBCM realization over 70%, 80%, and 90% of WBCM expected were, respectively, 78.1%, 70.0%, and 56.9% for subjects with schizophrenia and 71.3%, 63.2%, and 47.8% for PD subjects. Only hospitalization during the follow-up period for schizophrenia subjects was significantly associated with good WBCM realization. CONCLUSIONS We observed rather good results for compliance with clozapine initial monitoring. Other studies are needed to confirm our results.
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Affiliation(s)
- Edouard-Jules Laforgue
- Clinical Pharmacology Department, Nantes University Hospital, Nantes, France.,INSERM UMR 1246 SPHERE (Methods in Patients-centered Outcomes and HEalth Research), Nantes and Tours Universities, France
| | - Marion Istvan
- Clinical Pharmacology Department, Nantes University Hospital, Nantes, France.,INSERM UMR 1246 SPHERE (Methods in Patients-centered Outcomes and HEalth Research), Nantes and Tours Universities, France
| | - Marylène Guerlais
- Clinical Pharmacology Department, Nantes University Hospital, Nantes, France
| | - Anicet Chaslerie
- Medical Department, French Health Insurance System, Nantes, France
| | - Pascal Artarit
- Medical Department, French Health Insurance System, Nantes, France
| | - Genevieve Vallot
- Medical Department, French Health Insurance System, Nantes, France
| | - Pascale Jolliet
- Clinical Pharmacology Department, Nantes University Hospital, Nantes, France.,INSERM UMR 1246 SPHERE (Methods in Patients-centered Outcomes and HEalth Research), Nantes and Tours Universities, France
| | - Marie Grall-Bronnec
- INSERM UMR 1246 SPHERE (Methods in Patients-centered Outcomes and HEalth Research), Nantes and Tours Universities, France.,Addictology and Liaison-Psychiatry Department, Nantes University Hospital, Nantes, France
| | - Caroline Victorri-Vigneau
- Clinical Pharmacology Department, Nantes University Hospital, Nantes, France.,INSERM UMR 1246 SPHERE (Methods in Patients-centered Outcomes and HEalth Research), Nantes and Tours Universities, France
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10
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Toyoda K, Hata T, Yamauchi S, Kinoshita S, Nishihara M, Uchiyama K, Inada K, Kanazawa T. Clozapine Is Better Tolerated in Younger Patients: Risk Factors for Discontinuation from a Nationwide Database in Japan. Psychiatry Investig 2021; 18:101-109. [PMID: 33460532 PMCID: PMC7960752 DOI: 10.30773/pi.2020.0376] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/11/2019] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE The effectiveness of clozapine is clearly superior to other antipsychotics in the treatment of refractory schizophrenia. Clozapine leads to various side effects, and therefore many patients are forced to discontinue. In this study, we analyzed the registry database of all cases in Japan to identify risk factors for discontinuation of clozapine. METHODS The Clozaril patient monitoring service® (CPMS) database from July 31, 2009 to January 26, 2020 was acquired. We defined the following exclusion criteria: patients who had ever taken clozapine by a non-CPMS method, such as an individual import or clinical trial, patients who did not receive clozapine after being enrolled in CPMS, and patients with initial doses other than 12.5 mg (outside the current protocol). Therefore, all patients in this study are new users. Multivariate Cox regression analysis was used to investigate independent risk factors associated with time to discontinuation of clozapine. RESULTS We identified 8,263 patients as the study population. Clozapine discontinuation was significantly associated with age 40 and older [hazard ratio (HR)=1.66, p<0.001], intolerance to olanzapine (HR=1.31, p=0.018), previous treatment with clozapine (HR=1.30, p=0.001), and leukocyte counts <6,000/mm3 (HR=1.24, p<0.001). The Kaplan-Meier curves for clozapine discontinuation by age group revealed that older age at the time of clozapine introduction tended to have lower continuation rates. CONCLUSION Careful administration is important because patients with these factors have a high risk of discontinuation. In addition, the initiation of clozapine during the younger period was more effective and more tolerated.
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Affiliation(s)
- Katsunori Toyoda
- Department of Neuropsychiatry, Osaka Medical College, Osaka, Japan
| | - Takeo Hata
- Department of Pharmacy, Osaka Medical College Hospital, Osaka, Japan
| | - Shigeru Yamauchi
- Department of Neuropsychiatry, Osaka Medical College, Osaka, Japan
| | - Shinya Kinoshita
- Department of Neuropsychiatry, Osaka Medical College, Osaka, Japan
| | - Masami Nishihara
- Department of Pharmacy, Osaka Medical College Hospital, Osaka, Japan
| | - Kazuhisa Uchiyama
- Department of Pharmacy, Osaka Medical College Hospital, Osaka, Japan
| | - Ken Inada
- Department of Psychiatry, Tokyo Women's Medical University, Tokyo, Japan
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11
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Stam N, Taipale H, Tanskanen A, Isphording L, Okhuijsen‐Pfeifer C, Schuiling‐Veninga CC, Bos JH, Bijker BJ, Tiihonen J, Luykx JJ. Persistence of Antipsychotic Use After Clozapine Discontinuation: A Real-World Study Across Antipsychotics. Clin Transl Sci 2020; 13:1170-1177. [PMID: 32441836 PMCID: PMC7719358 DOI: 10.1111/cts.12801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/07/2020] [Indexed: 01/08/2023] Open
Abstract
Although clozapine treatment is often discontinued due to limited efficacy or low tolerability, there is a lack of guidelines and evidence on treatment options after discontinuation of clozapine in patients with schizophrenia. Persistence has proven to be an adequate indicator for treatment effectiveness in patients with schizophrenia. The aim of this study was, therefore, to compare persistence of antipsychotic use between antipsychotic treatment options in patients after stopping clozapine treatment. Registry data from a prescription database representative of the Dutch population (1996-2017) was collected to investigate persistence in patients with schizophrenia who had been using clozapine for ≥ 90 days. Persistence with antipsychotics after clozapine discontinuation was analyzed using Cox-proportional hazard regression models. Our study population consisted of 321 participants, of whom 138 re-initiated clozapine and 183 started some other antipsychotic in the year after clozapine discontinuation (N = 518 antipsychotic use periods, N = 9,178 months). Second-generation antipsychotics (SGAs) as a group were associated with better persistence compared to first-generation antipsychotics (adjusted hazard ratio (aHR), 0.73; 95% confidence interval (CI) 0.57-0.93; P = 0.011). Compared with other antipsychotics, the following oral monotherapy antipsychotics were associated with significantly better persistence: restarting clozapine (aHR 0.48; 95% CI 0.32-0.71; P < 0.001) and switching to risperidone (aHR 0.52; 95% CI 0.32-0.84; P = 0.008) or olanzapine (aHR 0.55; 95% CI 0.35-0.87; P = 0.010). Sensitivity analyses confirmed the results. In conclusion, oral SGAs are associated with better persistence than alternative antipsychotic treatment options in patients discontinuing clozapine for undefined reasons. Especially clozapine (except in those with previous serious adverse reactions to clozapine), olanzapine and risperidone should be considered as oral monotherapy for these patients.
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Affiliation(s)
- Noraly Stam
- Department of PsychiatryUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Heidi Taipale
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of Forensic PsychiatryUniversity of Eastern FinlandNiuvanniemi HospitalKuopioFinland
- School of PharmacyUniversity of Eastern FinlandKuopioFinland
| | - Antti Tanskanen
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of Forensic PsychiatryUniversity of Eastern FinlandNiuvanniemi HospitalKuopioFinland
- Public Health SolutionsNational Institute for Health and WelfareHelsinkiFinland
| | - Luka Isphording
- Department of PsychiatryUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Cynthia Okhuijsen‐Pfeifer
- Department of PsychiatryUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Catharina C.M. Schuiling‐Veninga
- Department of Pharmacotherapy, Epidemiology, and EconomicsFaculty of Science and EngineeringUniversity of GroningenGroningenThe Netherlands
| | - Jens H.J. Bos
- Department of Pharmacotherapy, Epidemiology, and EconomicsFaculty of Science and EngineeringUniversity of GroningenGroningenThe Netherlands
| | - Bert J. Bijker
- Department of Pharmacotherapy, Epidemiology, and EconomicsFaculty of Science and EngineeringUniversity of GroningenGroningenThe Netherlands
| | - Jari Tiihonen
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden
- Department of Forensic PsychiatryUniversity of Eastern FinlandNiuvanniemi HospitalKuopioFinland
- Center for Psychiatric ResearchStockholm City CouncilStockholmSweden
| | - Jurjen J. Luykx
- Department of PsychiatryUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
- Department of Translational NeuroscienceUMC Utrecht Brain CenterUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
- GGNet Mental HealthApeldoornThe Netherlands
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12
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Luykx JJ, Stam N, Tanskanen A, Tiihonen J, Taipale H. In the aftermath of clozapine discontinuation: comparative effectiveness and safety of antipsychotics in patients with schizophrenia who discontinue clozapine. Br J Psychiatry 2020; 217:498-505. [PMID: 31910911 PMCID: PMC7511905 DOI: 10.1192/bjp.2019.267] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although clozapine is often discontinued, there is a paucity of guidelines and evidence on treatment options after clozapine discontinuation. Moreover, it is currently unknown whether reinstating clozapine in patients formerly using clozapine should be avoided. AIMS To compare the real-world effectiveness of antipsychotics after clozapine cessation. METHOD From Finnish registry data (1995-2017), we identified 2250 patients with schizophrenia who had been using clozapine for ≥1 year before treatment cessation. The primary analysis consisted of adjusted within-individual analyses of psychiatric ward readmission owing to psychosis and treatment failure. Secondary analyses concerned between-individual mortality differences. RESULTS Compared with no use of antipsychotics, risk of psychiatric ward readmission was lowest for reinitiation of clozapine (adjusted hazard ratio (aHR) 0.49; 95% CI 0.40-0.61; P < 0.0001), oral olanzapine (aHR 0.58; 95% CI 0.48-0.71; P < 0.0001) and antipsychotic polypharmacy (aHR 0.62; 95% CI 0.53-0.72; P < 0.0001). Risk of treatment failure was lowest for aripiprazole long acting injectable (aHR 0.42; 95% CI 0.27-0.65; P < 0.0001), reinitiation of clozapine (aHR 0.49; 95% CI 0.43-0.57; P < 0.0001) and oral olanzapine (aHR 0.69; 95% CI 0.61-0.77; P < 0.0001). Mortality risk was lowest for reinitiation of clozapine (aHR 0.18; 95% CI 0.09-0.36; P < 0.0001) and oral olanzapine (aHR 0.26; 95% CI 0.17-0.40; P < 0.0001). CONCLUSIONS Clozapine and olanzapine are the most effective and safest treatment options in those discontinuing clozapine for undefined reasons. Clozapine should therefore be reconsidered in patients with schizophrenia who previously discontinued this compound.
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Affiliation(s)
- Jurjen J. Luykx
- Assistant Professor, Departmentsof Psychiatry and Translational Neuroscience, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University; and Department of Outpatient Psychiatry, GGNet Mental Health, The Netherlands,Correspondence: Jurjen J. Luykx.
| | - Noraly Stam
- Researcher, Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Antti Tanskanen
- Researcher, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital; and Public Health Solutions, National Institute for Health and Welfare, Finland
| | - Jari Tiihonen
- Professor, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Finland; and Center for Psychiatric Research, Stockholm City Council, Sweden
| | - Heidi Taipale
- Assistant Professor, Department of Clinical Neuroscience, Karolinska Institutet, Sweden; Academy Research Fellow, Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital; and Associate Professor, School of Pharmacy, University of Eastern Finland, Finland
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13
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Yi W, She S, Zhang J, Wu H, Zheng Y, Ning Y. Clozapine Use in Patients with Early-Stage Schizophrenia in a Chinese Psychiatric Hospital. Neuropsychiatr Dis Treat 2020; 16:2827-2836. [PMID: 33262597 PMCID: PMC7699990 DOI: 10.2147/ndt.s261503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 11/09/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Previous studies suggest that clozapine is commonly underutilized and that its initiation is delayed in patients with first-episode schizophrenia. Knowledge regarding clozapine use among Chinese patients with early-stage schizophrenia is limited. The aim of the present study was to investigate the point prevalence of and patterns and factors associated with clozapine use in patients with early-stage schizophrenia discharged from a psychiatric hospital in China. METHODS A retrospective study was conducted to analyze the prescriptions of 867 consecutive patients with early-stage schizophrenia who were admitted to the Affiliated Brain Hospital of Guangzhou Medical University between Jan 1, 2011 and Dec 31, 2016. RESULTS At discharge from the hospital, 114 (13.1%) patients were prescribed clozapine. Among the patients taking clozapine, 93 patients (81.6%) were prescribed clozapine polypharmacy, and only 21 patients (18.4%) were prescribed clozapine monotherapy. None of the patients were prescribed an overdose of clozapine. The mean daily dosage of clozapine was 160.97 mg, 149.05 mg and 213.69 mg among all patients taking clozapine, patients taking clozapine polypharmacy and patients taking clozapine monotherapy, respectively. The antipsychotic most frequently combined with clozapine was risperidone. Logistic regression suggested that the length of hospital stay, high school education, lower benzodiazepine use and antipsychotic polypharmacy were independently and significantly associated with clozapine use (P<0.05). CONCLUSION Although clozapine has been commonly used in China in recent years, the present study found that clozapine was not commonly used in patients with early-stage schizophrenia. An underutilization and delayed initiation of clozapine may exist in a portion of patients with early-stage schizophrenia. Given the unfavorable outcomes of underutilized and delayed clozapine use, future studies may be needed to assess and increase clozapine use in this population.
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Affiliation(s)
- Wenying Yi
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.,Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Shenglin She
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Jie Zhang
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Haibo Wu
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Yingjun Zheng
- Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
| | - Yuping Ning
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.,Department of Psychiatry, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, People's Republic of China
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14
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Predicting Unsuccessful Clozapine Treatment After First Use in Adult Patients With Psychotic Disorders. J Clin Psychopharmacol 2018; 38:604-608. [PMID: 30371636 DOI: 10.1097/jcp.0000000000000977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE/BACKGROUND Cessation of clozapine therapy and insufficient response may result in relapse of psychotic symptoms and in clinical admissions. However, discontinuation rates are high. Identifying patients at risk for unsuccessful clozapine use might enable clinicians to direct specific attention to them. METHODS/PROCEDURES Routinely collected data from a large insurance company were used to develop a simple prediction model for unsuccessful clozapine treatment in psychiatric patients 1 year after clozapine was first dispensed by a community pharmacy in the Netherlands. Multivariate logistic regression analyses were performed with the Nagelkerke R statistic as a measure of the predictive value of the model. FINDINGS/RESULTS A total of 937 patients were dispensed clozapine for the first time by their community pharmacy between January 1, 2011, and December 31, 2015 (index date). Of these, 741 patients had started their clozapine treatment in hospital before the index date (inpatient starters); the remaining 196 patients started clozapine as outpatients on the index date (outpatient starters). In 191 patients (20.4%), clozapine treatment was unsuccessful 1 year after the index date. Unsuccessful treatment was more common among outpatient starters than among inpatient starters (32.1% vs 17.3%). Using backward selection of the variables, a model consisting of 61 variables had the best predictive value overall (Nagelkerke R = 0.301), whereas a model consisting of 52 variables had the best predictive value in outpatient starters (Nagelkerke R = 0.676). IMPLICATIONS/CONCLUSIONS The likelihood of unsuccessful clozapine treatment after 1 year was higher among patients who started clozapine as outpatients. Despite the use of a diversity of variables and different statistical approaches, it was not possible to make a simple prediction model for unsuccessful clozapine treatment using relatively easily accessible data.
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15
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Ingimarsson O, MacCabe JH, Sigurdsson E. Constipation, ileus and medication use during clozapine treatment in patients with schizophrenia in Iceland. Nord J Psychiatry 2018; 72:497-500. [PMID: 30348045 DOI: 10.1080/08039488.2018.1517189] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
UNLABELLED Purpose of the article: Clozapine is the only evidence based treatment for treatment-resistant schizophrenia. Constipation is a well known side effect of clozapine treatment. The aims of this study are to describe the prevalence of constipation and ileus during clozapine treatment of patients with schizophrenia in Iceland and to assess the concomitant use of medication that can cause constipation, and laxatives used to treat constipation. MATERIALS AND METHODS We identified 188 patients treated with clozapine by searching the electronic health records of Landspitali, the National University Hospital, during the study period 1.1.1998 - 21.11.2014. Cases of constipation and ileus were identified using an electronic search with keywords related to ileus in the patients' electronic health records. Detailed medication use was available for 154 patients that used clozapine for at least one year. RESULTS Four out of 188 patients were diagnosed with ileus that resulted in admission to hospital. Two of these required a permanent stoma as a consequence of their ileus. Laxatives were prescribed for 24 out of 154 patients (15.4%) while on clozapine. In total 40.9% of the patients either had laxatives prescribed or had constipation documented in the medical records. Apart from clozapine, other medications known to cause constipation were prescribed to 28 out of 154 patients (18.2%). CONCLUSIONS Constipation is a common problem during clozapine treatment which can progress to full-blown ileus which can be fatal. Clinicians need to monitor signs of constipation during treatment with clozapine and respond to it with lifestyle advice and laxative treatment.
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Affiliation(s)
- Oddur Ingimarsson
- a Faculty of Medicine, School of Health Sciences , University of Reykjavik, Iceland.,b Mental Health Services , Landspitali University Hospital , 101 Reykjavik , Iceland
| | - James H MacCabe
- c Institute of Psychiatry, Psychology and Neuroscience , King's College London , UK.,d South London and Maudsley NHS Foundation Trust , London , UK
| | - Engilbert Sigurdsson
- a Faculty of Medicine, School of Health Sciences , University of Reykjavik, Iceland.,b Mental Health Services , Landspitali University Hospital , 101 Reykjavik , Iceland
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16
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Boazak M, Kahn B, Cox L, Ragazino J, Goldsmith DR, Cotes RO. Re-titration rates after clozapine-induced neutropenia or agranulocytosis: A case report and literature review. CLINICAL SCHIZOPHRENIA & RELATED PSYCHOSES 2018:10.3371/CSRP.BOKA.061518. [PMID: 29944418 PMCID: PMC6443488 DOI: 10.3371/csrp.boka.061518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Clozapine-induced neutropenia occurs in 3-5% of individuals treated with clozapine. Current US guidelines require interruption of clozapine when the absolute neutrophil count (ANC) drops below 1000 cells/mm3. There is minimal available guidance for what dosing schedule to use when restarting clozapine after an episode of neutropenia. Here, we present a case of a 50-year-old Caucasian female with a history of schizoaffective disorder who was successfully rechallenged on clozapine one month after developing clozapine-induced neutropenia (ANC 600 cells/mm3). To understand published re-titration rates of clozapine after neutropenia, we conducted a literature review using a using the PubMed database and found only seven case reports that unambiguously reported a clozapine dosing schedule during re-challenge. All were successful except one, a case of clozapine rechallenge after agranulocytosis. Including this case presentation, six out of eight cases restarted clozapine more cautiously than recommended by the US guidelines for a new clozapine initiation. We cannot comment what role a slower or more rapid titration plays in a successful rechallenge after neutropenia with the available evidence. We encourage researchers to publish their dosing schedule in detail after an episode of neutropenia or agranulocytosis.
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Affiliation(s)
- Mina Boazak
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Benjamin Kahn
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Lindsay Cox
- Department of Psychiatry & Behavioral Sciences, University of Miami Leonard Miller School of Medicine
| | - James Ragazino
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - David R. Goldsmith
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
| | - Robert O. Cotes
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine
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17
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Ingimarsson O, MacCabe JH, Haraldsson M, Jónsdóttir H, Sigurdsson E. Risk of diabetes and dyslipidemia during clozapine and other antipsychotic drug treatment of schizophrenia in Iceland. Nord J Psychiatry 2017. [PMID: 28632422 DOI: 10.1080/08039488.2017.1334821] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Type 2 diabetes (T2D) and raised blood lipids are associated with the use of antipsychotics, not least clozapine. AIMS To describe the prevalence of high blood glucose levels, T2D, and dyslipidemia, in association with the use of clozapine or other antipsychotics in patients with schizophrenia in Iceland. METHOD This study identified 188 patients treated with clozapine and 395 patients never treated with clozapine by searching the electronic health records of Landspitali, the National University Hospital. The comparison group consisted of Icelandic population controls. Data were obtained on blood glucose, HbA1c, and blood lipid levels from these health records. RESULTS The prevalence of T2D was 14.3% in the clozapine group, where the mean age was 51.2 years, and 13.7% in the never-on-clozapine group, where the mean age was 58.6 years. Males on clozapine were 2.3-times more likely and females 4.4-times more likely to have developed T2D than controls from an age-adjusted Icelandic cohort, while males on other antipsychotics were 1.5-times more likely and females 2.3-times as likely to have T2D than controls. Only one case of ketoacidosis was identified. Triglyceride levels were significantly higher in both treatment groups compared to controls in the age-adjusted Icelandic cohort. CONCLUSIONS Clinicians must take active steps to reduce the risk of T2D and raised triglycerides in patients with schizophrenia. Antipsychotics were associated with a greater risk of T2D developing in females compared to males.
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Affiliation(s)
- Oddur Ingimarsson
- a Faculty of Medicine, School of Health Sciences , University of Iceland , Reykjavik , Iceland.,b Landspitali University Hospital, Mental Health Services , Reykjavik , Iceland
| | - James H MacCabe
- c Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience , Kings College , London , UK.,d National Psychosis Unit , Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust , London , UK
| | - Magnús Haraldsson
- a Faculty of Medicine, School of Health Sciences , University of Iceland , Reykjavik , Iceland.,b Landspitali University Hospital, Mental Health Services , Reykjavik , Iceland
| | - Halldóra Jónsdóttir
- a Faculty of Medicine, School of Health Sciences , University of Iceland , Reykjavik , Iceland.,b Landspitali University Hospital, Mental Health Services , Reykjavik , Iceland
| | - Engilbert Sigurdsson
- a Faculty of Medicine, School of Health Sciences , University of Iceland , Reykjavik , Iceland.,b Landspitali University Hospital, Mental Health Services , Reykjavik , Iceland
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18
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Bachmann CJ, Aagaard L, Bernardo M, Brandt L, Cartabia M, Clavenna A, Coma Fusté A, Furu K, Garuoliené K, Hoffmann F, Hollingworth S, Huybrechts KF, Kalverdijk LJ, Kawakami K, Kieler H, Kinoshita T, López SC, Machado-Alba JE, Machado-Duque ME, Mahesri M, Nishtala PS, Piovani D, Reutfors J, Saastamoinen LK, Sato I, Schuiling-Veninga CCM, Shyu YC, Siskind D, Skurtveit S, Verdoux H, Wang LJ, Zara Yahni C, Zoëga H, Taylor D. International trends in clozapine use: a study in 17 countries. Acta Psychiatr Scand 2017; 136:37-51. [PMID: 28502099 DOI: 10.1111/acps.12742] [Citation(s) in RCA: 183] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE There is some evidence that clozapine is significantly underutilised. Also, clozapine use is thought to vary by country, but so far no international study has assessed trends in clozapine prescribing. Therefore, this study aimed to assess clozapine use trends on an international scale, using standardised criteria for data analysis. METHOD A repeated cross-sectional design was applied to data extracts (2005-2014) from 17 countries worldwide. RESULTS In 2014, overall clozapine use prevalence was greatest in Finland (189.2/100 000 persons) and in New Zealand (116.3/100 000), and lowest in the Japanese cohort (0.6/100 000), and in the privately insured US cohort (14.0/100 000). From 2005 to 2014, clozapine use increased in almost all studied countries (relative increase: 7.8-197.2%). In most countries, clozapine use was highest in 40-59-year-olds (range: 0.6/100 000 (Japan) to 344.8/100 000 (Finland)). In youths (10-19 years), clozapine use was highest in Finland (24.7/100 000) and in the publicly insured US cohort (15.5/100 000). CONCLUSION While clozapine use has increased in most studied countries over recent years, clozapine is still underutilised in many countries, with clozapine utilisation patterns differing significantly between countries. Future research should address the implementation of interventions designed to facilitate increased clozapine utilisation.
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Affiliation(s)
| | - L Aagaard
- Life Science Team, Bech-Bruun Law Firm, Copenhagen, Denmark
| | - M Bernardo
- Barcelona Clinic Schizophrenia Unit, Neuroscience Institute, and Hospital Clínic, Department of Medicine, Barcelona University, and Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), and Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Barcelona, Spain
| | - L Brandt
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Cartabia
- Pharmacoepidemiology Unit, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - A Clavenna
- Pharmacoepidemiology Unit, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - A Coma Fusté
- Pharmacy Department of Barcelona Health Region, Catalan Health Service (CatSalut), Barcelona, Spain
| | - K Furu
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - K Garuoliené
- Medicines Reimbursement Department, National Health Insurance Fund of the Republic of Lithuania, Vilnius, Lithuania.,Faculty of Medicine, Department of Pathology, Forensic Medicine and Pharmacology, Vilnius University, Vilnius, Lithuania
| | - F Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - S Hollingworth
- School of Pharmacy, University of Queensland, Woolloongabba, Qld, Australia
| | - K F Huybrechts
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - L J Kalverdijk
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, the Netherlands
| | - K Kawakami
- Department of Pharmacoepidemiology and Clinical Research Management, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - H Kieler
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - T Kinoshita
- Department of Pharmacoepidemiology and Clinical Research Management, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - S C López
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira - Audifarma S.A., Pereira, Colombia
| | - J E Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira - Audifarma S.A., Pereira, Colombia
| | - M E Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira - Audifarma S.A., Pereira, Colombia
| | - M Mahesri
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - P S Nishtala
- New Zealand's National School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - D Piovani
- Pharmacoepidemiology Unit, Department of Public Health, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - J Reutfors
- Centre for Pharmacoepidemiology, Department of Medicine, Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - L K Saastamoinen
- Kela Research, The Social Insurance Institution, Helsinki, Finland
| | - I Sato
- Department of Pharmacoepidemiology and Clinical Research Management, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - C C M Schuiling-Veninga
- Unit of Pharmacotherapy, -Epidemiology and -Economics, Department of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Y-C Shyu
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan.,Institute of Molecular Biology, Academia Sinica, Taipei, Qld, Taiwan.,Department of Nutrition, Chang Gung University of Science and Technology, Kwei-Shan, Taiwan
| | - D Siskind
- School of Medicine, University of Queensland, Woolloongabba, Qld, Australia
| | - S Skurtveit
- Division of Mental and Physical Health, Norwegian Institute of Public Health, Oslo, Norway
| | - H Verdoux
- University Bordeaux, INSERM, Bordeaux Population Health Research Center, team Pharmaco-epidemiology, UMR 1219, F-33000, Bordeaux, France
| | - L-J Wang
- Department of Child & Adolescent Psychiatry, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C Zara Yahni
- Pharmacy Department of Barcelona Health Region, Catalan Health Service (CatSalut), Barcelona, Spain
| | - H Zoëga
- Bordeaux Population Health Research Center, INSERM, Univ. Bordeaux, team Pharmaco-epidemiology, UMR 1219, Bordeaux, France
| | - D Taylor
- South London and Maudsley NHS Foundation Trust, London, UK.,Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Authors' reply — Clozapine for mitochondrial psychosis. Mol Genet Metab Rep 2017; 10:101. [PMID: 28224085 PMCID: PMC5295507 DOI: 10.1016/j.ymgmr.2017.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 01/29/2017] [Accepted: 01/29/2017] [Indexed: 11/23/2022] Open
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Lgaz H, Salghi R, Jodeh S, Hammouti B. Effect of clozapine on inhibition of mild steel corrosion in 1.0 M HCl medium. J Mol Liq 2017. [DOI: 10.1016/j.molliq.2016.11.039] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ingimarsson O, MacCabe JH, Haraldsson M, Jónsdóttir H, Sigurdsson E. Neutropenia and agranulocytosis during treatment of schizophrenia with clozapine versus other antipsychotics: an observational study in Iceland. BMC Psychiatry 2016; 16:441. [PMID: 27955666 PMCID: PMC5153901 DOI: 10.1186/s12888-016-1167-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 12/09/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Data on the haematological outcomes of patients who continue clozapine treatment following neutropenia are very rare as even mild neutropenia results in mandatory discontinuation of clozapine in most countries. However, in Iceland where clozapine monitoring is less stringent allows an observational study to be done on the risk of agranulocytosis and neutropenia during treatment with clozapine compared with other antipsychotics among patients with schizophrenia. METHODS The present study is a part of a wider ongoing longitudinal study of schizophrenia in Iceland. We identified 201 patients with schizophrenia treated with clozapine and 410 patients with schizophrenia who had never been on clozapine by searching the electronic health records of Landspitali, the National University Hospital. Neutrophil counts were searched in electronic databases to identify patients who developed neutropenia/agranulocytosis and the frequency of neutrophil measurements was examined as well. RESULTS The median number of days between neutrophil measurements during the first 18 weeks of clozapine treatment was 25 days but after the first 18 weeks on the drug the median became 124 days. Thirty four cases of neutropenia were identified during clozapine treatment with an average follow up time of 9.2 years. The majority, 24 individuals developed mild neutropenia (1500-1900 neutrophils/mm3). None of these progressed to agranulocytosis. The remaining 10 patients developed neutropenia in the range 500-1400 /mm3 of whom one developed agranulocytosis, three stopped clozapine use and 6 patients continued on clozapine for at least a year without developing agranulocytosis. Unexpectedly, schizophrenia patients on other antipsychotics had an equal risk of developing neutropenia as those on clozapine. CONCLUSIONS Neutropenia is common both in patients with schizophrenia on clozapine treatment and in those never on clozapine. Therefore a large part of neutropenia during clozapine treatment is probably not caused by clozapine. These findings have implications in assessing the balance between the risk of progression from neutropenia to agranulocytosis against the morbidity resulting from the premature discontinuation of clozapine under the current monitoring regulations in the US and in most of Europe.
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Affiliation(s)
- Oddur Ingimarsson
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavík, Iceland ,Landspitali University Hospital, Mental Health Services, Hringbraut, 101 Reykjavik, Iceland
| | - James H. MacCabe
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, Kings College, London, UK ,National Psychosis Unit, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - Magnús Haraldsson
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavík, Iceland ,Landspitali University Hospital, Mental Health Services, Hringbraut, 101 Reykjavik, Iceland
| | - Halldóra Jónsdóttir
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavík, Iceland ,Landspitali University Hospital, Mental Health Services, Hringbraut, 101 Reykjavik, Iceland
| | - Engilbert Sigurdsson
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavík, Iceland. .,Landspitali University Hospital, Mental Health Services, Hringbraut, 101, Reykjavik, Iceland.
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