Delay in starting clozapine and treatment guidelines

There is a reasonable level of information to suggest that clozapine is effective in patients who have treatment-resistant schizophrenia. Hence, clozapine should be started at the right time so that patients can draw maximum benefit from it. In this vein, the article by Howes et al ¹ provides important insights into the clinical practice with regard to the use of clozapine. The authors showed that clozapine is delayed by about 4 years and many patients are treated with polypharmacy and receive higher than recommended doses, which is contrary to the recommendations made by several practice guidelines. However, it is important to note that the conclusions drawn about the delay in starting clozapine might not be a true reflection of actual delay, because often patients who are offered clozapine refuse to take it. Hence, some of the delay may be due to lack of agreement of the patient and this in general does not reflect the delay in the clinician offering the medication. It would have been better had the authors extracted the data pertaining to initial offering of clozapine and the number of patients who refused clozapine at the first instance as part of this study. This would have actually given the true clinical picture.

Another issue is the definition of duration of illness used. The authors have defined duration of illness as ‘the time from the first recording of the diagnosis of a psychotic illness by a clinician to the present’, which may not be a true reflection of duration ofillness, because there may be varying periods of duration of untreated psychosis and this can have its own treatment implications. Despite these shortcomings, findings of the study suggest that even with a national healthcare system in place and the wider dissemination of treatment guidelines, there is still only a modest impact of these on real clinical practice. The possible effect of treatment guidelines is reflected by the fact that today patients receive fewer trials of other antipsychotics (2.8 v. 4 trials) before being started on clozapine compared with earlier studies. ²