How do you present clozapine to a person who might benefit from it?

The manner in which prescribers present clozapine to someone can be an important factor if that person will decide to take the medication or not.  Deciding to take clozapine is a major decision that requires a lot of trust in the prescribing team.  Individuals may have paranoia, disorganization, cognitive, or negative symptoms that can make these conversations challenging. When initiating conversations about clozapine, prescribers can make the mistake of not emphasizing enough the potential life-changing benefits, and may become too focused on explaining the side effects (Center for Practice Innovations 2013). The initial decision to pursue clozapine does not require a person’s lifelong commitment. If someone develops tolerability issues or the medication is not as helpful as the person/team would like, they can always go back to what they were previously prescribed.

Keep in mind about 40% of people who take clozapine will have a clinically significant improvement in symptoms or functioning (Siskind, Siskind, and Kisely 2017). In a study of 86 individuals on clozapine, 72% reported they were more satisfied on clozapine than their prior antipsychotic (Sharma et al. 2021). It is important to present clozapine in a balanced way, where both its pros and the cons can be adequately explored.

When discussing clozapine with patients, consider the acronym TEAM UP:

• Time and Setting. Talking to people about clozapine is often a process, not a one-time conversation. People will have questions. Make sure you have an adequate amount of time to have this discussion.
• Elicit goals and recovery priorities. It may be helpful to connect the medication to helping the person accomplish their goals (The National Council for Behavioral Health. The Care Transitions Network 2016). These goals are sometimes, but not always, about the amelioration of symptoms. Other goals might include returning to work/school, improving relationships, or finding meaning in life.
• Anticipate possible barriers and strategize ahead of time. Might the bloodwork interfere with a person’s work schedule? Is transportation a barrier? What is their current impression of clozapine? Most people don’t like getting weekly labs at first and some people are afraid of needles. Consider how to address these issues up front.
• Medical side effects: Discuss several key side effects like severe neutropenia, myocarditis, seizures, constipation, and cardiometabolic issues. It is helpful to have a few key facts in mind when you present this information. For example, 0.9% of people who take clozapine will develop severe neutropenia (Myles et al. 2018). While you are discussing the side effects, talk about what steps you will take to help prevent them and how you treat them if they occur. Reassure the patient you will be working together to help mitigate and manage any side effects.
• Utilize family or other supports. Hopefully, the person’s family or supports will be included in the discussion already. If they are not present for the discussion, consider engaging them for a later time. In addition, you may ask, “What would your mom/dad/brother/sister think about clozapine if they were here?” Invite your patient to talk to other individuals who are taking clozapine to get their perspectives on the medication. If someone has a legal guardian, the information should be shared with both the individual and their legal guardian, and it is important to get buy-in from both.
• Produce a decision matrix (pros and cons) with the person considering clozapine. To generate this, ask questions like, “What would the downsides be about staying on your current medication?  What concerns to do you have about clozapine? What might the benefits be?” It may be helpful to keep this document on hand for future conversations and adjust it over time.

REFERENCES

• Center for Practice Innovations. (2013). “Motivating Clozapine Use: An Aid for Prescribers.”   Retrieved Sept 30, 2020, from https://www.practiceinnovations.org/CPI-Resources/Medication-and-Medication-Side-Effects.
• Myles N, Myles H, Xia S, et al: Meta-analysis examining the epidemiology of clozapine-associated neutropenia. Acta Psychiatr Scand 138:101-109, 2018
• Sharma S, Kopelovich SL, Janjua AU, et al: Cluster Analysis of Clozapine Consumer Perspectives and Comparison to Consumers on Other Antipsychotics. Schizophrenia Bulletin Open 2:sgab043, 2021
• Siskind D, Siskind V, Kisely S: Clozapine Response Rates among People with Treatment-Resistant Schizophrenia: Data from a Systematic Review and Meta-Analysis. Can J Psychiatry 62:772-777, 2017
• The National Council for Behavioral Health. The Care Transitions Network. (2016). “Talking to Patients and Their Families About Clozapine.”   Retrieved Dec 1, 2021, from https://www.thenationalcouncil.org/wp-content/uploads/2016/08/Talking-to-Patients-and-Their-Families-About-Clozapine.pdf?daf=375ateTbd56.