Clozapine for Treating Schizophrenia

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Clozapine for Treating Schizophrenia:

A Comparison of the States

November 2015

 

Clozapine is regarded as the “gold standard” for treating schizophrenia, one of the most disabling of psychiatric diseases. The second-generation antipsychotic is the only medication approved by the Food and Drug Administration (FDA) for treating individuals with schizophrenia whose symptoms do not respond to other treatments. It is also the only medication approved by the FDA for the prevention of suicide and aggressive and violent behavior.

Clozapine for Treating Schizophrenia: A Comparison of the States utilized Medicaid prescription data in 44 states from 2006-2009 and pharmacy prescription data in all the states for 2009-2011 to compare usage as a measure of states’ efforts to treat individuals with schizophrenia. Because clozapine is typically prescribed by psychiatrists, the distribution of psychiatrists by state was also analyzed.

Top Takeaway

Although clozapine is used to treat 20% or more of individuals with schizophrenia in most industrial countries, it is prescribed to fewer than 5% of candidate patients nationwide in the United States and to as few as 2% of individuals who might benefit in some states.

Fast Facts

  • The range of effort to utilize clozapine in the United States varies widely from South Dakota, where 15.6% of candidates receive prescriptions for clozapine, to Oregon, Nevada and Louisiana, where the medication is prescribed to 2% of candidates.
  • In nine states, fewer than 3% of clozapine candidates received prescriptions: Georgia, Kentucky, North Carolina, Mississippi, Alabama, Arizona, Louisiana, Nevada and Oregon.
  • In only six states did as many as 10% of candidate patients receive clozapine prescriptions: South Dakota, Connecticut, Colorado, Washington, Vermont and Maine.
  • The correlation between clozapine use and the availability of psychiatrists was not statistically significant.

Behind the Facts

  • Schizophrenia is a severe psychiatric disease that is among the most disabling mental illnesses, resulting in high rates of unemployment, poverty, homelessness, hospitalization and rehospitalization, suicide, repeated arrest and incarceration and other poor outcomes, including early death.
  • An estimated 20%-30% of individuals with the disease have symptoms that do not respond to treatment. At least half of this population experiences improvement with clozapine.
  • Clozapine has significant side effects including a reduction in white blood cells (neutropenia) that occurs in 8 out of every 1,000 individuals. These side effects and monitoring requirements associated with them, especially at the beginning of treatment, are believed to be one of the reasons clinicians do not prescribe the medication more widely in the United States.

Since the Study

  • The FDA in January 2016 issued new guidance clarifying and simplifying federal requirements for monitoring, prescribing, dispensing and receiving clozapine, including a program to address safety concerns and current knowledge about neutropenia.
  • The National Association of State Mental Health Program Directors in November 2016 issued an assessment of clozapine use concluding it was underused not because of patient opposition but because of provider attitudes and other non-medical factors. The report concluded with 34 recommendations to removing barriers to the medication’s use.