Prevalence of treatment resistance and clozapine use in early intervention services

Imogen Stokes¹, Siân Lowri Griffiths², Rowena Jones³, Linda Everard⁴, Peter B Jones⁵, David Fowler⁶, Joanne Hodgekins⁷, Tim Amos⁸, Nick Freemantle⁹, Vimal Sharma¹⁰, Max Marshall¹¹, Swaran P Singh¹², Max Birchwood¹³, Rachel Upthegrove¹⁴

Affiliations

¹ Birmingham Medical School, College of Medical and Dental Sciences, University of Birmingham, UK.
² School of Psychology, Institute for Mental Health, University of Birmingham, UK.
³ School of Psychology, Institute for Mental Health, University of Birmingham; and Research and Innovation, Birmingham and Solihull Mental Health Foundation Trust, UK.
⁴ Research and Innovation, Birmingham and Solihull Mental Health Foundation Trust, UK.
⁵ University of Cambridge, UK.
⁶ Department of Psychology, University of Sussex, UK.
⁷ Norwich Medical School, University of East Anglia, UK.
⁸ University of Bristol, UK.
⁹ Institute of Clinical Trials & Methodology, University College London, UK.
¹⁰ Faculty of Health and Social Care, University of Chester, UK.
¹¹ Lancashire Care NHS Foundation Trust, UK.
¹² Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Trust, UK.
¹³ University of Warwick, UK.
¹⁴ Birmingham Medical School, College of Medical and Dental Sciences, University of Birmingham; School of Psychology, Institute for Mental Health, University of Birmingham; Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Trust, UK.

PMID: 32938513
PMCID: PMC7576650
DOI: 10.1192/bjo.2020.89

Prevalence of treatment resistance and clozapine use in early intervention services

Imogen Stokes et al. BJPsych Open. 2020.

. 2020 Sep 17;6(5):e107.

doi: 10.1192/bjo.2020.89.

Authors

Affiliations

¹ Birmingham Medical School, College of Medical and Dental Sciences, University of Birmingham, UK.
² School of Psychology, Institute for Mental Health, University of Birmingham, UK.
³ School of Psychology, Institute for Mental Health, University of Birmingham; and Research and Innovation, Birmingham and Solihull Mental Health Foundation Trust, UK.
⁴ Research and Innovation, Birmingham and Solihull Mental Health Foundation Trust, UK.
⁵ University of Cambridge, UK.
⁶ Department of Psychology, University of Sussex, UK.
⁷ Norwich Medical School, University of East Anglia, UK.
⁸ University of Bristol, UK.
⁹ Institute of Clinical Trials & Methodology, University College London, UK.
¹⁰ Faculty of Health and Social Care, University of Chester, UK.
¹¹ Lancashire Care NHS Foundation Trust, UK.
¹² Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Trust, UK.
¹³ University of Warwick, UK.
¹⁴ Birmingham Medical School, College of Medical and Dental Sciences, University of Birmingham; School of Psychology, Institute for Mental Health, University of Birmingham; Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Trust, UK.

PMID: 32938513
PMCID: PMC7576650
DOI: 10.1192/bjo.2020.89

Abstract

Background: Treatment resistance causes significant burden in psychosis. Clozapine is the only evidence-based pharmacologic intervention available for people with treatment-resistant schizophrenia; current guidelines recommend commencement after two unsuccessful trials of standard antipsychotics.

Aims: This paper aims to explore the prevalence of treatment resistance and pathways to commencement of clozapine in UK early intervention in psychosis (EIP) services.

Method: Data were taken from the National Evaluation of the Development and Impact of Early Intervention Services study (N = 1027) and included demographics, medication history and psychosis symptoms measured by the Positive and Negative Syndrome Scale (PANSS) at baseline, 6 months and 12 months. Prescribing patterns and pathways to clozapine were examined. We adopted a strict criterion for treatment resistance, defined as persistent elevated positive symptoms (a PANSS positive score ≥16, equating to at least two items of at least moderate severity), across three time points.

Results: A total of 143 (18.1%) participants met the definition of treatment resistance of having continuous positive symptoms over 12 months, despite treatment in EIP services. Sixty-one (7.7%) participants were treatment resistant and eligible for clozapine, having had two trials of standard antipsychotics; however, only 25 (2.4%) were prescribed clozapine over the 12-month study period. Treatment-resistant participants were more likely to be prescribed additional antipsychotic medication and polypharmacy, instead of clozapine.

Conclusions: Prevalent treatment resistance was observed in UK EIP services, but prescription of polypharmacy was much more common than clozapine. Significant delays in the commencement of clozapine may reflect a missed opportunity to promote recovery in this critical period.

Keywords: Treatment resistance; clozapine; early intervention; early psychosis; schizophrenia.

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Conflict of interest statement

Supplementary material

Figures

**Fig. 1**
Pie charts showing the number of antipsychotics and second-generation antipsychotics prescribed before clozapine.

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Prevalence of treatment resistance and clozapine use in early intervention services

Affiliations

Prevalence of treatment resistance and clozapine use in early intervention services

Authors

Affiliations

Abstract

Conflict of interest statement

Supplementary material

Figures

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References

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