Clozapine Utilization in the United States: Disparities and Concerns

At the American Psychiatric Association 2023 Annual Meeting, Dr. Claire Holderness chaired a session titled “Confident Clozapine Prescribing: Motivating Clinicians to Address Racial and Ethnic Disparities in Clozapine Utilization,” which sought to discuss the underutilization of clozapine in the United States.

The presentation emphasized racial and ethnic disparities, perceived barriers, and monitoring guidelines related to clozapine for at-risk patients. Dr. Holderness noted clozapine was the focus because of its significant potential benefits in patients with treatment-resistant schizophrenia, which affects up to one-third of patients, according to Dr. Holderness.

“Clozapine is now considered standard of care for treatment-resistant schizophrenia,” she said, citing various studies that showed clozapine was the most effective and cost-effective antipsychotic medication for this population. Additional data showed that clozapine reduced hospitalizations, self-harm, all-cause mortality, suicidal behavior, and agitation.

Clozapine is approved by the U.S. Food and Drug Association (FDA) for treatment-resistant schizophrenia and also FDA approved for recurrent suicidal behavior in either schizophrenia or schizoaffective disorder. Guidelines from the Schizophrenia Patient Outcomes Research Team recommend that patients with schizophrenia and persistent positive symptoms receive an adequate trial of clozapine, while the National Institutes of Health and Care Excellence Clinical Guidelines for Schizophrenia recommend clozapine after two failed trials of other antipsychotic medications.

Yet Dr. Holderness still stated that clozapine is underutilized in the United States. She suggested that between 35% and 40% of all patients with schizophrenia should be considered for a clozapine trial; however, only 4% to 5% of patients with schizophrenia in the United States have ever received clozapine. She added that the proportion in other countries is approximately 20% or more of patients.

Dr. Holderness then gave the floor to Dr. Jean Marie Bradford to describe the racial and ethnic disparities in clozapine utilization.

Dr. Bradford presented several reports showing that individuals from minority groups are prescribed clozapine significantly less frequently than their white counterparts, clozapine prescribing significantly differed across states, and clozapine utilization was lower in Black patients compared with white patients, with less frequent initiation and more frequent discontinuation.

In treatment-resistant schizophrenia, specifically, a U.K. study (Fonseca de Freitas et al, 2022) found that Black patients had half the odds of being treated with clozapine compared with white patients. Dr. Bradford added that neutropenia did not account for ethnic differences in utilization.

On the provider side, she said, data showed physicians deliver less information to Black and Hispanic patients. Those patients report being less satisfied with their care and rate patient-provider communication as poorer than white patients.

“[The] racial and ethnic identity of the patient can affect the provider’s ability to understand the presentation of symptoms,“ she noted. “We really encourage people to use things like cultural formulations, strict adherence to criteria for diagnostic instruments, and medication algorithms,” though she added that more interventions to reduce disparities are needed.