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Abstract
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OBJECTIVE: To present information about the value of clozapine in treatment-resistant schizophrenia. Data is reported on the use of clozapine in an entire cohort of (42) patients in a community, the Australian Capital Territory. It extends a 3-year study of clinical and financial outcomes to 5 years.
METHOD: Experiences during the 2 years before clozapine was prescribed and those of the 5 years following prescription were compared by a records review, including hospital and hostel bed use and estimated treatment costs. Changes in dose levels, living circumstances and employment status were assessed, and treating psychiatrists reported on side-effects and their impression of clinical change since clozapine was prescribed.
RESULTS: Ten subjects were excluded. The remaining cohort (32 subjects) demonstrated continuing clinical improvement and cost savings during follow-up. Those (22) remaining on clozapine after the five year period showed continuing clinical improvement, reduced hospital admissions and hospital bed usage and significantly large cost savings, and were moderately to markedly improved after 3 years. Only one patient (of 22) showed a slight deterioration in the next two years while 14 showed further improvement. After 5 years, the clinical status of four of the 10 subjects who discontinued clozapine was unchanged or deteriorated compared with their preclozapine status. There were no suicides.
CONCLUSION: The findings of continuing clinical improvement and decreased costs after long-term (5 years) use of clozapine supports the selective use of clozapine in community practice.; Indications:42 patients with resistant schizophrenia or schizoaffective disorder. Coexisting disease: 1 senile dementia.; Patients:42 patients, of whom 10 dropped out (9 withdrawal and 1 due to side effects), thus 32 (mostly aged between 20 and 45 years) were included in the cohort analysis. Follow-up: 5 years. Dropouts: n=10 (including 4 due to side effects).; TypeofStudy:An open-label, retrospective study investigating the clinical and financial outcomes of 5 years use of Leponex in treatment-resistant schizophrenic patients in a community practice (the Australian Capital Territory).
RESULTS were compared with data from the preceding 2 years before Leponex was prescribed.; AdverseEffects:5 patients had severe side-effects leading to withdrawal including 2 with cardiac disorders (1 cardiomyopathy and 1 cardiac arrhythmia) and 1 agranulocytosis. 6 became non-compliant predominantly because of side-effects. There were no fatalities from side-effects or toxicity, and there were no suicides.; DosageDuration:100-575 mg daily as tablets. Duration: few weeks to 5 years.; Results:Among the 10/42 patients who were not included in the cohort analysis, 2 died from causes unrelated to either psychiatric illness or treatment. Of the remaining 32 patients, 22 were continuers and 10 were discontinuers. Among the continuers, there was little change in the mean dose between YEAR3 and YEAR5 (375 mg/day; range = 100-575, and 356 mg/day; range = 100-575, respectively). 4 discontinuers used Leponex continuously for 3 years after which 1 changed to risperidone and maintained her improvement; 1 became non-compliant and Leponex was stopped, 2 developed cardiac problems during YEAR4 and Leponex was withdrawn. BPRS scores did not improve significantly over time either for the cohort (n=13) or for the continuers (n=3) for whom data were available. Life skills improved significantly over time both for the cohort (n=11) and for the continuers (n=8) At YEAR3, 30 of the cohort and all of the continuers showed moderate or marked improvement in clinical status and no patient deteriorated. 18 of the cohort and 14 of the continuers further improved after YEAR3 while 4 of the cohort and 1 of the continuers deteriorated. Significantly fewer of the cohort were admitted to hospital in YEARS 2-5 than in 1 YR PRE. Similarly, significantly fewer of the cohort were admitted to hospital in YEARS 3-5 than 2 YRS PRE. Significantly fewer continuers were admitted to hospital in YEARS 3-5 than in the 2 YRS PRE. The cohort spent significantly less time in hospital in YEARS 2-4 than in the 2 YRS PRE. Likewise, the cohort showed a shorter stay in hospital in YEAR5 compared to preLeponex. The continuers spent significantly less time in hospital in YEARS 2-5 compared to preLeponex. For the continuers, a reduced time was spent in hostels at YEAR5 compared to preLeponex. A significant decrease in bed costs between preLeponex and YEARS 2-5 for the continuers and cohort was noted. Compared with preLeponex, treatment costs decreased in YEAR5 for the cohort with a 10 250 (35% of median preLeponex combined costs) median difference of the annual costs. The treatment costs for the continuers in YEAR5 were significantly less than preLeponex, and for YEARS 1, 2 and 3. The median of the difference between the annual preLeponex combined costs and the YEAR5 costs was 11 845 (36% of median preLeponex treatment costs). Significantly fewer continuers were institutionalized after 5 years of Leponex use than prior to commencing Leponex. Significantly more of the cohort and the continuers were employed or studying at YEAR3 than preLeponex but at YEAR5 employment status had declined to baseline levels. For discontinuers there was no significant change in the mean number of admissions to hospital each year as time progressed. There was no significant change in bed costs, treatment costs (the median of the difference between preLeponex total costs and post Leponex costs was -1325), employment status or living circumstances over time. In YEAR5 a smaller percentage of continuers than discontinuers were admitted to hospital, and continuers were admitted to hospital less frequently and spent significantly less time in hospital than discontinuers. There was no statistical difference between continuers and discontinuers in other outcome measures at YEAR5 (clinical status, hostel bed days, treatment costs, employment status and living circumstances). Other than greater clinical improvement and a smaller percentage of hospital admissions in YEAR3 in continuers, there were no significant differences between continuers and discontinuers in YEARS 1-4.; AuthorsConclusions:This study is one of only a few documenting outcomes of the long-term use of clozapine in clinical practice in the community. The results suggest that clozapine is a valuable treatment option for community practice with long-term clinical and cost benefits, some of which may increase for up to 5 years. However, we acknowledge that the evidence is subject to criticism and other long-term prospective studies (with a comprehensive range of outcome measures) of the use of clozapine are urgently needed.; FreeText:The cohort was divided into 2 groups [continuers (on Leponex 3 years after starting Leponex (YEAR3) and remained on Leponex for the next 2 years (YEAR5) without having 12 weeks or more off Leponex in that period) and discontinuers]. Outcome measures were changes in clinical state [measured by the Brief Psychiatric Rating Scale (BPRS) and Life Skills Profile (LSP)] and occurrence of side-effects, living circumstances and employment status at YEAR3 and YEAR5 compared with baseline, and changes in hospital admissions, occupied bed days (including hostel beds) and costs of treatment (hospital and hostel bed costs plus Leponex costs) in each of the 5 years after Leponex was prescribed (YEAR1, YEAR2, YEAR3, YEAR4 and YEAR5) compared with the 2 years preceding Leponex use (2 YRS PRE and 1 YR PRE), and dose of Leponex. Tests: Brief Psychiatric Rating Scale (BPRS) and Life Skills Profile (LSP).
Language: en |