Early diagnosis of treatment-resistant schizophrenia may lead to better outcomes for young people with this disorder, researchers from Orygen, the National Centre of Excellence in Youth Mental Health, have found.
Although the majority of young people who experience their first episode of psychosis respond well to their initial treatment, about 10% experience persistent symptoms.
Dr Brian O’Donoghue, a clinical research fellow at Orygen, led the research with colleagues Dr Kristen Thien, Dr Aswin Ratheesh and Professor Patrick McGorry. Dr O’Donoghue said the study showed that the antipsychotic medication clozapine could produce good outcomes when used to treat young people with treatment-resistant schizophrenia
Clozapine is the most effective antipsychotic medication, with better long-term outcomes including remission of symptoms, better education and employment outcomes, lower rates of hospitalisation and better long-term survival. However, it is used only after failure of two or more other antipsychotic medications, due to its side-effects, which can, on rare occasions, include death. Consequently, there can be delays of up to 10 years before clozapine prescription.
However Dr O’Donoghue said the study indicated that clozapine could be prescribed as little as three to six months after a diagnosis of treatment-resistant schizophrenia if candidates were able to be identified early and monitored safely.
“The average delay for treatment-resistant patients to access clozapine in routine care, if indeed they ever do, is four years,” Dr O’Donoghue said. “During this period they suffer and languish with a severely disabling illness which may respond very well to clozapine.
“There is very limited research and guidance on how to ensure that clozapine is introduced in a timely fashion for those who need it. This research supports the idea of personalising treatments to match the phase of illness and severity in young people affected by psychotic disorders.”
The study, published online in March in the journal Schizophrenia Research, was a retrospective study of 544 young people who were treated for their first episode of psychosis over three years at the Early Psychosis Prevention and Intervention Centre (EPPIC) at Orygen Youth Health.
Dr O’Donoghue said nearly 10% of the young people in the study experienced persistent psychotic symptoms despite being treated with anti-psychotic medications. Of these, nearly 60% were subsequently prescribed clozapine. “More than three-quarters of the young people treated with clozapine achieved remission of their symptoms and half returned to education or employment,” Dr O’Donoghue said.
“Some people remain fearful of this drug because, rarely, it poses a major risk of cardiac and blood count problems. However, with monitoring, these risks can be managed, and in fact clozapine treatment substantially increases life expectancy in those treated.
“As a result of this study we have established a clozapine service within the early intervention for psychosis program at Orygen Youth Health. A prompting system for case managers and a treatment resistance review panel assists clinicians in supporting clozapine initiation. The service assists in determining who should commence treatment with clozapine, and when, while also monitoring the side-effects of the medication. Clients also have the opportunity to meet with an exercise physiologist and dietitian in order to help prevent the metabolic side-effects associated with clozapine.
“This study highlights the need for early intervention and the crucial role that psychosis services have in ensuring timely initiation of clozapine in young people who have not responded adequately to other medications.”