Managing the seriously mentally ill while inpatient

[BiscoDisco]

A common issue I run into is I will get a patient who is just out of their minds psychotic with a history of low to moderate baseline. Perhaps they've been trialed on a few antipsychotics in the past with middling success. These are not patients who will have the support or clear up enough to become dependable for regular labs so clozapine is out.

I'll start them on risperdal for example, maybe they'll get 20% better. Of course I am faced with the ever pressing silent push to move the meat and clear up beds for the surrounding ERs (I am in a county hospital). My question is, at what point do I abandon the first antipsychotic and try another one in an effort to get them slightly more clear to discharge to a sub-acute facility or back to a board and care? I want to avoid jumping from medication to medication, but I don't feel I have the luxury of time, particularly when we know a more robust response can take 4 or more weeks. But starting a new medicine feels like it just resets the clock so to speak and now I need to wait and see how they do on this new medication.

As an example, had a guy who wouldn't talk to anyone, just pacing the unit. Refused any and all meds. Had zero insight. Got him on court ordered risperdal which he now takes PO. I am able to have a coherent conversation with him. He feels medicine is helping. However he is still very disorganized, has no ability to make a rational discharge plan, very internally preoccupied. The guy is MUCH better, but I suspect his baseline is just low. Do I stop the risperdal and try something else which may or may not be any better and risk a decompensation back to where things were?

Any thoughts on what to do generally speaking about any of the above?

As an aside, this is my first job just having finished residency 3ish months ago. I feel like discharge planning, working under a clock to move people, etc. is a huge area that was lacking in my training. We were shielded from a lot of it and the attendings were always the ones to really determine when a patient was good to go...so a lot of this is learning for me.

---

Members don't see this ad.

 

[nexus73]

1. Are these types of patients getting court committed? Does your state hospital system take these patients eventually?
2. Are you increasing to top of dose range?
3. Might be privilege of my current job, but I wouldn't discharge someone if they are still gravely disabled. Sounds like the person you are describing needs placement in ALF adult family home etc, outpatient commitment, long acting injectable med.
4. Who is pressuring you to discharge patients?

 

[BiscoDisco]

1. Are these types of patients getting court committed? Does your state hospital system take these patients eventually?
2. Are you increasing to top of dose range?
3. Might be privilege of my current job, but I wouldn't discharge someone if they are still gravely disabled. Sounds like the person you are describing needs placement in ALF adult family home etc, outpatient commitment, long acting injectable med.
4. Who is pressuring you to discharge patients?

1. They are often times court committed. State hospital is a very long wait list, however I do have a locked sub acute facility I can discharge to. I will often times discharge patients on a temporary conservatorship to this facility if they are still gravely disabled.
2. I tend to max out risperdal at 8mg, seroquel at 800, olanzapine at 50mg, abilify at 40mg, haldol at 50mg. Most of the data I've seen suggests there really isn't much benefit beyond certain doses (which I'm certain I'm already going beyond).
3. See #1 - most of these patients are able to be d/c to a locked facility once they accept which can take 1-2 weeks.
4. The medical director. However this isn't a for profit driven decision. He is trying to keep resources to the community open as our EDs get very backed up. We deal with a very low SES population and get the sickest of the sick.

 

[Celexa]

1. They are often times court committed. State hospital is a very long wait list, however I do have a locked sub acute facility I can discharge to. I will often times discharge patients on a temporary conservatorship to this facility if they are still gravely disabled.
2. I tend to max out risperdal at 8mg, seroquel at 800, olanzapine at 50mg, abilify at 40mg, haldol at 50mg. Most of the data I've seen suggests there really isn't much benefit beyond certain doses (which I'm certain I'm already going beyond).
3. See #1 - most of these patients are able to be d/c to a locked facility once they accept which can take 1-2 weeks.
4. The medical director. However this isn't a for profit driven decision. He is trying to keep resources to the community open as our EDs get very backed up. We deal with a very low SES population and get the sickest of the sick.

Discharging faster doesn't actually open up resources if the patients end up bouncing back faster. Unfortunately that's a difficult thing to prove in the data. You can still bring it up when you get pressure though. It's the type of short-term mindset that doesn't actually help anyone in the long term. Particularly if discharging them right back to the exact same circumstances and level of care that they had when they had when they decompensated. Do you have any ability to connect with ACT teams etc?

This type of pressure and inability to keep patients long enough to actually get them better is one of the main reasons inpatient is my least favorite psychiatric setting...

 

[ObsequiousAplomb]

It's weird that you aren't trying clozapine because you're convinced it won't help and not because there's any evidence it won't help.

 

[Stagg737]

As an example, had a guy who wouldn't talk to anyone, just pacing the unit. Refused any and all meds. Had zero insight. Got him on court ordered risperdal which he now takes PO. I am able to have a coherent conversation with him. He feels medicine is helping. However he is still very disorganized, has no ability to make a rational discharge plan, very internally preoccupied. The guy is MUCH better, but I suspect his baseline is just low. Do I stop the risperdal and try something else which may or may not be any better and risk a decompensation back to where things were?

If the bolded is true, then why would you stop the Risperdal if it's been that effective? I would absolutely continue at possibly start a second antipsychotic or augmenting agent acutely if necessary as there's more evidence emerging that 2 antipsychotic meds is actually warranted for some patients. Outpatient can taper that once he's in a more stable situation.

1. They are often times court committed. State hospital is a very long wait list, however I do have a locked sub acute facility I can discharge to. I will often times discharge patients on a temporary conservatorship to this facility if they are still gravely disabled.

Then why not discharge there? Sometimes acute units have to keep people longer-term to establish more stable long-term care. If you can't do that where you're at, then would the sub-acute unit? Or is there an ACT or mobile crisis team that can follow-up with him closely once discharged? These are some of the toughest patients because they resources they need just don't exist in the volume we need them to anymore. I feel for you because I see these patients come through our ER all the time and no hospitals are willing to accept them.

It's weird that you aren't trying clozapine because you're convinced it won't help and not because there's any evidence it won't help.

OP can correct me, but it seems like OP doesn't want to start Clozapine because they're worried that it would be stopped after discharge d/t patient not being able to adhere to treatment protocol, not because it wouldn't help. If the issue is maintaining compliance and risk of it being stopped, then I agree with OP that they shouldn't bother trying it in the first place. If that's the case though, LAIs should probably be the goal.

 

[Sushirolls]

LAIs if you have court ability should be the top of the list.
Haldol
prolixin
risperdal
Invega
Oral doses to observe, injections to follow in first few days. Then if doing low injection, by day of discharge, full dose...
Strive to get into housing/group home environment where injections can continue...
Even if you can't get the residential dispo to improve injection odds.
LAIs will possibly delay the eventual re-admit bounce back by few days to weeks? months?

LAIs are your real world answer most likely.
So many injections given in residency just the few hours before discharge. Man, I don't miss inpatient.

 

[BiscoDisco]

If the bolded is true, then why would you stop the Risperdal if it's been that effective? I would absolutely continue at possibly start a second antipsychotic or augmenting agent acutely if necessary as there's more evidence emerging that 2 antipsychotic meds is actually warranted for some patients. Outpatient can taper that once he's in a more stable situation.


Then why not discharge there? Sometimes acute units have to keep people longer-term to establish more stable long-term care. If you can't do that where you're at, then would the sub-acute unit? Or is there an ACT or mobile crisis team that can follow-up with him closely once discharged? These are some of the toughest patients because they resources they need just don't exist in the volume we need them to anymore. I feel for you because I see these patients come through our ER all the time and no hospitals are willing to accept them.


OP can correct me, but it seems like OP doesn't want to start Clozapine because they're worried that it would be stopped after discharge d/t patient not being able to adhere to treatment protocol, not because it wouldn't help. If the issue is maintaining compliance and risk of it being stopped, then I agree with OP that they shouldn't bother trying it in the first place. If that's the case though, LAIs should probably be the goal.

Correct. I don't see the homeless low baseline schizophrenic following up with weekly labs.

 

[BiscoDisco]

LAIs if you have court ability should be the top of the list.
Haldol
prolixin
risperdal
Invega
Oral doses to observe, injections to follow in first few days. Then if doing low injection, by day of discharge, full dose...
Strive to get into housing/group home environment where injections can continue...
Even if you can't get the residential dispo to improve injection odds.
LAIs will possibly delay the eventual re-admit bounce back by few days to weeks? months?

LAIs are your real world answer most likely.
So many injections given in residency just the few hours before discharge. Man, I don't miss inpatient.

I could do LAIs but if I'm not seeing response to the oral version, I'm not aware of the injectable being particularly more efficacious. I do think I recall something in Schatzberg text which indicated LAI had improved efficacy even when controlling for compliance, but I digress.

The main issue I have is I have a bunch of minimal responders and I'm left wondering if I should go supra supra therapeutic, stack multiple antipsychotics, or abandon ship and start another new med to see if there's any improvement. I augment with depakote, lithium regularly. Anything else you might recommend as an augmenting agent?

 

[Celexa]

I could do LAIs but if I'm not seeing response to the oral version, I'm not aware of the injectable being particularly more efficacious. I do think I recall something in Schatzberg text which indicated LAI had improved efficacy even when controlling for compliance, but I digress.

The main issue I have is I have a bunch of minimal responders and I'm left wondering if I should go supra supra therapeutic, stack multiple antipsychotics, or abandon ship and start another new med to see if there's any improvement. I augment with depakote, lithium regularly. Anything else you might recommend as an augmenting agent?

It can take months for the full effects of antipsychotics to kick in. If you're seeing improvement at a full rational dose, it's ok to just wait. Adding in meds might lose you ground to side effects or cognitive effects of the extra meds while gaining you little. If the person looks manic sure, add a mood stabilizer. But if they aren't manic it probably won't help much in terms of psychosis.

Our meds aren't magic and unless the desire is to knock someone all the way out for a few hours, all need weeks to months to actually do what theyre supposed to. The fact that our health care system's screwed up prirotirs and poor resources does it's best to try and make us forget that fact doesn't mean we should.

 

[BiscoDisco]

It can take months for the full effects of antipsychotics to kick in. If you're seeing improvement at a full rational dose, it's ok to just wait. Adding in meds might lose you ground to side effects or cognitive effects of the extra meds while gaining you little. If the person looks manic sure, add a mood stabilizer. But if they aren't manic it probably won't help much in terms of psychosis.

Our meds aren't magic and unless the desire is to knock someone all the way out for a few hours, all need weeks to months to actually do what theyre supposed to. The fact that our health care system's screwed up prirotirs and poor resources does it's best to try and make us forget that fact doesn't mean we should.

Exactly.

I'll have someone like 40% better on 6mg risperdal but they've already been here 10 days and they're still gravely disabled. We both know it could just take more time, but I'm feeling pressure to do "something" and discharge them. So do I go above and beyond a reasonable dose...add another med they may not need if we just waited another few weeks...etc. it just feels like there isn't a good answer.

 

[psychmd03]

If the bolded is true, then why would you stop the Risperdal if it's been that effective? I would absolutely continue at possibly start a second antipsychotic or augmenting agent acutely if necessary as there's more evidence emerging that 2 antipsychotic meds is actually warranted for some patients. Outpatient can taper that once he's in a more stable situation.


Then why not discharge there? Sometimes acute units have to keep people longer-term to establish more stable long-term care. If you can't do that where you're at, then would the sub-acute unit? Or is there an ACT or mobile crisis team that can follow-up with him closely once discharged? These are some of the toughest patients because they resources they need just don't exist in the volume we need them to anymore. I feel for you because I see these patients come through our ER all the time and no hospitals are willing to accept them.


OP can correct me, but it seems like OP doesn't want to start Clozapine because they're worried that it would be stopped after discharge d/t patient not being able to adhere to treatment protocol, not because it wouldn't help. If the issue is maintaining compliance and risk of it being stopped, then I agree with OP that they shouldn't bother trying it in the first place. If that's the case though, LAIs should probably be the goal.

Agreed if they are better why stop why not add a second antipsychotic since I also agree with the last point you shouldn't be putting someone on clozapine that has no follow up. They either need ACT or a psychiatric nursing home or an amazing family to do the follow up necessary.

 

[comp1]

This might benefit from some data analysis. You're kind of going on gut feelings, which is normal, but not ideal. What is your 30 day and annual bounce back rate? If possible, see if you can pull county data from other hospitals. What is your length of stay? Reach out to other counties and see if yours is similar or shorter. County hospitals generally run off single pots of money (not RVUs) and are always full. Clinically, I'd definitely second the LAIs. You're not looking for immediate effect while inpatient with LAIs, you're looking for decreased or at least delayed bouncebacks. That said, there's definitely nothing in the literature supporting that they are LESS effective immediately. And yes, clozapine is very rare in county settings for a reason. No matter how well you get a person, it doesn't improve their finances at discharge. These patients generally have no home, much less transportation to weekly CBC monitoring, even if they were willing and had some insight into need. My hope is that eventually we can get approval or make it standard of care to be able to initiate the six month LAIs after demonstration of just oral tolerance. ACT is fine if it exists and is actually able to find the person, but in my personal experience, they tend to work with the least ill of the seriously mentally ill because they're the only ones who can actually be reached.

 

[FlowRate]

The main issue I have is I have a bunch of minimal responders and I'm left wondering if I should go supra supra therapeutic, stack multiple antipsychotics, or abandon ship and start another new med to see if there's any improvement. I augment with depakote, lithium regularly. Anything else you might recommend as an augmenting agent?

The long-tenure psychiatrists who had been treating CMHC SMI pop for 50 years who taught some of our didactics would say a couple things would be your next step, but these apply more to tentatively stableish outpatients more than to an inpatient setting with a time crunch:

1. Truly very high doses above what you mentioned in some cases. Go very slow. Give each dose increase at least 8 weeks.
2. Add a different antipsychotic and (slowly) titrate that medication. If you see improvement, it's more likely because of the new antipsychotic than the combination of the two. Once you've reached your goal with improvement or max dose of the second med, slowly taper the first.

and just a random data point from some of my residency inpatient expereince:
3. Occasionally you see a patient who does need a high dose of two antipsychotics to stabilize and then can be managed long-term on just one. (Until they decomp from not taking the one or just because they decomp occasionally when taking just one but are overall more functional when on one than two thanks to less side effects.)

 

[annoyedpsychiatrist]

Issue with clozapine is its a great medication but getting people to do weekly labs isnt likely in most cases. You need a highly involved family member, a community health center that will prescribe it, etc. Many areas of the country have zero-very few clozapine prescribers in the outpatient setting because of compliance issues causing prescriber burden.

If the patient is improving on an SGA after a day or two, they will likely continue to have increased improvement over several weeks. Benefite does not plateau after a few days. Remember goal of inpatient is to stabilize enough for outpatient- finding a treatment they can tolerate, ensuring not a risk to themself/others/involuntary criteria, and coordinating a good dispo plan such as strong f/u with the services they need. Stabilize enough, assess baseline through prior notes/collateral, secure a good dispo.

 

[comp1]

As far as I'm aware, the benefit for an antipsychotic plateaus around six months. You're going to mostly see sedation during the first several days. The sedation can be extremely useful, but ideally it's not the long term effect you're going for.

 

[BiscoDisco]

Issue with clozapine is its a great medication but getting people to do weekly labs isnt likely in most cases. You need a highly involved family member, a community health center that will prescribe it, etc. Many areas of the country have zero-very few clozapine prescribers in the outpatient setting because of compliance issues causing prescriber burden.

If the patient is improving on an SGA after a day or two, they will likely continue to have increased improvement over several weeks. Benefite does not plateau after a few days. Remember goal of inpatient is to stabilize enough for outpatient- finding a treatment they can tolerate, ensuring not a risk to themself/others/involuntary criteria, and coordinating a good dispo plan such as strong f/u with the services they need. Stabilize enough, assess baseline through prior notes/collateral, secure a good dispo.

I think this is the part I need to keep reminding myself - inpatient is to stabilize, not bring about 90% remission of symptoms. I sometimes find myself wanting to wait and or do more when in reality I could probably discharge.

 

[ObsequiousAplomb]

My point was it's not entirely accurate to say someone has a "low baseline" without trying clozapine. If they've really failed a ton of antipsychotics and they're homeless and psychotic, and chronically in and out of the hospital, then yeah, they should have an ACT team. (This of course requires that an ACT team exists)

And that ACT team should actually put forth the effort to arrange that clozapine, not scoff at the notion of providing the very services they're actually funded for. (This of course requires the impossible - that an ACT team isn't just an excuse to get extra funding but provide services only to those who don't need them)

Providing Haldol Dec + Invega for this patient is also acceptable, but it's also incredibly expensive. A nurse driving out to draw the blood every week is actually cheaper than some of the more expensive LAIs. Obviously not when compared to the decanoates, though. But the combination, yeah.

 

[mistafab]

I am quite against a lot in this thread. You’re practicing purely from emotions and dogma. The only true evidence you have is clozapine or ECT. You’re against trialing the only things that may actually improve someone’s functioning. Everyone deserves at least one trial - hell you are inpatient you have full control. Let them get better, discharge, fail to get labs and get cut off. Don’t decide for them if it’s never been trialed at least once. The relief some of these folks feel can be a life changing experience - they may never have experienced life in full remission since symptom onset - a possibly achievable goal. That’s a motivating experience if it happens.

If you are in lalaland going supratherapeutic, at least do it logically. You know that going higher than dopamine blockade ~80% is nonsensical if you haven’t even given it 3 months at that dose. Then you’re adding poly pharmacy or high dose monotherapy and equating the improvement to increase dopamine antagonism or ‘synergistic effects’ when most likely they just got better by compliance and time (I.e. that 3-6 month period).

The data is clear that if you hit the neuroleptic threshold, the further improvement with these agents is not substantially different at higher doses. In fact, pushing higher will even start tanking their progress depending on how you measure it (separate discussion). You’re creating side effects for the sake of your own discomfort and need to ‘do something’ when really you just need to give it time, or switch to a more effective approach (clozapine/ect).

Trialing 2 antipsychotics (serial, not together) before jumping to clozapine is sensible given the burden, but realistically if you fail 2 trials we all know the truth - the pt is f***ed without better treatments. Let’s not kid ourselves and then just try to sedate the patient to death, or eps them to oblivion. Give them a trial of clozapine before you start making them a walking (or eps frozen) chemistry set of two or more high dose meds. They deserve a shot.

 

[bashir]

This is an interesting and deeply sad thread. I empathize with your plight, OP, as the resources in my community are terrible too and it puts patients and inpatient docs in impossible situations. But ultimately I agree with those who have said you're not doing the patient any favors by ramping up to supratherapeutic doses in a matter of days in order to get them "well enough" to go to subacute. What looks like additional benefit is likely sedation. We see what we want to see.

It's impossible to evaluate a patient's baseline without some idea of their longitudinal functioning (not sure whether that's available in this case) and as others have said, you can't really say they have a low baseline if clozapine hasn't been trialed. I'm curious about a couple of things. Have all reasonable attempts been made to find someone who knows and cares about this person who can give a good history and maybe even be enlisted in their care to some degree moving forward? Often of course there is no one, but I ask because in my area I'm sad to say that the inpatient teams don't try that hard on this front.

The other point I wanted to make is that I think the lowest threshold for being good enough to discharge to a lower level of care, for someone who is chronically pretty sick, is "are they well enough now to meaningfully participate in their own care and make decisions that line up with their goals and values?" And if you've concluded that they're never going to get there (which would really take some time and a clozapine trial) do they have a guardian in place? They need and deserve a guardian.

Parting thoughts for anyone out there: please advocate for the abolition of clozapine rems. It's well past time.

 

[annoyedpsychiatrist]

I am quite against a lot in this thread. You’re practicing purely from emotions and dogma. The only true evidence you have is clozapine or ECT. You’re against trialing the only things that may actually improve someone’s functioning. Everyone deserves at least one trial - hell you are inpatient you have full control. Let them get better, discharge, fail to get labs and get cut off. Don’t decide for them if it’s never been trialed at least once. The relief some of these folks feel can be a life changing experience - they may never have experienced life in full remission since symptom onset - a possibly achievable goal. That’s a motivating experience if it happens.

I have mixed feelings on this, because part of me agrees with you but part of me has slightly different views in some aspects. There are some areas, and some community health settings that just dont have clozapine providers. In my last job i was the only clozapine provider in >60 mile radius if I recall. And i worked at a community health setting. If everything has been tried then realistically clozapine is the best choice, and I do agree if they have tried multiple antipsychotics and a fair trial of zyprexa, then its probably not likely they would do significantly better unless on clozapine.

I actually agree to abolish rems, and if anything make the monitoring requirement to just monthly period. I would argue the weekly monitoring does more harm than good. The low amount of people that get agranulo, vs the high amount of people that go off because they dont get their weekly CBC, and then decompensate. The end justifies the means to me on this. If they're a clozapine patient than the small risk of agranulo is nothing in comparison to living psychotic for the rest of your life.

Being pretty much the only prescriber previously was a huge burden. I did all the stupid rems reporting, and those sheets that they started requiring which I absolutely hate. Sometimes id have issues and have to call REMs. Then keeping track of when each person needs monitoring, etc. Drove me nuts, its hard to do without a lot of staff support and once you have a lot of people on it. For me in my new setting I dont integrate clozapine into my practice and refer those patients to community health setting, because its stupidly hard to get labs in this area for some reason.

 

[dozitgetchahi]

I have mixed feelings on this, because part of me agrees with you but part of me has slightly different views in some aspects. There are some areas, and some community health settings that just dont have clozapine providers. In my last job i was the only clozapine provider in >60 mile radius if I recall. And i worked at a community health setting. If everything has been tried then realistically clozapine is the best choice, and I do agree if they have tried multiple antipsychotics and a fair trial of zyprexa, then its probably not likely they would do significantly better unless on clozapine.

I actually agree to abolish rems, and if anything make the monitoring requirement to just monthly period. I would argue the weekly monitoring does more harm than good. The low amount of people that get agranulo, vs the high amount of people that go off because they dont get their weekly CBC, and then decompensate. The end justifies the means to me on this. If they're a clozapine patient than the small risk of agranulo is nothing in comparison to living psychotic for the rest of your life.

Being pretty much the only prescriber previously was a huge burden. I did all the stupid rems reporting, and those sheets that they started requiring which I absolutely hate. Sometimes id have issues and have to call REMs. Then keeping track of when each person needs monitoring, etc. Drove me nuts, its hard to do without a lot of staff support and once you have a lot of people on it. For me in my new setting I dont integrate clozapine into my practice and refer those patients to community health setting, because its stupidly hard to get labs in this area for some reason.

I’m not psych, but I’m a rheumatologist who reads this with interest because we obviously manage a lot of patients on potentially hemotoxic DMARDs.

For drug monitoring, the only patients where I have ever gotten weekly labs are those on Cytoxan - which is obviously a very heavy hitting drug as far as marrow suppression is concerned. But for everyone on MTX, leflunomide, sulfasalazine, azathioprine etc - general guidelines are once a month for a period of time until you’ve demonstrated stability, then maybe once every 3 months. Some argue that the data don’t support a need for regular labs altogether in these patients.

Is clozapine really more risky than the drugs I’ve listed above? I don’t know enough to know for sure, but I doubt it.

 

[ObsequiousAplomb]

I’m not psych, but I’m a rheumatologist who reads this with interest because we obviously manage a lot of patients on potentially hemotoxic DMARDs.

For drug monitoring, the only patients where I have ever gotten weekly labs are those on Cytoxan - which is obviously a very heavy hitting drug as far as marrow suppression is concerned. But for everyone on MTX, leflunomide, sulfasalazine, azathioprine etc - general guidelines are once a month for a period of time until you’ve demonstrated stability, then maybe once every 3 months. Some argue that the data don’t support a need for regular labs altogether in these patients.

Is clozapine really more risky than the drugs I’ve listed above? I don’t know enough to know for sure, but I doubt it.

as far as my memory serves, all of those rheum drugs are more likely to cause fatal blood dyscrasias than clozapine.
For reference: with clozapine, the incidence any neutropenia is less than 1%, and 99.999% of cases occur within the first 90 days of taking the drug. It's also almost always reversed upon stopping the drug without sequelae.

I don't remember the exact risks with the rheum drugs, but based on my limited knowledge they should be riskier.

I do know that as a patient, the decision to take Humira (and then the not-decision to have that switched to Amjevita) is what I would consider one of the most serious decisions I have ever made in my life. I read that package insert dozens of times and asked so many questions of my rheumatologist over the course of more than one office visit. And that's for one of the safe(r) ones!

 

[clausewitz2]

I’m not psych, but I’m a rheumatologist who reads this with interest because we obviously manage a lot of patients on potentially hemotoxic DMARDs.

For drug monitoring, the only patients where I have ever gotten weekly labs are those on Cytoxan - which is obviously a very heavy hitting drug as far as marrow suppression is concerned. But for everyone on MTX, leflunomide, sulfasalazine, azathioprine etc - general guidelines are once a month for a period of time until you’ve demonstrated stability, then maybe once every 3 months. Some argue that the data don’t support a need for regular labs altogether in these patients.

Is clozapine really more risky than the drugs I’ve listed above? I don’t know enough to know for sure, but I doubt it.

No, the difference is that the approval for clozapine was pulled when the agranulocytosis concerns became evident originally and the FDA was only willing to reinstate approval years later after an extensive lobbying campaign on condition that we have a REMS with the current monitoring condition. Agranulocytosis numbers like they saw in the original Finnish studies have also not really been replicated since in other countries or borne out in clinical practice. Given how genetically unusual Finns are in many respects it is not impossible that those numbers were an artifact of the population being studies.



EDIT: clozapine kills far more people by causing intestinal obstruction than via agranulocytosis in any event.

 

[comp1]

Don't give the FDA any ideas on intestinal obstructions. It's going to be weekly abdominal x-ray's for stool burden next. I'm the first one to argue that clozapine is NOT underprescribed given current regulations, but I am a little confused about a lack of "clozapine prescribers." It seems...ethically...that every mental health prescriber should be a "clozapine prescriber." Do people mean there are just no mental health prescribers for dozens of miles around? There's always going to be a couple of people with refractory schizophrenia who just happen to have an invested ACT team or (more likely) a family member that actually cares a little.

 

[ObsequiousAplomb]

Don't give the FDA any ideas on intestinal obstructions. It's going to be weekly abdominal x-ray's for stool burden next. I'm the first one to argue that clozapine is NOT underprescribed given current regulations, but I am a little confused about a lack of "clozapine prescribers." It seems...ethically...that every mental health prescriber should be a "clozapine prescriber." Do people mean there are just no mental health prescribers for dozens of miles around? There's always going to be a couple of people with refractory schizophrenia who just happen to have an invested ACT team or (more likely) a family member that actually cares a little.

based on my experiences, fewer than 10% of psychiatrists have ever prescribed clozapine.

 

[FlowRate]

Don't give the FDA any ideas on intestinal obstructions. It's going to be weekly abdominal x-ray's for stool burden next. I'm the first one to argue that clozapine is NOT underprescribed given current regulations, but I am a little confused about a lack of "clozapine prescribers." It seems...ethically...that every mental health prescriber should be a "clozapine prescriber." Do people mean there are just no mental health prescribers for dozens of miles around? There's always going to be a couple of people with refractory schizophrenia who just happen to have an invested ACT team or (more likely) a family member that actually cares a little.

I agree with you AND I can see how a solo PP doc would be more reluctant to take on the typical patient who needs clozapine in terms of both monitoring and patient acuity.

My situation with nursing support staff and working in an integrated healthcare system makes things a good bit easier.

 

[mistafab]

I think we all know the truth. There is a REMS because patented med manufacturers at the time were protecting their investment. In China, clozapine is first line for schizophrenia - no REMs. There is not an epidemic of agranulocytosis there, just an epidemic of profit-seeking pharma lobby here.

 

[bashir]

I love clozapine and prescribe a fair amount of it in my outpatient practice in an academic medical center. But it takes skill, experience, and effort to manage it competently (even aside from REMS, which is highly annoying but not actually all that much work for the prescriber compared to the patient and/or whoever is helping make sure they get to weekly lab draws). So many side effects to monitor for and manage. There are definitely NPs who I feel should not be prescribing it for lack of training/experience. Better persistently psychotic than dead from a bowel obstruction in my book. And probably some psychiatrists are in that category too, although I agree there's really no excuse for psychiatrists to not prescribe clozapine, unless they know another psychiatrist in their area they can refer patients to when clozapine is indicated. We are the specialists. If we "don't prescribe" the one drug approved for treatment resistant schizophrenia (the most disabling mental illness) what are we even doing?

I really appreciate the rheumatology perspective. Clozapine REMS is insane.

I talked to someone at the rems hotline last week who said that with the currently relaxed reinforcement of clozapine REMS, some pharmacies are choosing not to require it, and dispensing the medication regardless of CBCs/PSFs. Now it's my life's mission to make my university pharmacy one of those pharmacies, at least until we can get it abolished by the FDA. There's been a fair amount of advocacy by various groups in the past couple of years on this and I am a little bit hopeful.

Schizophrenia: Fighting the FDA for Clozapine Access

Are FDA REMS restrictions blocking access to clozapine for people with schizophrenia?

www.webmd.com

 

[psychmd03]

I am quite against a lot in this thread. You’re practicing purely from emotions and dogma. The only true evidence you have is clozapine or ECT. You’re against trialing the only things that may actually improve someone’s functioning. Everyone deserves at least one trial - hell you are inpatient you have full control. Let them get better, discharge, fail to get labs and get cut off. Don’t decide for them if it’s never been trialed at least once. The relief some of these folks feel can be a life changing experience - they may never have experienced life in full remission since symptom onset - a possibly achievable goal. That’s a motivating experience if it happens.

If you are in lalaland going supratherapeutic, at least do it logically. You know that going higher than dopamine blockade ~80% is nonsensical if you haven’t even given it 3 months at that dose. Then you’re adding poly pharmacy or high dose monotherapy and equating the improvement to increase dopamine antagonism or ‘synergistic effects’ when most likely they just got better by compliance and time (I.e. that 3-6 month period).

The data is clear that if you hit the neuroleptic threshold, the further improvement with these agents is not substantially different at higher doses. In fact, pushing higher will even start tanking their progress depending on how you measure it (separate discussion). You’re creating side effects for the sake of your own discomfort and need to ‘do something’ when really you just need to give it time, or switch to a more effective approach (clozapine/ect).

Trialing 2 antipsychotics (serial, not together) before jumping to clozapine is sensible given the burden, but realistically if you fail 2 trials we all know the truth - the pt is f***ed without better treatments. Let’s not kid ourselves and then just try to sedate the patient to death, or eps them to oblivion. Give them a trial of clozapine before you start making them a walking (or eps frozen) chemistry set of two or more high dose meds. They deserve a shot.

The bold IMO is very poor doctoring you are setting someone up for failure. If you know they do not have the means to follow up you are doing much worse for them than anything else mentioned there is no reason to do something just because you want to just "because they deserve a chance" when you already know they have 0 chance of being able to continue the medication regimen. Inpatients job is to stabilize to 60-80% of best baseline on a regimen they can actually continue to take so they actually have a shot at getting to 100%.

Also I do not really see literature on patients that I would ever classify as my actual very sick patients. They are the ones that are disqualified from all the studies. So for 60-70% of my very sick patients I have no literature to base any treatment on. I do fully agree going the multi antipsycohtic route should be done with thought to spread around the receptors you are hitting, balancing side effects making sure there is logic to the stacking. And doing this over the course of a week to more. And ECT is really not a good or supported option for schizophrenia. You don't get robust results in those patients literature is not in support of that.

 

[mistafab]

The bold IMO is very poor doctoring you are setting someone up for failure. If you know they do not have the means to follow up you are doing much worse for them than anything else mentioned there is no reason to do something just because you want to just "because they deserve a chance" when you already know they have 0 chance of being able to continue the medication regimen. Inpatients job is to stabilize to 60-80% of best baseline on a regimen they can actually continue to take so they actually have a shot at getting to 100%.

Also I do not really see literature on patients that I would ever classify as my actual very sick patients. They are the ones that are disqualified from all the studies. So for 60-70% of my very sick patients I have no literature to base any treatment on. I do fully agree going the multi antipsycohtic route should be done with thought to spread around the receptors you are hitting, balancing side effects making sure there is logic to the stacking. And doing this over the course of a week to more. And ECT is really not a good or supported option for schizophrenia. You don't get robust results in those patients literature is not in support of that.

In the same post you say clozapine is bad doctoring because of dispo planning, and ect is not a good option for schizophrenia when other treatments have failed.

You really can say or hear anything on here I guess.

Maybe put it on the unit to actually do foot work and create a plan for after discharge instead of simply giving up and going to the next med. If the unit is unhelpful, then bring it up to the director or facility at large to develop a program after you show them the data that xyz patients 1, 2, and 3 were ‘terrible forever’ but then got fully better - tell them they would save money if they petitioned for money to create something. What if they opened s half day a week clozapine outpatient hooked to your site and protected your time for it? You could see them, prescribe, and have a facility staff to draw blood on site. Or get an affiliated pharmacy to join a provider practice plan or something to routinely get the lab and dispense or even deliver the med same day - they can be assigned as designees to input the cbc on the physicians behalf. Or get a SW to assist in medicaid applications, medicaid transportation arrangement ahead of outpatient appointments (free for patient), etc after that goes through. Just giving up is 100% BS. Where is the act team? Where is DMH? Where is a guardian? Where is the nearest CMHC? Nothing I said is relying on a family member. Do the footwork and give the patient a shot.

No literature to base your opinions on? If you are simply choosing to ignore what data is available (decades worth) because they dont have your exact patient in a study, then that’s just poor understanding of science or simply poor application of EBM. Does your patient have schizophrenia? then every study in schizophrenia has at least something meaningful that you as the physician could use in your treatment of patients, even if you dont agree with the author’s design or conclusions.

 

[ObsequiousAplomb]

Imagine how much rationalization had to occur for a psychiatrist to say without any irony that clozapine is only prescribed for emotional reasons and that clozapine is not a rational choice and somehow "bad doctoring."

Somehow, you then come to the (not at all reality based, deeply held, and apparently unchangeable) belief that the only choice with the potential to be helpful is to intentionally choose drugs you know have no evidence base.

I guess I can see why someone who has undergone that much rationalization may also collude with the patients resistances to improve to this degree.

 

[bashir]

I believe there are situations where someone who didn't respond well to multiple trials of antipsychotics should not be trialed on clozapine in the hospital, due to practical limitations. But I also think when that happens there should be gnashing of teeth and soul searching and we should be asking ourselves "what can I possibly do to change this situation, if I can't help this patient, so maybe the next patient in this situation has a chance?" If we don't advocate for our patients, who will? We need to get creative and demanding. If someone gets better with clozapine, and there are barriers to keeping them on it outside the hospital, it's everyone's responsibility to address those barriers. The state mental health entity, their insurance company, the hospital, you as the inpatient psychiatrist.

I'm gonna tell you a true story. Details have not been embellished. I have a family member who had been on a merry-go-round of different hospitals in another state, had been sick for a decade but stable and functioning very well prior to this episode, during which she had become very sick for months on end. She wouldn't allow inpatient docs to talk to her family and they didn't seem to care that I was a psychiatrist. They concluded she had a "low baseline" and called it good, sent her out on something that wasn't really working. Rinse and repeat. Eventually we were able to get her into a hospital in my community, under the care of an inpatient doc who is a champion of clozapine. I had started to wonder if they were right, she just had "a low baseline" now and lose hope, but we weren't gonna give up before getting her on clozapine. Guess what? She got better. Like fully back to herself. She's back to work now at her professional job. The only outpatient clozapine prescribers in my area are close friends of mine, who my family member understandably isn't comfortable getting psychiatric care with. No worries, the inpatient doc (friend of a friend of mine) wasn't gonna let something like that keep someone from staying well, and now has exactly one outpatient. Now this obviously only played out this way because the patient had a psychiatrist as a sister, but what if we committed to a mindset of "what would I want to have happen here if this were my father/mother/sister/brother?"

So let's imagine this patient is your father/mother/sister/brother, and creative and get demanding. Is there a way to start a small clozapine-only outpatient practice at the hospital? What can the insurance company do to help in this situation? Around here the Medicaid managed care organizations actually have care managers who are field workers and meet with "high utilizers" in the community. Is this a possibility? Suggest that the insurance company buy an athelas device and get the care manager trained in taking POC ANCs so they don't have to transport to and from the lab, just show up wherever the patient is and poke their finger. (I have one patient whose husband did this, so I know that it's possible.) Could you set something up with their insurance company as a single case agreement? Would the insurance company pay for a cell phone and cab rides to the lab and appointments? The FDA has relaxed enforcement of REMS and there are some pharmacies now that will dispense clozapine without bloodwork. Is there a pharmacy in your city that you might be able to persuade to do that? How do you know if you haven't tried? There are bigger issues than just the blood draws of course, they WILL NEED regular follow-up with the psychiatrist if they're taking clozapine. Is there a local ACT team? Do they prescribe clozapine? If not, is there a way to educate the ACT doc on clozapine? If someone has gotten dramatically better on clozapine, and clozapine isn't available in the community, shouldn't we be calling the state and asking them what they're gonna do for this person? Hell, the state could send them to a residential treatment facility in another state if there truly was no way to get them clozapine in their home state. If the patient gets better enough to understand they need the clozapine, and that the barriers to getting it outside the hospital haven't been resolved (yet), they may be OK living in the hospital for a while until it gets sorted out.

Let's say this patient gets better on clozapine. You don't know what you don't know at this point about what resources THEY might bring to the table to help them stay better. Long-lost relatives who might come out of the woodwork if they come to understand that a small investment of their time/energy could yield huge benefits for a cousin they used to love and thought was lost and gone forever. My grandmother was a social worker who invested in getting to know a homeless man with schizophrenia, building a relationship over time that eventually led to getting him successfully treated. He had said all along he owned a large farm in Tennessee which she assumed was most likely a grandiose delusion, but helped him investigate. Well turns out he owned a large farm in Tennessee. Those who seem to be without connections or resources when psychotic are not always without connections or resources. We often don't know what we don't know about people who are too sick to give a good history.

If this sounds like an awful lot of work, that's because it is. But if you stop accepting the status quo and start changing it, it will get easier over time. You'll be able to effectively treat people you previously would have thought of as lost causes. Your job satisfaction will skyrocket. What do you have to lose?

 

[clausewitz2]

I believe there are situations where someone who didn't respond well to multiple trials of antipsychotics should not be trialed on clozapine in the hospital, due to practical limitations. But I also think when that happens there should be gnashing of teeth and soul searching and we should be asking ourselves "what can I possibly do to change this situation, if I can't help this patient, so maybe the next patient in this situation has a chance?" If we don't advocate for our patients, who will? We need to get creative and demanding. If someone gets better with clozapine, and there are barriers to keeping them on it outside the hospital, it's everyone's responsibility to address those barriers. The state mental health entity, their insurance company, the hospital, you as the inpatient psychiatrist.

I'm gonna tell you a true story. Details have not been embellished. I have a family member who had been on a merry-go-round of different hospitals in another state, had been sick for a decade but stable and functioning very well prior to this episode, during which she had become very sick for months on end. She wouldn't allow inpatient docs to talk to her family and they didn't seem to care that I was a psychiatrist. They concluded she had a "low baseline" and called it good, sent her out on something that wasn't really working. Rinse and repeat. Eventually we were able to get her into a hospital in my community, under the care of an inpatient doc who is a champion of clozapine. I had started to wonder if they were right, she just had "a low baseline" now and lose hope, but we weren't gonna give up before getting her on clozapine. Guess what? She got better. Like fully back to herself. She's back to work now at her professional job. The only outpatient clozapine prescribers in my area are close friends of mine, who my family member understandably isn't comfortable getting psychiatric care with. No worries, the inpatient doc (friend of a friend of mine) wasn't gonna let something like that keep someone from staying well, and now has exactly one outpatient. Now this obviously only played out this way because the patient had a psychiatrist as a sister, but what if we committed to a mindset of "what would I want to have happen here if this were my father/mother/sister/brother?"

So let's imagine this patient is your father/mother/sister/brother, and creative and get demanding. Is there a way to start a small clozapine-only outpatient practice at the hospital? What can the insurance company do to help in this situation? Around here the Medicaid managed care organizations actually have care managers who are field workers and meet with "high utilizers" in the community. Is this a possibility? Suggest that the insurance company buy an athelas device and get the care manager trained in taking POC ANCs so they don't have to transport to and from the lab, just show up wherever the patient is and poke their finger. (I have one patient whose husband did this, so I know that it's possible.) Could you set something up with their insurance company as a single case agreement? Would the insurance company pay for a cell phone and cab rides to the lab and appointments? The FDA has relaxed enforcement of REMS and there are some pharmacies now that will dispense clozapine without bloodwork. Is there a pharmacy in your city that you might be able to persuade to do that? How do you know if you haven't tried? There are bigger issues than just the blood draws of course, they WILL NEED regular follow-up with the psychiatrist if they're taking clozapine. Is there a local ACT team? Do they prescribe clozapine? If not, is there a way to educate the ACT doc on clozapine? If someone has gotten dramatically better on clozapine, and clozapine isn't available in the community, shouldn't we be calling the state and asking them what they're gonna do for this person? Hell, the state could send them to a residential treatment facility in another state if there truly was no way to get them clozapine in their home state. If the patient gets better enough to understand they need the clozapine, and that the barriers to getting it outside the hospital haven't been resolved (yet), they may be OK living in the hospital for a while until it gets sorted out.

Let's say this patient gets better on clozapine. You don't know what you don't know at this point about what resources THEY might bring to the table to help them stay better. Long-lost relatives who might come out of the woodwork if they come to understand that a small investment of their time/energy could yield huge benefits for a cousin they used to love and thought was lost and gone forever. My grandmother was a social worker who invested in getting to know a homeless man with schizophrenia, building a relationship over time that eventually led to getting him successfully treated. He had said all along he owned a large farm in Tennessee which she assumed was most likely a grandiose delusion, but helped him investigate. Well turns out he owned a large farm in Tennessee. Those who seem to be without connections or resources when psychotic are not always without connections or resources. We often don't know what we don't know about people who are too sick to give a good history.

If this sounds like an awful lot of work, that's because it is. But if you stop accepting the status quo and start changing it, it will get easier over time. You'll be able to effectively treat people you previously would have thought of as lost causes. Your job satisfaction will skyrocket. What do you have to lose?

Just to add to this, when clozapine really works for people who have gone through a bunch of revolving door hospital admissions where no other medications seem to accomplish anything and there seems to have been no insight, I have often been struck by how much motivated the patients themselves often are to making sure clozapine is doable. Some apparently insurmountable barriers just melt away when someone really wants to make sure they don't lose access to the first thing that's really helped, especially if they have a life or profession they had to leave because of what they were struggling with. At least one ICU nurse in my area has a job again because of clozapine.

 

[comp1]

The what if this was my family member emotional argument doesn't quite resonate for me with clozapine like it does in some cases. The patients who have caring and involved family members tend to be the ones who do really well on clozapine. It's hard to imagine myself out of existence, at least for emotional arguments.

 

[psychmd03]

Imagine how much rationalization had to occur for a psychiatrist to say without any irony that clozapine is only prescribed for emotional reasons and that clozapine is not a rational choice and somehow "bad doctoring."

Somehow, you then come to the (not at all reality based, deeply held, and apparently unchangeable) belief that the only choice with the potential to be helpful is to intentionally choose drugs you know have no evidence base.

I guess I can see why someone who has undergone that much rationalization may also collude with the patients resistances to improve to this degree.

I’d fully disagree with your digestion of what was said. Which is pretty standard on this forum many times which causing really poor discourse in some truly interesting topics. You make some wide sweeping statement about someone based on one post rather than engaging in a anything that resembles a professional discussion. Truly disappointing

 

[psychmd03]

The what if this was my family member emotional argument doesn't quite resonate for me with clozapine like it does in some cases. The patients who have caring and involved family members tend to be the ones who do really well on clozapine. It's hard to imagine myself out of existence, at least for emotional arguments.

I used it often as long as family is there and know what needs the be done for the patient to continue to get the medication. Or at a psychiatric nursing home. It can really have a significant effect on sick patients but only the ones that will have an ability to get weekly labs. Living on the streets no access to labs besides 2-3 busses and/or ACT teams makes the ability to stay stable very difficult

In the same post you say clozapine is bad doctoring because of dispo planning, and ect is not a good option for schizophrenia when other treatments have failed.

You really can say or hear anything on here I guess.

Maybe put it on the unit to actually do foot work and create a plan for after discharge instead of simply giving up and going to the next med. If the unit is unhelpful, then bring it up to the director or facility at large to develop a program after you show them the data that xyz patients 1, 2, and 3 were ‘terrible forever’ but then got fully better - tell them they would save money if they petitioned for money to create something. What if they opened s half day a week clozapine outpatient hooked to your site and protected your time for it? You could see them, prescribe, and have a facility staff to draw blood on site. Or get an affiliated pharmacy to join a provider practice plan or something to routinely get the lab and dispense or even deliver the med same day - they can be assigned as designees to input the cbc on the physicians behalf. Or get a SW to assist in medicaid applications, medicaid transportation arrangement ahead of outpatient appointments (free for patient), etc after that goes through. Just giving up is 100% BS. Where is the act team? Where is DMH? Where is a guardian? Where is the nearest CMHC? Nothing I said is relying on a family member. Do the footwork and give the patient a shot.

No literature to base your opinions on? If you are simply choosing to ignore what data is available (decades worth) because they dont have your exact patient in a study, then that’s just poor understanding of science or simply poor application of EBM. Does your patient have schizophrenia? then every study in schizophrenia has at least something meaningful that you as the physician could use in your treatment of patients, even if you dont agree with the author’s design or conclusions.

Clearly you are a very dedicated doctor. You’re somehow conquering the administrative department of not only your own hospital to create a new program to manage you inpatient all while keeping your patient locked in a hosptial while yoh pull together a brand new program and then also coordinate and cut through the administrative red tape with other facilities as well? Honestly that’s extremely impressive and I’m happy to admit that is well beyond something I’ll be doing. I have no aspirations to be an administrator and coordinating new programs and then running it. I just want to work with my patients.

Also who said anything about giving up. I don’t believe that was said anywhere. It’s impressive the poor reading comprehension across the board. Again I said for particular patients there are suggestions across literature but in the end you have to make educated (please read educated) clinical decisions and choose your medications based on evidence as well as your current patient in front of you. This forum gives me a headache. So many people spend so much time posting that would probably be better spent seeing patients or starting all these new utopia like programs.

 

[ObsequiousAplomb]

I’d fully disagree with your digestion of what was said. Which is pretty standard on this forum many times which causing really poor discourse in some truly interesting topics. You make some wide sweeping statement about someone based on one post rather than engaging in a anything that resembles a professional discussion. Truly disappointing

You took issue at what I said? Can you be specific? My goal wasn't to offend. My goal was to point out the common thinking error. Just like in the other thread about withholding stimulants for ADHD contrary to the current evidence. Notice the commonality - psychiatrists who were smug in their decision to insist on an inferior treatment? If you were too offended by having someone ask about it, was it because I was making a broad sweeping statement about your entire being? No.
Rationalization - I think that's the right word for the action of choosing the inferior option knowing that it won't work (which is, again, what I was talking about in this discussion the entire time).
I'm responding to a quote that did say all those mean things about clozapine.
There wasn't a rational argument at any time against clozapine. Just "I'm afraid that the patient might not improve enough with clozapine." I was pointing out that the fear isn't rational. Instead people attacked the idea of trying clozapine. Do you have an explanation for why people attacked the very notion of prescribing clozapine in treatment resistant psychosis? I'm happy to engage in a professional dialogue with anyone who can give a good explanation for why "low baseline" on a forum of psychiatrists when discussing the treatment of schizophrenia, is ever allowed to be said without a trial of clozapine.

 

[Ceke2002]

1. They are often times court committed. State hospital is a very long wait list, however I do have a locked sub acute facility I can discharge to. I will often times discharge patients on a temporary conservatorship to this facility if they are still gravely disabled.
2. I tend to max out risperdal at 8mg, seroquel at 800, olanzapine at 50mg, abilify at 40mg, haldol at 50mg. Most of the data I've seen suggests there really isn't much benefit beyond certain doses (which I'm certain I'm already going beyond).
3. See #1 - most of these patients are able to be d/c to a locked facility once they accept which can take 1-2 weeks.
4. The medical director. However this isn't a for profit driven decision. He is trying to keep resources to the community open as our EDs get very backed up. We deal with a very low SES population and get the sickest of the sick.

Are you able to arrange longer term type conservatorships? Not sure what the setup is like where you are, but I had an old acquaintance in South Australia with a level of schizophrenia similar to what you're describing & they were placed under a long term treatment and administration order under the Public trustee (basically if they didn't turn up for medication or other mental health appointments, police could take them in against their will, plus their money and basic needs in terms of rent, bills, and groceries were taken care of as well). It really helped reduce both the number of emergency hospitalisations needed (significantly) and also meant when they did require hospitalisation they went in at a less severe level. Just something to consider if you have it available to you.

(obligatory note, not a Doctor, this is just from my own personal experience with a similar situation).

 

[clausewitz2]

Are you able to arrange longer term type conservatorships? Not sure what the setup is like where you are, but I had an old acquaintance in South Australia with a level of schizophrenia similar to what you're describing & they were placed under a long term treatment and administration order under the Public trustee (basically if they didn't turn up for medication or other mental health appointments, police could take them in against their will, plus their money and basic needs in terms of rent, bills, and groceries were taken care of as well). It really helped reduce both the number of emergency hospitalisations needed (significantly) and also meant when they did require hospitalisation they went in at a less severe level. Just something to consider if you have it available to you.

(obligatory note, not a Doctor, this is just from my own personal experience with a similar situation).

Outpatient commitments are a thing in the States but they vary tremendously from state to state. In my state there is a mechanism for them but it is precedent that one cannot be hospitalized for violating an outpatient commitment so a bit toothless. It is also totally separate from the apparatus that would get someone designated a representative payee (i.e. holds their money for them)

 

[Ceke2002]

Outpatient commitments are a thing in the States but they vary tremendously from state to state. In my state there is a mechanism for them but it is precedent that one cannot be hospitalized for violating an outpatient commitment so a bit toothless. It is also totally separate from the apparatus that would get someone designated a representative payee (i.e. holds their money for them)

As far as I know it's the same in South Australia as well. A Doctor can section a patient into hospital if they're unwell enough to require hospitalisation, but they can't be forced into hospital just for missing an appointment. Under the SA system, at least when my friend was in it, if a patient didn't turn up for an appointment the police would pick them up and escort them to the appointment. Of course that did sometimes mean that if a patient couldn't be bothered making their own arrangements, they'd just wait for the nice police officers to give them a ride free of charge.

Also same with administration orders being separate to treatment orders. You could be on either, or both, but they were separate things.

Discussions like this do make me wonder if we need to bring back asylums for long term care and support of a certain patient population.

 

[whopper]

I remember having all the antipsychotics memorized on the back of my hand so we could IM anyone quick. That's a foundation of good inpatient psychiatry. Haldol IM, Olanzapine (but not with lorazepam), Chlorpromazine, etc.

Next is to memorize all of the atypicals, their efficacy rates and side effects. CATIE is a good place to start.

I've been doing private practice for years and haven't and can't do IM antipsychotics.

 

[Stagg737]

Maybe put it on the unit to actually do foot work and create a plan for after discharge instead of simply giving up and going to the next med. If the unit is unhelpful, then bring it up to the director or facility at large to develop a program after you show them the data that xyz patients 1, 2, and 3 were ‘terrible forever’ but then got fully better - tell them they would save money if they petitioned for money to create something. What if they opened s half day a week clozapine outpatient hooked to your site and protected your time for it? You could see them, prescribe, and have a facility staff to draw blood on site. Or get an affiliated pharmacy to join a provider practice plan or something to routinely get the lab and dispense or even deliver the med same day - they can be assigned as designees to input the cbc on the physicians behalf.

How much experience do you have with the administrative workings of actually getting this done? You're essentially suggesting a longitudinal QI project which would include showing improved clinical outcomes and complex financial calculations to justify implementation of the latter parts of the project which includes contracting with outside entities and/or other physicians to accomplish this. This would likely be a quite tremendous undertaking in multiple domains (inpatient clinical data, outpatient, involvement of pharma/lab groups, administrative) for a single psychiatrists or even a small group to undertake.

Or get a SW to assist in medicaid applications, medicaid transportation arrangement ahead of outpatient appointments (free for patient), etc after that goes through. Just giving up is 100% BS. Where is the act team? Where is DMH? Where is a guardian? Where is the nearest CMHC? Nothing I said is relying on a family member. Do the footwork and give the patient a shot.

Some of that can be accomplished before discharge, but some is completely dependent on resources available outside of the hospital which may not even exist. It's naive to think that the bolded are going to be helpful or even available to provide or assist with these resources. I see patients come into our ER who have been on a waitlist for literally 3+ years for state appointed guardianship as well as plenty of patients who we're told "don't meet criteria" despite very obviously needing it and meeting criteria. These are also areas that OP literally has no control over whatsoever unless they decide to start lobbying or actually become a politician. Idk how much "footwork" you expect OP to be doing for these people, but unless he's got a census of 3 then some of what you're expecting seems pretty unrealistic.

No literature to base your opinions on? If you are simply choosing to ignore what data is available (decades worth) because they dont have your exact patient in a study, then that’s just poor understanding of science or simply poor application of EBM. Does your patient have schizophrenia? then every study in schizophrenia has at least something meaningful that you as the physician could use in your treatment of patients, even if you dont agree with the author’s design or conclusions.

Going to have to disagree to a certain extent here on multiple levels with the biggest being that we don't even really understand "schizophrenia" as a disease. How many different disorders do we call "schizophrenia"? We weren't aware of disorders like Wilson's Disease until the early 1900's and didn't know it was related to copper for another 30-40 years. Encephalitis Lethargica was described in the 1910's, and various forms including tick-borne encephalitides weren't identified until the 40's. Autoimmune encephalitis wasn't described until 1968, not long after we realized HSV could be treated and we're still discovering new forms that we weren't previously aware of, Anti-NMDA wasn't discovered until 2005 and didn't enter the literature until 2007. More recently, there seems to be more emerging data that the entire concept of the dopamine hypothesis and antipsychotic treatment has been based on the wrong dopamine receptor subtype all along (see recent thread).

When compared to other fields, our understanding of the actual science IS poor, and criticizing the application of EBM when the underlying science is poor seems silly. Yes, I agree that there are things we can take from the data which can help guide our treatment. But saying that if we (supposedly correctly) diagnose a patient with schizophrenia then EVERY STUDY can provide meaningful direction in treatment of patients is an argument based heavily in fallacy.

Again, I agree that when good data (or any data) doesn't exist then we should examine what we have to guide treatment. I also agree that much of the monitoring requirements for clozapine are based more in politics than data. However, it's not a benign medication by any means and I do understand the OP's concerns, both from a practical standpoint based in realistic understanding of required protocol and a safety perspective. I say this as someone who considers themselves an advocate for increased clozapine use and decreased monitoring.