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Am J Psychiatry 1995; 152:827-832
Copyright © 1995 by American Psychiatric Association
Patient response and resource management: another view of clozapine treatment of schizophrenia
WT Carpenter Jr, RR Conley, RW Buchanan, A Breier and CA Tamminga
Maryland Psychiatric Research Center, Baltimore 21228, USA.
OBJECTIVE: Issues in clozapine treatment were considered in terms of
implications for resource management. METHOD: A critical review of the
literature on time course and pattern of response to clozapine was used to
address treatment of negative symptoms, late responders, and extent of
clinical benefit in ordinary settings. RESULTS: Superior efficacy of
clozapine for partial and poor neuroleptic responders is observed in about
one-half of the cases. Response is rapid once a therapeutic dose is
reached, and the data do not support the proposition that some patients
first respond only after 3-12 months of therapy. The cumulative benefit
over several months of treatment and the broad range of symptoms involved
in response are similar to those for typical neuroleptic drugs, suggesting
that clozapine's superiority is based on greater effectiveness rather than
a unique profile of treatment effects. Clozapine appears to be effective
for secondary, but not primary, negative symptoms. Modal response is
moderate, and extensive rehabilitation and clinical services are required
to substantially enhance functional outcome. CONCLUSIONS: Many more
patients merit trials with clozapine. Economic costs and adverse drug
effects can be minimized by selecting patients most likely to benefit and
discontinuing clozapine treatment when benefit is not observed within 2- 4
months. Appropriate patients include 1) those with good responses to
typical neuroleptics who experience substantial adverse effects and 2)
those whose disorders respond poorly to standard neuroleptics and are
defined by psychotic symptoms, thought disorder, and hostility. Treatment
of primary negative symptoms is not supported by the current experimental
data.
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