Sceptic 'Tank: The Hidden Cost of Clozapine

There’s no doubt clozapine is very effective in suppressing some psychotic symptoms for some people.  And compared with drugs that have been around much longer, it’s a Cruise missile rather than cluster bomb, high-tec sniper’s rifle rather than blunderbuss.  It takes out its target without causing collateral damage to benign or desirable aspects of mental functioning – drive, expressiveness, creativity and so on.

It appears that its side-effects – extreme drowsiness, dribbling and a dry mouth – may be less disabling than the shakes and shuffle brought on by its older, cruder rivals. Sudden death from neutropenia or agranulocytosis is a risk for all those who take it but then sudden death is a higher than average risk for soldiers , cyclists and mountaineers.  Personally, I would probably opt for the fortnightly blood-tests that this risk requires rather than the large needle that is needed to inject older forms of anti-psychotic drugs into the muscle at the top of the thigh every few weeks.

But the increasing use of clozapine is, as all innovations or inventions do, having unintended and costly consequences.  Being an oral medication taken at least once and often twice a day, it requires continuous willingness on the part of patients to take it.  An injection – a so-called depot – given every two to four weeks only needs only occasional agreement of this kind – and the half-life of these older drugs is such that the odd injection can be delayed or missed without any detriment.  Miss a few doses of clozapine because staff are irritating you or you just don’t like the idea of being dependent on dodgy chemicals for the rest of your life, and whatever symptoms  you had originally will be redoubled and you might end up with a much more serious and debilitating illness than you had in the first place.

What this means in practice is that patients who would a few years back be happily hunkered down in a shared house (essentially the same as the discredited “group home”) or council flat waiting for the fortnightly or monthly knock from their community nurse are instead doing time on an acute ward or in a residential institution of some kind because the risks of their defaulting on their clozapine are considered too great.  When the twentieth century patient dodged a few depots and began harassing his neighbours, he could be brought back into hospital, settled back on his medication and slotted fairly quickly back into his flat or bedsit. The twenty-first century clozapine patient who misses a few doses for whatever reason is likely to become floridly ill and need a good long stay on the acute ward before he gets back to a reasonable level which, occasionally, may never happen.

The answer, of course, is for professionals to take the long view – which is difficult in a clinical culture which shows the early signs of ADHD, hopping from one bright idea to the next clever wheeze in an ever-tightening cycle.  Even where there is compulsion (in the form of detention under the Mental Health Act), there can be choice and there must always be the truth, which is: “with clozapine, you may eventually be better but you may not be free”.