Key Takeaways
Extended Takeaways
- In this EPINET sample of 5,324 participants, 1,261 (23.7%) received an LAI and 297 (5.6%) received clozapine at any point, suggesting that evidence-based pharmacotherapy remains uncommon even within coordinated specialty care.
- Clinic-level variation was especially striking for clozapine, with rates ranging from 0.005 to 0.33 across 113 clinics and a site random-effect standard deviation of 0.92, pointing clinicians to local workflow and staffing barriers rather than patient mix alone.
- Men were more likely than women to receive both LAIs and clozapine, with higher utilization for LAIs (logOdds=1.11, SE=0.099, P<.00001) and clozapine (logOdds=0.83, SE=0.17, P<.00001), so programs may want to review whether prescribing discussions are occurring equitably across sex.
- Black participants were more likely than White participants to receive LAIs (logOdds=0.47, SE=0.079, P<.000001), while differences for clozapine were nonsignificant (logOdds=−0.29, SE=0.16, P=.067), which may warrant clinic review of how adherence concerns and treatment resistance are being interpreted across racial groups.
- Because one-third of patients referred to a treatment-resistant schizophrenia program had subtherapeutic or non-detectable antipsychotic levels, an LAI trial can help distinguish nonadherence from true treatment resistance before concluding that clozapine is indicated.
- For relapse after first-episode psychosis, the article highlights data that switching to clozapine after a first relapse was associated with the lowest risk of second relapse, with adjusted hazard ratio 0.66 and relapse rate 73% with oral non-clozapine antipsychotic monotherapy continuation vs 57% with switch to clozapine.
