An attempt to discontinue clozapine – Worth a try?

To the Editor

The principal drawback of clozapine is its adverse effects leading to significant numbers of participants leaving treatment early after initiation (Legge et al., 2010). Experience on discontinuation of clozapine after several years of treatment is not much reported. I am reporting here an attempt to cease clozapine for six patients in a community psychiatric rehabilitation service. The Hunter New England Research Ethics Committee identified this work as a non-research activity and does not require its approval.

The six patients, all males aged between 36 and 58 years, were on clozapine for a period of 4–14 years and were mentally stable. They requested discontinuation since they could not function as well as they wished, due to the side effect of the medication like sedation and dullness. The dose of clozapine was reduced gradually after discussion with them about the possible risks of ceasing the medication, the need to stop or reverse the process of dose-reduction at any time and the possible need to use additional medications for control of any deterioration in mental status.

All six of them improved in the side effects and level of functioning as the dosage reduction progressed. Over a period of time, all of them exhibited worsening of psychosis with deterioration in functioning that ended in a brief hospitalisation. Three of them had ceased clozapine without medical advice. The dose of clozapine was brought up back to be in the range of 100–400 mg a day. This was less than the pre-reduction dose range of 400–700 mg a day. The follow-up on the reduced dose of clozapine ranged from 5 months to 4 years. All received an augmenting antipsychotic medication (olanzapine, amisulpride, paliperidone or risperidone). They did not report any side effects related to them. All six did not seek to cease clozapine again acknowledging that they needed it. The adjunct medication was ceased in two patients (after 2 and 10 months).

While the overall experience for the patients was negative, positive changes were noted in their functioning, attitude to treatment, adherence to continued treatment with clozapine and sense of recovery. They were all happy that they were supported in their risking to cease the medication they were struggling to take. Such positive risk-taking, by trying something one is not sure one can achieve, leads to personal growth and development and, as part of recovery, develops resilience (Slade, 2009).