Abstract
In 1993, in New South Wales, a lady with intractable paranoid schizophrenia was referred to me, at Kenmore Hospital, from the Liverpool Mental Health Service, for long-term institutional care. After a few months I put her on clozapine, with dramatic results. Sadly, a few months later (just before she was to be discharged) she registered a RED result and clozapine was terminated, permanently. She immediately regressed to her previous state. Her family were devastated.
In 1993, in Canberra, a female patient (now aged 52) with intractable paranoid schizophrenia was commenced on clozapine. I have treated her since 1994. In 2009 she requested withdrawal from clozapine to facilitate an overseas trip. Clozapine was gradually replaced by ziprasidone but, six months after ceasing clozapine, her psychosis returned. She was admitted to hospital where another psychiatrist reinstituted clozapine with an excellent response. I resumed her care, but on 4 January 2011 she had a RED result.
The clozapine protocol [1], whose main aim is to ‘minimise the risk of any patients on Clozaril developing agranulocytosis’ (p.3), unequivocally commands (p.17, section 4.3) that ‘ïf the results are in the RED range… - STOP CLOZARIL IMMEDIATELY’.
I knew that there was little danger of physical harm: benign neutropenia is well documented [2,3], wide variations in neutrophil levels occur day by day with diurnal variation, there is always the possibility of a mistake in estimating or reporting a blood result, and the risk of agranulocytosis is only minimally raised above normal in patients who have been on clozapine for over a year [4]. On the other hand the risk of permanent mental impairment is extremely high if clozapine is suddenly stopped. Abrupt withdrawal from clozapine is often followed by a withdrawal psychosis [5] and this patient was unlikely to respond to other medication.
I discussed the situation with the patient and together we determined to disregard the protocol's demand, and to continue with clozapine – but to increase the intensity of blood and clinical monitoring. As shown in Table 1, the patient had only one, inexplicable and isolated, RED result. The decision to continue (disobeying the protocol) saved the patient's mental health and demonstrated that her physical health was never under threat.
Neutrophil counts (109/L) for M (ref. range: normal 2.0–7.5; amber 1.5–2.0; red < 1.5)
