Antipsychotics and Physical Health-the Clozapine Resources

1. Antipsychotics and Physical Health-the Clozapine Resources Dr Nathan Gibson Chief Psychiatrist WA Chair, WAPDC 27 October 2017

2. Today, in brief • Some harsh and practical realities about antipsychotics • What we have done • What we need to do

3. The Harsh Realities • The mortality gap for patients of mental health services in WA • 15.5 years for men • 12.0 years for women • For psychosis, the story is worse: • 22.7 years for men • 22.6 years for women (Lawrence et al 2013) • It’s getting worse, not better…

4. The Harsh Realities • Suicide only contributes to 14% • 78% of excess deaths were attributed to physical health conditions, incl cardiovascular and cancer (and 50% less treatment) (Lawrence et al 2013) • High dose antipsychotics are associated with excess cardiovascular mortality (Torniainen et al 2014)

5. The Practical Realities • Severe and enduring mental illness is complex • Antipsychotic medication is often a critically important part of care, but how do we find the balance for an individual when their medication may also be causing harm ?

6. The Practical Realities • ACSQHC Atlas of Variation 2015 • WA has second lowest rate of PBS antipsychotic prescribing in Australia • Do we use a lot of polypharmacy or high dose antipsychotics in WA? • We don’t know…

7. The Practical Realities • Psychotropics are listed in the WA Health High Risk Medication Policy (2014) • Because of metabolic syndrome • Because of the complex interplay with suicide • Clozapine and Lithium are mentioned specifically

8. Why clozapine focus today? • Clozapine is the gold standard antipsychotic • It can work when nothing else does • It’s been around since the 1970s • There are 1200 people on clozapine in WA • (Note 6000 people with psychotic illness in WA) • There was a cluster of 5 deaths of individuals taking clozapine in East Metro • Review identified clozapine as not contributing, but made recommendations for better physical health care

9. Existing Clozapine Resources • Clozapine Initiation and Titration Chart • Plus Guidelines for using this • 2015 • Mandatory (Kerry Fitzsimons et al)

10. What Clozapine resources have just been developed? • Clozapine Guidelines for Safe, Quality Use • Clozapine monitoring form • Guidelines for completing the clozapine monitoring form • Side effects associated with clozapine therapy (list) • Clinician prompt checklist to assess clozapine side effects

11. Clozapine Monitoring Form

12. Guidelines for the monitoring form

13. Side Effects reference sheet

14. Clinician SE prompt

15. Implementation • Implementation Steering Committee • Dr Duy Tran, Chair • Questions: • Will GPs use these? • How do we get engagement with MH clinicians? • Clozapine is uncommon- how do we translate better physical health care with all antipsychotics?

16. What do we need to do? • The physical health issue is bigger than clozapine! • National priority: • 5th National Mental Health and Suicide Prevention Plan • Physical health and reducing early mortality is Priority Area 5 • Safety and Quality Partnerships Standing Committee(national interjurisdictionalS&Q group for mental health) are meeting in two weeks to discuss the strategies for these priorities. • There is a national subcommittee (RAMEMHWP) looking at reducing adverse medication events • Local strategies: • M3Q patient self-report med adverse event questionnaire • High dose/polypharmacy audit

17. Antipsychotic Polypharmacy and High-Dose Prescribing Audit

18. Where do you get these clozapine resources? http://ww2.health.wa.gov.au/Health-for/Health-professionals It’s very difficult to find, and not up yet: Click on Safety and Quality, then Medication Safety

19. Questions?