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Amresh Shrivastava1,Megan Johnston2,Avinash De Sousa3,Sushma Sonavane4Nilesh Shah5

1 Department of Psychiatry, Elgin Early Intervention Program for Psychosis, The University of Western Ontario, Ontario, Canada, and Mental Health Resource Foundation, Mumbai, Maharashtra, India.

2 Department of Psychology, University of Toronto, 100 St. George, Toronto, Ontario, Canada.

3 Research Associate4, Professor, Professor and Head

3,4,5 Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumba



Background:TRS’/ treatment resistant schizophrenia or ‘refractory schizophrenia’ define as a result of lack of compliance, and some authors argue that it suggests ‘nothing can be done’, embedding the notion that the patient is resisting the treatment, rather than the illness itself is resistant to treatment, and it has been suggested that the term for ‘incomplete recovery’ be used instead of ‘treatment refractory’

Objective: Clozapine is the drug of choice for treatment resistant schizophrenia. Clozapine is known to be efficacious in both positive and negative symptoms as well is known to improve suicidality and social behaviour in schizophrenia.

Methodology: A total of 100 patients with DSM IV schizophrenia and Kane criteria treatment resistant schizophrenia who were acutely hospitalized were recruited. Psychiatrists administered the Clinical Global Impression – Severity (CGI-S), Positive and Negative Symptom Scale for Schizophrenia (PANSS), Hamilton Depression Rating Scale (HDRS) and Global Assessment of Functioning (GAF) scales while changes from baseline to end point were measured. Statistical analysis using SPSS was performed.

Results: 57% patients completed the study and out of this group 38% showed clinical improvement. The changes for both positive and negative symptom scores were significant (p<0.0001). No differences existed between completed and drop out cases while 61.4% cases had at least one side effect. .

Conclusion:Our results suggest that clozapine is safe and effective in treatment resistant schizophrenia though further studies determining dose related response are needed as well studies that monitor plasma clozapine levels.

Key words: Clozapine, treatment resistant schizophrenia, schizophrenia.


About 2/3 of patients of schizophrenia either do not respond to antipsychotics or become resistant to treatment. Much of the burden of schizophrenia is due to chronic state, nonresponse and functional decline.1 Clozapine remains the treatment of choice for such patients and has been consistently shown to be more effective than other atypical as well as typical antipsychotics particularly in negative symptoms and to some extent in cognitive symptoms.2 It has been shown to improve the level of functioning and quality of life and it also reduces the burden of the disease in many patients.3 A recent study suggests that Clozapine delays hospitalization in patients with treatment resistant schizophrenia if they are started on clozapine in the community or successfully discharged from hospital following their index admission.4 Clozapine further has also been shown to reduce suicidality in patients with schizophrenia.5 Despite good efficacy its remains highly under-utilized medication, primarily because of range of life threatening and other side effects and difficulties in frequent blood monitoring.6

In an evidence based review, authors highlighted several limitations in studies conducted in India about clozapine citing that most of the studies were    open-labelled, retrospective chart reviews, or case reports from a total sample of approximately 500 subjects. Despite such limitations the review concluded that    clozapine leads to significant improvement in patients having history of poor response to other antipsychotics.7 The present study was undertaken in a prospective naturalistic design to examine the efficacy and side effects of clozapine in treatment resistant schizophrenia in patients who were hospitalized due to a relapse.

Methods and materials

We carried out   an open level naturalistic study of 3 months follows up in non-governmental psychiatric hospital in Mumbai. We enrolled 100 DSM-IV criteria8 diagnosed schizophrenia patients who also met treatment resistant’s schizophrenia as per Kane’s criteria9 and were hospitalized in an acute state. The inclusion criteria were diagnosis of schizophrenia as per DSM-IV criteria, age between 18-45 years, treatment resistant state and hospitalization in an acute state. Exclusion criteria were pregnancy, presence of current or history of organic mental disorder, neurological conditions, cardiac or metabolic disease or presence of seizures or head injury.   Local ethics committee approved the study. Consenting patients were recruited after discussion about risk, benefits, procedure and cost involved from a sample of an ongoing long term follows up study of first episode schizophrenia. Blood test and ECG was done and all patients were medically cleared. The study design was a treatment as usual (TAU). All patients were paying for their care in this private set-psychiatric centre. Clinical assessment was done using Clinical Global Impression of Severity Scale10, Positive and Negative Symptom Scale for Schizophrenia (PANSS)11, Hamilton Depression Rating Scale (HDRS)12, Global Assessment of Functioning (GAF)8 and a side effect checklist at the base and endpoint of 12 weeks treatment. Clozapine was initiated with a dose of 25 mg per day and increased by 25 mg every 4th or 5th day, with weekly blood count monitoring for the first 4 weeks and thereafter once in 2 weeks and followed up every 2 weeks after discharge.   Outcome criteria was improved and much improved CGIS score of =/< 2. Data was recorded and analyzed using SPSS software.


We recruited 100 patients and 43 dropped out during 12 weeks treatment. Out of the 57 who continued 27 patients recovered as per CGIS criteria. Majority of patients in this study were predominantly male (83%), young, married (50%) and educated. Sample characteristics (Table 1) shows that the duration of illness was 30 months, 59% had either current or past suicide ideation or  history of attempt, 30% subjects had shown violent behavior, 37% had substance abuse, only 18% were never hospitalized, 14% had comorbidity of on both axis I and II. This short term 12 weeks study found  that 38% (27/57) showed  improvement as per CGIS Criteria. There was significant reduction in the total scores of PANSS (p<0.001), positive symptoms (p<0.001) and negative symptoms (p<0.001) from baseline to endpoint (Table 2). The patients who improved did not differ on any base line characteristics from drop out patients (Table 3). 57% patients did not discontinue the treatment. Out of these 35 (61.4%) subjects experienced at least one side effect. In a number of patients additional add-on drug was prescribed, commonest being benzodiazepines in 50%, and trihexyphenidyl in 33% cases (Table 4).


A number of studies have confirmed clinical superiority of clozapine in comparison to conventional as well as atypical antipsychotics.13 The sample characteristics appear to what has been generally reported in the literature14 except the duration of illness which was relatively shorter (30 months). Relatively shorter duration of illness observed in our study is not surprising which appears to be related to growing awareness about mental illnesses and increased access to care, patients are reporting relatively earlier for treatment, particularly in urban and metropolis regions.15-16 Clozapine response has generally been from 30-60% the main characteristic has been the quality of response.17 The present study shows improvement in 38% amongst the patients who continued treatment. A number of studies from India and other regions have shown almost similar rate of recovery.18  Authors have found a recovery in 50% subjects in 20 months with no gender differences were seen in the response rate, significant improvement was seen  in an the urban population in India.19 Good response to clozapine has been consistently shown, particularly amongst the resistant patients.

However response around 40% has also been substantially documented.20 Recovery in 38% is relatively low which may partially be due to shorter duration of follow up. Clozapine response is time-specific and incremental response is relatively faster in first 6 months.21 In a one-year follow up comparative study on clozapine versus haloperidol, researchers showed that the  response as defined by more than 20% reduction in PANSS total, score was 27.1% at 6 weeks, 23.4% at 3 months, and 24.7% at 6 months.22 Our study also showed significant reduction (46.52) in psychopathology as per >20% reduction in PANSS total score in 3 months duration which is also similar to what has been reported earlier.23-24 Authors evaluated the short term and long term effectiveness of clozapine in 51 subjects and reported that during the inpatient stay (mean duration 63 days), there was 34.7% reduction in total PANSS rating after starting clozapine at a mean dose of 298.97 mg/day.25

Early introduction of clozapine is now being recommended in guidelines (Texas) though in general there is scepticism. Though clozapine has been used in first episode psychosis, several authors have questioned whether clozapine should be indicated as a first-line treatment for early psychosis.26-27 A recent meta-analysis28 has shown poor response to clozapine but those studies had definite limitations of using low dosage. A moderate level of response in our study may be due to shorter time period and the nature of illness. Though moderate dosage of clozapine was used, dose response relationship in Indian studies remains undetermined.

In this study recovered and unrecovered patients did not significantly differ on any psychopathological parameter like that of age, gender, duration of illness, sub-types of schizophrenia, baseline glucose and triglyceride except baseline weight, A number of other studies have reported a correlation between baseline parameters and clinical recovery.29

One of the landmark studies from Asian countries comparing pattern of clozapine usage showed that patients taking clozapine were significantly younger, had a higher dose of antipsychotic drugs in chlorpromazine equivalents, were more likely to be female, had fewer extrapyramidal symptoms, and had more negative symptoms, admissions and weight gain in the past month than those not receiving clozapine.30 However such differences were not seen in  our study, possibly because of small sample size which could be because  expected predictors were not studied. Most consistent clinical predictor for clozapine response has been extrapyramidal symptoms at baseline31, negative symptoms32, paranoid subtype33 and comorbid substance abuse also indicate faster response.34

A number of patients during the course of treatment do require additional medication either for a side effect, for treatment of different symptoms, delayed response or comorbid conditions. Use of another antipsychotic is common across all antipsychotics leave alone clozapine for treatment of symptoms like anxiety, depression, agitation, sleeplessness, etc. Studies have reported the tendency to combine antipsychotic medications as beneficial for patients, particularly in terms of reducing positive symptoms.35 In a sample of over 70,000 patients regularly receiving antipsychotics, 13.9% were receiving a combination of antipsychotics, and 6.6% of these combinations included clozapine.36 The high rates of combination may be due to late response, distressing symptoms, even from physicians’ preference or undue expectation of symptom remission due to need for early discharge in set-up where patient is paying for the facility.

Daily dose of psychotropic medications are generally lower in India due to ethnic variations, further these patients are also sensitive to a number of side effects in general, leave alone clozapine. In a study although Asian patients received a significantly lower mean clozapine dose (176 mg/day) than the Caucasian group (433 mg/day, P<0.001), plasma clozapine levels were similar between the groups. As a result, Asian patients had more than twice the effective clozapine concentration to dose ratio (P<0.001). The findings remained significant even after controlling for gender, body mass index, cigarette, alcohol and caffeine use.37 In a national survey of prescribing pattern in India average dose among the stabilized schizophrenia patients was reported to be 50 mg by 12%, 75–100 mg by 25%, 150 mg by 23%, 150–300 mg by 24% and more than 300 mg by 14% doctors. About 50% physicians reported effective dose between 150 and 300 mg per day. It is noteworthy that 37% physicians find effective response in symptoms at a dose of 50, 75, and 100 mg per day also. Low-dose maintenance is an interesting finding, which needs confirmation and further study.38

In this study 43% patients dropped out, there was no significant difference between baseline characteristics of those who continues and those who did not. A drop out of 66% at the end of 13 weeks was reported in a study for acute treatment of the first episode of schizophrenia or schizoaffective disorder this was comparable to conventional antipsychotic in one of the previous study.39 Contrarily wheeler reported a Low clozapine discontinuation rates, which was associated with real-world improvements in functional and clinical outcomes.  Further Clozapine was less likely to be withdrawn because of ineffectiveness. Of late all-cause discontinuation has been considered as an outcome criteria.40 Despite the wide range of side effects and complications, clozapine remains the gold standard medication in patients with treatment resistant schizophrenia. Clozapine has affinity for several different receptors, and it may thus elicit a wide range of side-effects, some of which can be as potentially life threatening. Metabolic side effects and weight gain continues to be main challenge in prescribing of clozapine. At number of times a patients who are recovering well have to be withdrawn due to potentially serious side effects like myocarditis, agranulocytosis or seizures.41

We did not find any unreported or unusual side effects. Appearance of high incidence of side effects in short term treatment is particularly significant   particularly when none of these patients were on complex polypharmacy. It is likely that presence of comorbidity, substance abuse and individual sensitivity, particularly in younger population, might be responsible.42

Clozapine is useful in treatment resistant schizophrenia but studies in diverse populations across various groups shall help us understand the parameters that affect efficacy and faster response better. We need further studies that look at older versus younger subjects while also determining a dose related response to Cloazpine. Studies that monitor plasma clozapine levels in Asian patients and their comparison to international data are warranted.


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14.     El-Badri S, Mellsop G. Clozapine use and outcomes among patients with treatment resistant schizophrenia. Australas Psychiatry. 2011;19(5):410-414.

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18.     Thirthalli J, Channaveerachari NK, Subbakrishna DK, Cottler LB, Varghese M, Gangadhar BN Prospective study of duration of untreated psychosis and outcome of never-treated patients with schizophrenia in India. Indian J Psychiatry. 2011;53(4):319-323.

19.     Conley RR, Buchanan RW. Evaluation of treatment-resistant schizophrenia. Schizophr Bull. 1997;23:663–674.

20.     Taylor DM, Duncan-McConnell D. Refractory schizophrenia and atypical antipsychotics. J Psychopharmacol. 2000;14:409–418.

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22.     McEvoy JP, Liberman JA, Stroup TS, Davis SM, Meltzer HY, Rosenheck RA, et al. Effectiveness of clozapine versus olanzapine, quetiapine and risperidone in patient with chronic schizophrenia who did not respond to prior atypical antipsychotic treatment. Am J Psychiatry. 2006;163:600–610.

23.     Stroup TS, McEvoy JP, Swartz MS, Byerly MJ, Glick ID, Canive JM. The national institute of mental health clinical antipsychotic trials of intervention effectiveness (CATIE) project: Schizophrenia trial design and protocol development. Schizophr Bull. 2003;29:15–31.

24.     Agid O, Arenovich T, Sajeev G, Zipursky RB, Kapur S, Foussias G, Remington G. An algorithm-based approach to first-episode schizophrenia: response rates over 3 prospective antipsychotic trials with a retrospective data analysis. J Clin Psychiatry. 2011;72(11):1439-1444.

25.     Dutt A, Grover S, Chakrabarti S, Kulhara P, Avasthi A, Basu D, et al. Effectiveness of Clozapine: A study from North India. Asian J Psychiatry. 2010;3:16-19. 

26.     Raja M. Clozapine safety, 35 years later. Curr Drug Saf. 2011;6(3):164-184.

27.     Honer WG, Procyshyn RM, Chen EY, MacEwan GW, Barr AM. A translational research approach to poor treatment response in patients with schizophrenia: clozapine-antipsychotic polypharmacy. J Psychiatry Neurosci. 2009;34(6):433-442.

28.     Szymanski S, Masiar S, Mayerhoff D, Loebel A, Geisler S, Pollack S. Clozapine response in treatment-refractory first-episode schizophrenia. Biol Psychiatry. 1994;35:278–280.

29.     Hector RI. The use of clozapine in the treatment of aggressive schizophrenia. Can J Psychiatry. 1998;43:466–472.

30.     Green AI, Schildkraut JJ. Should clozapine be a first-line treatment for schizophrenia? The rationale for a double-blind clinical trial in first-episode patients. Harv Rev Psychiatry. 1995;3:1–9.

31.     Lerner V, Libov I, Kotler M, Strous RD. Combination of "atypical" antipsychotic medication in the management of treatment-resistant schizophrenia and schizoaffective disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2004;28(1):89-98.

32.     Goyal N, Praharaj SK, Desarkar P, Nizamie H. Electroencephalographic abnormalities in clozapine-treated patients: a cross-sectional study. Psychiatry Investig. 2011;8(4):372-376.

33.     Ng CH, Chong SA, Lambert T, Fan A, Hackett LP, Mahendran R, Subramaniam M, Schweitzer I. An inter-ethnic comparison study of clozapine dosage, clinical response and plasma levels. Int Clin Psychopharmacol. 2005;20(3):163-168.

34.     Tang Y, Mao P, Li FM, Li W, Chen Q, Jiang F, Cai Z, Mitchell PB. Gender, age, smoking behaviour and plasma clozapine concentrations in 193 Chinese inpatients with schizophrenia    Br J Clin Pharmacol. 2007;64(1):49–56.

35.     Couchman L, Maccabe JH, Flanagan RJ  Bowskill S. Plasma clozapine and norclozapine in relation to prescribed dose and other factors in patients aged 65years and over: data from a therapeutic drug monitoring service, 1996-2010., Hum Psychopharmacol. 2012;27(3):277-283.

36.     Solanki RK, Singh P, Swami MK. Clozapine: Current perspective. Indian J Psychiatry. 2007;10:271-276.

37.     Yagcioglu AE, Kivircik BB, Turgut TI, Tümüklü M, Yazici MK, Alptekin K. A double blind controlled study of adjunctive treatment with risperidone in schizophrenic patient partially responsive to clozapine: Efficacy and safety. J Clin Psychiatry. 2005;66:63–72.

38.     Chung C, Remington G. Predictors and markers of clozapine response. Psychopharmacology (Berl). 2005;179:317–325.

39.     Umbricht DS, Wirshing WC, Wirshing DA, McMeniman M, Schooler NR, Marder SR, Kane JM.Clinical predictors of response to clozapine treatment in ambulatory patients with schizophrenia.              J Clin Psychiatry. 2002;63(5):420-424.

40.     Krivoy A, Malka L, Fischel T, Weizman A, Valevski A. Predictors of clozapine discontinuation in patients with schizophrenia. Int Clin Psychopharmacol. 2011;26(6):311-315.

41.     Pai NB, Vella SC. Reason for clozapine cessation. Acta Psychiatr Scand. 2012;125(1):39-44.

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Table 1 – Baseline characteristics



Values (baseline N = 100)

Age -- Mean (SD)

33.12 (6.71)







       Up to 10th standard


       Up to 12th standard










Marital status








Sample characterstics


       Number enrolled


       Completed study


       Dropped out


Duration of illness (months)

30.42 (8.36)

Type of Schizophrenia


       Disorganized Schizophrenia


       Paranoid Schizophrenia


       Schizoaffective disorder


       Undifferentiated Schizophrenia


       Residual Schizophrenia


Family History of Mental Illness


       No history


       In first degree relative


       In second degree relatives




       No history of suicide


       Past history of suicidal gesture


       Past history of  1 or 2 attempts


       Past history of > 2 attempts


       Currently Suicidal




        Past history of violent behaviour


        History of violence in this episdoe


Substance abuse


        No substance abuse






         Cannabis and alcohol


Previous Hospitalization










Previous antipsychotic





















Previous antipsychotics  (n)






Three  or more




        Axis 1


        Axis 2


        Axis 3



101.78 (13.19)


25.75 (3.98)


26.88 (5.53)


17.05 (3.99)


35.94 (10.32)




















Table 2 – Change from the baseline in all values




3 months









Gender – male






Mean (sd)

5.11 (0.86)

1.51 (0.51)



CGIS   > 2

n (%)

100 (100%)

 35 (62%)

22 (38%)


PANSS total

101.78 (13.19)

54.43 (10.38)

47.35 (46.52%)


> 30% PANSS Reduction (n)


48 (84.21%)




25.75 (3.98)

13.00 (4.33)

12.75 (49.51%)



26.88 (5.53)

11.38 (3.94)

15.50 (57.66%)



Mean (sd)

35.94 (10.32)

52.73 (9.94)

-16.79 (-46.72%)



17.05 (3.99)




Mean Dose







33.09 (5.82)



Any side effect


35 (61.4)




(normal = 100)

111.95 (22.50)

139.49 (40.66)

 -27.54 (-24.60%)


Triglycerides (normal = 120)

114.75 (29.94)

172.50 (43.69)

-57.75 (-50.33%)


Weight  (Kg) (normal= 50kg)

59.30 (8.66)

63.64 (7.05)

-4.34 (-7.32%)





Table 3 - Comparison of patients who continued treatment and who dropped out from treatment



Continued treatment

Dropped out from treatment

F Value /

χ2 value









Age (years) Mean (sd)

33.12 (6.71)





F = 0.001

p = .972

Gender: Male







χ2  = 1.54

p = .214


Duration of illness (months) Mean (sd)

30.42 (8.36)





F = 0.149

p = .700

PANSS Total Mean (sd)

101.78 (13.18)

101.37 (13.58)



F = 0.128

p = .72

PANSS Positive symptoms Mean (sd)

25.75 (3.97)





F = 1.46

p = .22

PANSS Negative symptoms Mean (sd)

26.88 (5.53)





F = 1.21

p = .27

HDRS – Mean (sd)

17.05 (3.99)





F = 0.067

p = .79

GAF – Mean (sd0

35.94 (19.31)

35.19 (10.14)



F = 0.69

p = .40







Table 4 - Major side effects



(n = 49)


(n = 8)

Total 57



15 (30.6%)

4 (50.0%)

19 (33.3%)

 1.16 (1)

 ANC <1500

3 (6.1%)




Abnormal EKG

3 (6.1%)

0 (0.0%)

3 (5.3%)



7 (14.3%)

0 (0.0%)

7 (12.3%)

1.30 (1)

Myoclonic Jerks

2 (4.1%)


3 (5.3%)

0.98 (1)


0 (0.0%)

1 (12.5%)

1 (1.8%)

6.23 (1)





Age < 35, (n = 32)

Age >35

(n =25)

Total  57



10 (31.3%)

9 (36.0%)

19 (33.3%)

0.14 (1)

 ANC <1500

2 (6.3%)

2 (8.0%)

4 (7.0%)

0.07 (1)

Abnormal EKG

3 (9.4%)

0 (0.0%)

3 (5.3%)

2.47 (1)


4 (12.5%)

3 (12.0%)

7 (12.3%)

0.003 (1)

Myoclonic Jerks

2 (6.3%)


3 (5.3%)

0.14 (1)


0 (0.0%)

1 (4.0%)

1 (1.8%)

1.30 (1)