By Lauren DeSouza- Master of Public Health, Simon Fraser Public Research University – Canada

https://nhcrisishouse.com/our-team/

Staff Research and Content Writer

© Copyright – SUD RECOVERY CENTERS – A Division of Genesis Behavioral Services, Inc., Milwaukee, Wisconsin – August 2024 – All rights reserved.

Schizophrenia, a severe and debilitating mental disorder, affects approximately 2.8 million American adults. 20-30% of these individuals have treatment-resistant schizophrenia, wherein they do not respond to first-line antipsychotic medications. Clozapine, the gold standard medication for treatment-resistant schizophrenia, is under-prescribed, particularly among Black patients, leading to disproportionate suffering and poorer health, social, and economic outcomes.

A new study uses six years’ worth of electronic health record data to understand the extent of the racial differences in clozapine prescribing, using an approach that accounts for the social determinants of health. By employing a social determinants of health approach, the researchers aimed to account for the social and economic inequities that contribute to the disparity in

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clozapine prescribing and, thus, to poorer health outcomes in Black patients

Clozapine Controversy

While clozapine is considered the most efficacious medication for treatment-resistant schizophrenia, healthcare providers are sometimes reluctant to prescribe it. Clozapine can cause some potentially dangerous side effects, including neutropenia (lowered white blood cell counts) in some patients. Despite its potential for severe side effects, clozapine remains the most effective medication for schizophrenia. However, these risks mean it is typically reserved for patients who have not responded to first-line antipsychotic treatments.

Controversy aside, clozapine can be a lifesaving medication for patients with treatment-resistant schizophrenia, who are at a higher risk for early mortality and suicidal behavior. Unfortunately, as this study has uncovered, clozapine prescriptions are significantly influenced by a patient’s race and socioeconomic status.

What did this study do?

This retrospective cross-sectional study used six years of data from the Electronic Health Records (EHR) system at the University of North Carolina (UNC) Health to investigate racial differences in clozapine prescriptions among patients with treatment-resistant schizophrenia. The researchers analyzed clozapine prescriptions by race, incorporating a social determinants of health framework. They analyzed data from 3,160 patients to identify differences between patients with schizophrenia who received a clozapine prescription and those who received

antipsychotic medications other than clozapine.

The Social Determinants of Health cover community factors that affect health and include five key domains:

  • Economic stability
  • Education quality and access
  • Healthcare access and quality
  • Social and community context
  • Neighborhood and built environment

The researchers employed the Social Vulnerability Index (SVI) to quantify the social determinants of health. SVI is a tool developed by the Centers for Disease Control and Prevention to quantify the extent of social vulnerability within a county or census tract. A higher SVI score indicates greater social vulnerability.

What were the main findings?

The researchers identified a racial disparity in clozapine prescription, with Black patients with schizophrenia being less likely to receive clozapine compared with White patients. This finding remained true even when analyses controlled for social determinants of health, care access, and other demographic factors.

Black people in North Carolina had a higher burden of schizophrenia relative to their population share; 53% of schizophrenia patients at UNC were Black, while only 22% of North Carolina residents were Black. Despite this higher burden, Black patients received fewer clozapine prescriptions. 10% of Black patients received a prescription for clozapine, compared with almost twice the amount (19%) of White patients during the 6-year study period. Instead, Black patients were often given prescriptions for second-line medications less effective than clozapine, which

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can have direct and serious consequences on their health.

The researchers also identified a trend in socioeconomic status and clozapine prescribing. Patients who received a clozapine prescription had a lower average SVI score (9.1% less) than those who did not. As higher SVI scores indicate greater social vulnerability, they conclude that patients who were not given prescriptions for clozapine had more significant amounts of social vulnerability. The researchers hypothesize that patients require more access to care to initiate and maintain clozapine treatment. The social determinants of health play a crucial role in determining access to healthcare treatment. This study underscores the strong connection between these determinants and prescription patterns, revealing that social and economic factors often dictate who receives potentially life-changing care.

Why do Black patients receive fewer clozapine prescriptions than White patients?

Lower clozapine prescription rates among Black patients highlight a gap in equitable access to effective schizophrenia treatment. Several factors may contribute to lower prescription rates, including:

  • Prescriber bias (e.g., that clozapine is not effective for Black patients or that Black patients will not adhere to the treatment)
  • Prescriber concerns about benign ethnic neutropenia
  • Structural barriers

Benign ethnic neutropenia (BNE) is a condition primarily affecting people of African descent, who naturally have lower neutrophil counts. Medical research has proven that BNE does not pose a health risk to patients. Still, prescribers may have preconceived notions that prevent them from prescribing clozapine to patients for fear it will further lower their neutrophil counts and compromise their immune systems.

From this study, we can posit that structural barriers, deeply rooted in social and economic inequities, play a significant role in the disproportionally low rates of clozapine prescriptions for Black patients. The social determinants of health analysis found that patients with more social vulnerability were less likely to receive clozapine prescriptions due to a lack of access to reliable medical care. Structural racism contributes to social vulnerability in Black populations by embedding disadvantages into societal systems—including access to healthcare—that determine essential resources and quality of life. This study’s focus on social determinants of health reveals how barriers to care rooted in structural racism diminish health outcomes, with Black patients facing cumulative hurdles in accessing the same standard of care as White patients.

What are the takeaways?

This study presents strong evidence that Black patients with schizophrenia receive fewer prescriptions for clozapine, a drug that could significantly increase their quality of life. This evidence suggests significant gaps in care quality for Black patients. This disparity highlights the need for healthcare policy reforms, culturally competent provider training, and systemic changes to reduce structural racism in the healthcare system. For example, culturally sensitive psychiatric training for prescribing physicians could help lead to more equitable treatment for Black patients with treatment-resistant schizophrenia. Addressing these lower clozapine prescription rates is essential to improve patient outcomes, increase trust in the healthcare system, and promote better mental health in underserved, racialized populations.

Key Points

  • Clozapine is the gold standard medication for treatment-resistant schizophrenia but is often under-prescribed.
  • Black patients are less likely to receive prescriptions for clozapine than White patients, a finding that holds true when accounting for demographic factors, social determinants of health, and access to care.
  • Patients who faced more social inequity were less likely to receive clozapine prescriptions, highlighting that the social determinants of health influence schizophrenia treatment.
  • Black patients may be less likely to be prescribed clozapine due to prescriber bias and structural barriers, many of which are rooted in structural racism in the healthcare system.

References

Barry, S., Jarskog, L. F., Xia, K., Torpunuri, R. S., Wu, X., & Zeng, X. (2024). Racial disparities in clozapine prescription patterns among patients with schizophrenia. Psychiatric Services, 75(8), 733–739. https://doi.org/10.1176/appi.ps.20230226

“Social Determinants of Health”. Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved from https://health.gov/healthypeople/objectives-and-data/social-determinants-health

“Schizophrenia Fact Sheet”. Treatment Advocacy Center. Retrieved from https://www.tac.org/reports_publications/schizophrenia-fact-sheet/