Treating Unmet Needs in Psychiatry (TUNE-UP): targeted service increases out-patient initiations of clozapine.
Ahmad Khan Z., Varvari I., Mancini V., Zita-Zauchenberger C., Kantor S., Fanshawe JB., Musiiwa S., Pledge A., Pearce B., de La Motte de Broöns de Vauvert SJGN., Quested D., Maughan D., Baskerville-Butler J., McGuire P., Howes OD., Pillinger T., McCutcheon RA.
BACKGROUND: In the UK, clozapine is the only licensed treatment for treatment-resistant schizophrenia (TRS). However, it is underused because initiation is often limited by the need for in-patient admission, which is costly and unattractive to patients. Community clozapine services may address this. AIMS: To describe a targeted out-patient clinic (Treating Unmet Needs in Psychiatry (TUNE-UP)) for TRS management and assess its impact on community clozapine initiation rates. METHOD: We reviewed clozapine titrations of patients under four community mental health teams from September 2021 to January 2025, recording whether titration occurred as in- or out-patient. The TUNE-UP clozapine clinic operated for 12 months (September 2023 to September 2024). Initiation rates during the TUNE-UP period were compared with those when the service was unavailable, using Poisson regression. Clinical outcomes were assessed using scales including the Positive and Negative Syndrome Scale (PANSS). RESULTS: Fifty-one individuals commenced clozapine during the study period. There was a significant increase in the rates of community initiation in the TUNE-UP period (11.0 per year) compared with those outside of this period (1.71 per year; incidence risk ratio 6.42 [95% CI 2.04-20.2, P = 0.0015]). Patients seen by TUNE-UP showed significant improvements in PANSS (n = 6, median improvement 21.5 [95% CI 7.0-33.0], P = 0.03). CONCLUSIONS: A specialist service was associated with a significant increase in community clozapine initiations. This approach offers a strategy to improve TRS treatment in the community.