Transitioning clozapine patients to GP care

Sacha Filia, research fellow at Monash Alfred Psychiatry Research Centre, addresses the issues that arise when patients on clozapine are transitioned from the public system to GP shared care.

From reminder phone calls to frequent follow-ups, psychiatric patients who are taking clozapine in the public system tend to be closely monitored to help them stay on track. 

“We ring them all the time,” says Sacha Filia, a research fellow at Monash Alfred Psychiatry Research Centre, who is the lead author of a study looking at the barriers to transitioning patients on clozapine out of the public system.

“If someone misses an appointment, we’ll ring to reschedule and make sure they’re okay – whereas in the private system, they’re likely to be charged for the appointment.”

When Ms Filia and her colleagues surveyed a total of 80 community mental health service providers, private psychiatrists and general practitioners they learned that the biggest barriers to transferring these patients were concerns about their personal organisational skills, ongoing case management needs, and lack of accountability and compliance – as well as worries about the costs.

For people with treatment-resistant schizophrenia and schizo-affective disorder, the RANZCP recommends clozapine as the treatment of choice.

But safety concerns mean patients need regular monitoring: clozapine can cause potentially life-threatening side effects, including agranulocytosis and neutropenia, as well as myocarditis and cardiomyopathy. Other potential complications include weight gain and an increased seizure risk.

But so far, Ms Filia’s research suggests that those barriers are far from insurmountable, and that GP shared care programs can be an effective way to ensure these patients get the help they need.

“Overall, GPs perceived less barriers than the people in community health services or private psychiatrists,” she says. They were significantly less likely to think that cost and ongoing case management needs were barriers.

“Perhaps GPs are accustomed to working with some of the more diversely complex patients on a regular basis,” Ms Filia speculates.

Another study, awaiting publication, by the same group retrospectively followed 30 patients in GP shared care.

Thirty patients stayed in the public system, and 30 went to a private psychiatrist. None had to be readmitted in the year following transition.

Bulk-billing is one practical way to address the cost concern. Having administration staff or, ideally, a specific designated clozapine coordinator or mental health nurse in the practice to provide additional support is also valuable, Ms Filia suggests. Links with the public system should also be maintained so that the patients have a case manager who can help with other needs, such as housing.

“In our service, when a patient first gets transitioned, the clozapine coordinator would actually take the patient to the first three or four appointments with the GP to help them feel more comfortable,” Ms Filia explains. “Outcomes are really good.”

Aust N Z J Psychiatry 2012;46:183-84