Document Type


Date of Original Version



Pharmacy Practice


Objective: Treatment-resistance schizophrenia occurs in 20-30% of patients. Clozapine is the only medication proven effective for treatment-resistant schizophrenia. However, less than 25% of treatment-resistant schizophrenia patients receive clozapine in most settings. Therefore, this study was conducted to identify facilitators and barriers to clozapine use, to inform development of interventions to maximize appropriate clozapine-utilization.

Methods: Seventy semi-structured phone interviews were conducted with five high- and five low-utilization VA Medical Centers, from different US regions including urban and rural areas. Interviewees were key informants of clozapine processes, including mental health leadership, psychiatrists, clinical pharmacists and advanced practice nurses. Interviews were analyzed using an emergent thematic strategy to identify barriers and facilitators to clozapine prescribing.

Results: Key elements associated with high-utilization included integration of non-physician psychiatric providers and clear organizational processes and infrastructure for treatment of severe mental illness (e.g. clozapine clinics, larger mental health intensive case management services). Low-utilization was associated with lack of champions to support clozapine processes and limited-capacity care systems. Obstacles identified at both high- and low-utilization sites included complex time-consuming paperwork, reliance on few individuals to facilitate processes, and issues related to transportation for patients living far from care facilities.

Conclusions: Implementation efforts to organize, streamline and simplify clozapine processes, development of a multidisciplinary clozapine clinic, increasing the size and capacity of existing clinics, and provision of transportation are reasonable targets to increase clozapine utilization.