The use of Clozapine in the treatment of schizophrenia - Essay Example

?TOPIC: THE USE OF CLOZAPINE IN THE TREATMENT OF SCHIZOPHRENIA Introduction It is the basic aim of health care systems to provide the highest qualityof service possible to patients and thus novel ways to enhance service delivery are always being sought. Over the last two decades, health care has seen tremendous advancements in terms of both technology and practice and it is expected that this is a trend which will be kept up in the future. Among the most revolutionary health care aspects that have emerged during this period is Evidence-based practice (EBP) (Trinder 2000). This is a concept that is applicable to all areas of health care and has received a great deal of backing by practitioners in health care. This essay seeks to appraise the use of EBP in the use of in the treatment of schizophrenia. The rationale for choice of Clozapine schizophrenia treatment to appraise use of EBP will be provided. This will be followed by an analysis of how the different types of evidence available influence use of Clozapine in the treatment of schizophrenia and the factors that hinder or promote this. Evidence-based Practice According to the National Library of Medicine (2011) Evidence-based practice is an approach to health care service provision which is guided by thoughtful integration of the best available scientific knowledge with clinical expertise. The medical practitioner can examine research data, clinical guidelines and other information tools in a bid to give the right diagnosis and thus quality treatment followed by reflection on the outcome which aid in improvements in the future. It is simply the integration of individual expertise and the best external evidence and patient values (Lang 2004, p. 91). Evidence-based Practice rightfully involves the best and most current research evidence with educational or clinical expertise and the relevant perspectives of stakeholders in order to ensure that the best possible decision is made for patients. The Tenets of Evidence-based Practice Evidence-based Practice can be broken down into four steps that begin and end with the patient, and whose mastery defines expertise in the practice. After the four steps, implementation and re-evaluation follow. The first step involves formulating a focused clinical question after observing the patient. Such questions are carefully thought out foreground queries that generally have answers. They serve as the anchors to the other three steps of Evidence-based Practice. A mnemonic approach involving examination of the patient, the possible intervention(s) and comparisons and finally the outcome of interest is one of the best approaches put forward for developing a good foreground question. This is usually referred to as PICO (Patient, Intervention, Comparison and Outcome) (Lang 2004, p. 91). Booth (2006, pp. 358-359) argues that challenging practice rituals is a good way to come up with focused clinical questions. The primary goal is conversion of a precise and sometimes unclear information need into a query that can be answered. The type of questions that one can come up with may be predictive, interventional or explorative. The next step after the formulation of a focused question is undertaking to search for evidence. Information literacy is important here as the practitioner is required to match the PICO question with a relevant study design. Internet is quite an important tool here as it facilitates the gathering of information, and the next step in search for information is selecting on a relevant database to use, a decision influences by the time constraints and degree of information being sought. Some of the studies usually used include systematic reviews, randomized control studies and case control studies and the choice is influenced by the PICO (Lang 2004, p. 92). Rodrigues (2000, p. 1345) is of the opinion that randomized clinical trials and systematic reviews of peer-reviewed primary research work provide coherent and systematic evidence on the effectiveness of interventions taken. The third step of Evidence-based Practice is appraisal of the evidence gathered from the previous stage. This is based on the bias arising from the evidence search or errors, comprehension of the quantitative effects from a trial, and finally the applicability to the present case being handled. Some of the challenges that may arise include the fact that the intent of critical appraisal may not be evident in the medical research (Lang 2004, p. 92). The fourth step is the drawing of conclusions based on the research evidence integrated with the patient’s perspectives and the clinical context. Other considerations emerge especially with regard to the patient, costs, side effects and resources available, which are all weighed against the strength of the study in discussions with the patient and possibly the family (Lang 2004, p. 93). By this time, the entire cycle that started with the patient has gone back to the patient, and the next step is to implement the intervention followed by re-evaluation for future implications. The importance of EBP to a mental health nurse cannot be overstated especially due to its capability of improving health care delivery to patients. A mental health nurse’s personal experience cannot be relied upon for lifelong practice hence there is need for balancing experiential practice with the best available knowledge. Besides, an experiential model of treatment and decision making has no way of ensuring that the practitioner keeps learning relevant content, and hinders access to the latest skills, information, technique and perspectives in the healthcare practice (Lursadi et al. 2002, pp. 40-50). Hierarchy of Evidence After understanding what EBP entails, the next important issue is the knowledge of what evidence to use since all evidence does not bears the same importance and relevance for use in practice. The concept of information literacy arises here where a practitioner such as a mental health nurse would need to know which information is the best available as is imperative in EBP (Rockman 2002, 185-200). Evans (2002, 77) states that the hierarchy of evidence for use in nursing practice should be based on three dimensions; effectiveness, appropriateness and its feasibility. Basing on these three dimensions; excellent evidence consists of systematic studies and multicentre studies; good evidence consists of randomised control trials; fair evidence consists of intervention studies; and the evidence at the bottom of the hierarchy is that based on expert opinion (79). For this particular study, the model for grading of evidence is adopted from the National Service Framework for Mental Health (NHS 1999, 6), where Type I evidence consists of at least one good systematic review containing at least one random trial; Type II from at least a randomised control trial; Type III consisting of at least an intervention study that is well designed but without randomisation; Type IV with at least a well designed study that is observational; and finally Type V where we have expert opinion. Evidence-based Practice in Treatment of Schizophrenic Patients using Clozapine The rationale for selection of the use of Clozapine in treatment of schizophrenia to help demonstrate the use of EBP is informed by two reasons. To begin with, schizophrenia is the most important mental disease basing on its prevalence and debilitating effects to the lives of those affected. According to Bengston (2001) schizophrenia is a chronic and severe mental illness, characterized by problems in thought patterns, behaviour and social life. It is also one of the most common psychoses affecting several millions of individuals across the world (NIMH 2009). Furthermore, its treatment is already controversial on several aspects hence justifying every effort for its study by mental nurses. The second reason for the choice of study is due to the importance of the Clozapine in treatment of schizophrenia. The drug has been considered the gold-standard for the treatment of this disease (Wheeler 2008, 852-860). The combination of schizophrenia and Clozapine is thus of particular importance to a mental health nurse since he/she will definitely at one time come across the disease and the drug. Hence, sufficient information is needed in this issue, thus justifying its selection for this study. The essay will establish the evidence behind use of Clozapine for the treatment of schizophrenia, and then find out the factors for and against use of EBP in this field. Basing on the hierarchy of evidence given earlier, the first evidence analysed here is based on a systematic review by Essali, Hassan and Rathbone (2009) titled ‘Clozapine versus typical neuroleptic medication for schizophrenia’ published by the Cochrane Collaboration. This piece of evidence also fulfils the requirements for the nature of good evidence as stated by Ryclone-Malone et al (2003, 83-84); it should be up-to-date since research evidence is continually changing and is thus treated as provisional. It should also undertake a deep review of all the component studies which should also be of proper quality. Essali, Hassan and Rathbone (2009) undertook a systematic review the use of Clozapine versus other antipsychotics in the treatment of schizophrenia. A brief background to their study indicates that Clozapine has been identified as a superior drug for the treatment of schizophrenia due to higher efficacy and lower motor side effects. It however is accompanied by serious blood disorders thus necessitating frequent monitoring. The aim of this study was to evaluate the effects of Clozapine on schizophrenic patients in comparison to other antipsychotic drugs. The method undertaken in this study involved review of 52 randomised control trials with a total of 4746 participants where the criteria for entry was based on a study being randomised and the search strategy for studies was limited to the peer reviewed Cochrane Schizophrenia Group Trials Register. Data analysis was quantitative, involving calculations of the relative risks of use of Clozapine at 95% confidence level based on a fixed effect model. The results of the study indicated that there were no significant differences between the Clozapine and other antipsychotic medications in terms of broad outcomes such as mortality, ability to get back to work and suitability for the patient being discharged. There however were clinical improvements and fewer relapses in favour of Clozapine. Blood problems, drowsiness and hypersalivation indicating temperature rise were noted to be higher for patients using Clozapine. The authors’ conclusion was that although Clozapine did achieve notable short term positive results, there were no broader benefits such as early discharges and ability to work. Besides, it had more side effects than other antipsychotic medication. Indication and prescription of the drug was also noted to not seek the input of participants and their families. In case a mental health nurse was to utilize this study in practice, they would have to weigh the short term benefits of Clozapine against the risk of adverse effects for the patients, besides practising consumer participation. The study analysed above was particularly important based on its range (52 randomised trials and a total of 4746 patients), besides being the latest edition of the first study conducted by the same researchers in 1997. It was published in Cochrane Collaborations who also provided a plain language summary so as to improve its accessibility since it had insightful information with important implications in mental healthcare. The second study analysed in this essay is one that was done by Smith, Weston and Lieberman (2006) titled ‘Drug treatments for positive and negative symptoms: Clozapine’ and published in the British Medical Journal for Mental Health. In terms of hierarchy, this study falls below the previous one since it is a bit older. The aim of the study was also to compare the benefits of Clozapine over other schizophrenia antipsychotic drugs and its side effects. Quantitative data analysis revealed that the drug increased clinical improvement in majority of the patients; limited suicidal tendencies and generally reduced schizophrenia symptoms better than other antipsychotic medications. In terms of side effects, the researchers found out that Clozapine was responsible for less movement disorders in comparison with the other drugs, but was however associated with blood cell effects. The conclusion of the researchers was that their study had produced high quality evidence favouring the use of Clozapine as an antipsychotic medication over other drugs. The last study analysed in this essay is one that was done by Jeyapaul and Vieweg (2006, pp. 318-323) titled “A case study evaluating the use of Clozapine in depression with psychotic features” and published in Biomed Central’s Annals of General Psychiatry. The study is graded the lowest in this essay’s evidence hierarchy since it is a non-randomised intervention study that would fall under Type III in National Service Framework for Mental Health guidelines (NHS 1999, 6). An in-patient suffering from severe refractory psychotic depression that had shown resistance to a combination of antidepressants, antipsychotics, mood stabilizers and ECT was placed on a Clozapine treatment and observed. An inventory system was used to monitor her mood and functional capabilities before and after the Clozapine intervention. The results indicated that there were significant improvements in the patient’s mood, and her symptoms improved to an extent that she was able to be discharged on a combination of Clozapine and an antidepressant. Follow up indicated that the benefits of use of the drug lasted for over two years, leading the researchers to conclude that such evidence was not supposed to be ignored in practice. Factors Facilitating and Hindering Evidence-based Practice in the Treatment of Schizophrenia through Clozapine EBP has found wide use in the treatment of schizophrenia with Barnes (2011, pp. 567-574) and Emsley and Oosthuizen (2004, 219-238) indicating that a great deal of guidelines have been developed for the Evidence-based antipsychotic treatment of schizophrenia. One of the factors facilitating the evidence-based use of Clozapine is the widening body of knowledge generated from research on the subject (NICE 2010). From across the hierarchy of such evidence the superiority of Clozapine over other antipsychotic medications is not in question. This can be extrapolated to the use of EBP in the wider aspect of healthcare where the more the evidence available the more practitioners will be open to using it. The increasing emphasis placed on EBP is also a driver of evidence-based use of Clozapine in treatment of schizophrenia. An example of this is in the code of practice for nurses that emphasises high quality care as based on the best available evidence (NMC 2008). Use of evidence is also promoted by development of guidelines such as the one by NICE (2010) which establishes the steps of action and decision-making to aid practitioners in delivery of the best healthcare. One of the factors hindering evidence-based use of Clozapine in schizophrenia patient has to do with practitioners’ decision-making, which Falzer and Garman (2009, 1142-1151) observe to be influenced by the complexity of the particular case and difficulty of personalising the evidence to such a patient. This confirms Jeyapaul and Vieweg (2006, pp. 318-323) study where the researchers conclude that there is limited use of evidence-based use of Clozapine in complicated cases. Falzer and Garman suggest a 3-step model that may perhaps help practitioners to find it easier to use evidence in practice. NICE (2010, 1) indicates that data gaps within the evidence available are also a reason behind the limited use of evidence among medical practitioners which can be extrapolated to the case of Clozapine. Conclusion Evidence-based Practice has found wide use in most aspects of health care, including the treatment of schizophrenia through antipsychotic drugs. This approach involves formulation of a focused question, and then analyzing the evidence available followed by appraisal of this evidence, and finally arriving at a conclusion on the applicability of the treatment. Schizophrenia is a good case study for the appraisal of Evidence-based Practice since there are many questions regarding its treatment, and a great deal of ongoing research and information dissemination. Besides this schizophrenia is also one of the most serious and widespread mental illnesses and thus data on the Evidence-based approach is significantly important as it will find wide use. When the study is narrowed down to Clozapine as the antipsychotic drug of choice, the evidence favours its use over the other drugs since they are not nearly as effective, although its use is accompanied by side effects such as hypersalivation. The factors that facilitate adoption of an Evidence-based approach in antipsychotic schizophrenia treatment are mainly centred on the effectiveness, opportunity to learn and heterogeneity of schizophrenia. A conclusion is thus arrived at that Evidence-based Practice is taking precedence over traditional experiential approach to general health care. References Barnes, RET 2011, ‘Evidence-based guidelines for the pharmacological treatment of schizophrenia: recommendations from the British Association for Psychopharmacology’, Journal of Psychopharmacology, vol 25, no. 5, pp. 567-574. Bengston, M 2001, ‘Schizophrenia information and Treatment, Schizophrenia and Psychoses’. Psychcentral, viewed 10 September, 2011 from . 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Wheeler, AJ, 2008, ‘Treatment pathway and patterns of clozapine prescribing for schizophrenia in New Zealand’, Pubmed, vol. 42 no. 6, 852-860. Read More