Ethnic inequalities in clozapine use among people with treatment-resistant schizophrenia: A retrospective cohort study using data from electronic clinical records

Daniela Fonseca de Freitas, India Patel, Giouliana Kadra-Scalzo, Megan Pritchard, Hitesh Shetty, Matthew Broadbent, Rashmi Patel, Johnny Downs, Aviv Segev, Mizanur Khondoker, James H. MacCabe, Kamaldeep Bhui, Richard D. Hayes

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Purpose: Clozapine is the most effective intervention for treatment-resistant schizophrenia (TRS). Several studies report ethnic disparities in clozapine treatment. However, few studies restrict analyses to TRS cohorts alone or address confounding by benign ethnic neutropenia. This study investigates ethnic equity in access to clozapine treatment for people with treatment-resistant schizophrenia spectrum disorder.

Methods: A retrospective cohort study, using information from 11 years of clinical records (2007–2017) from the South London and Maudsley NHS Trust. We identified a cohort of service-users with TRS using a validated algorithm. We investigated associations between ethnicity and clozapine treatment, adjusting for sociodemographic factors, psychiatric multi-morbidity, substance misuse, neutropenia, and service-use.

Results: Among 2239 cases of TRS, Black service-users were less likely to be receive clozapine compared with White British service-users after adjusting for confounders (Black African aOR = 0.49, 95% CI [0.33, 0.74], p = 0.001; Black Caribbean aOR = 0.64, 95% CI [0.43, 0.93], p = 0.019; Black British aOR = 0.61, 95% CI [0.41, 0.91], p = 0.016). It was additionally observed that neutropenia was not related to treatment with clozapine. Also, a detention under the Mental Health Act was negatively associated clozapine receipt, suggesting people with TRS who were detained are less likely to be treated with clozapine.

Conclusion: Black service-users with TRS were less likely to receive clozapine than White British service-users. Considering the protective effect of treatment with clozapine, these inequities may place Black service-users at higher risk for hospital admissions and mortality.
Original languageEnglish
Pages (from-to)1341–1355
Number of pages15
JournalSocial Psychiatry and Psychiatric Epidemiology
Issue number7
Early online date4 Mar 2022
Publication statusPublished - Jul 2022


  • Asian British
  • Benign ethnic neutropenia
  • Black British
  • Clozapine
  • Health inequalities
  • Refractory psychosis

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