The Schizophrenia Algorithm

To the Editor: The article by Dr. John Chiles and his colleagues (1) in the January 1999 issue about the schizophrenia algorithm developed by the Texas Medication Algorithm Project (TMAP) raises a question. Since clozapine is the final drug choice when other drugs fail, why not use it right off the bat?

I suppose one answer might be that the Food and Drug Administration has recommended it only for drug-resistant patients, but is that recommendation binding? Another reason might be the risk of agranulocytosis, but I have used clozapine with many patients, and in only one case did the drug have to be discontinued because of a drop in the white blood cell count. There are so many advantages. Why delay?

The question also arises about using clozapine in new cases of schizophrenia. It has been shown that young, first-break schizophrenic patients have a better prognosis and less danger of developing chronic illness with early treatment. The cost savings by avoiding hospitalization is another reason it might be advantageous to use clozapine as a first-line treatment. I haven't used clozapine for a newly diagnosed schizophrenic patient, but I'm not sure why. Can the authors comment?

Dr. Berman is a psychiatrist in Westport, Connecticut.