Tailoring Treatment to Patient Goals and Providing the Clozapine Option as Standard of Care With Dr Jonathan M. Meyer

In this video, Jonathan M. Meyer, MD, Voluntary Clinical Professor of Psychiatry, University of California, San Diego, provides insights on how to prioritize patients' goals for treatment when  living with schizophrenia, goals that sometimes differ from the clinical emphasis on symptom reduction. Dr Meyer also discusses the importance of offering clozapine as an option to treatment resistant patients and offers some advice on how to get comfortable with prescribing the drug. 

Missed the first part of this series? Watch Part 1: Making Space for Patient Needs When Treating First-Episode Schizophrenia With Dr Jonathan M. Meyer here!

Read the Transcript: 

Dr. Jonathan Meyer: Hi, this is Dr. Jonathan Meyer, clinical professor of psychiatry at the University of California, San Diego, and psychopharmacology consultant to various state hospital and first-episode psychosis programs here to talk about how to tailor treatment regimens for patients with schizophrenia.

The overarching statement is whether they are first episode or a more chronic schizophrenia patient, is to find out what are their goals of treatment? What is it that they want? Often, sometimes we as clinicians get locked into the mindset of symptom reduction as a goal. Well, symptom reduction is a step on the way to the goal, but what is it the patient wants to do? Does she want to have her own apartment? Does he want to go back to school? Does this lady want to go back and have a job or at least do some volunteer work? Does somebody want to learn a skill? Does somebody want to take up a sport? What is it that they would like to be doing, and work together to try to get them towards those goals knowing that medication is simply one tool in achieving those goals.

Once you understand the goal, then sometimes that conversation goes much better around medication because you can now reframe it not as something they have to do, but as something that will actually facilitate them achieving their goals, whatever they are.

Lastly, if it turns out that when people are adherent to medication, they are resistant, meaning they are nonresponders, do not deprive them of a trial of clozapine. We've learned the hard way over the last 30 years that people tend to respond better to clozapine the sooner they are identified as being treatment resistant. They have better outcomes and better response. It really is below the standard of care to deprive somebody whose treatment resistant of clozapine.

Learning to prescribe clozapine is not that difficult. Yes, there are more adverse effects than other antipsychotics, but it's really the only thing that has been proven effective in patients who are treatment resistant. But to say to the patient, "Well, let's try something else," when it's obvious that they are treatment resistant really is below the standard of care, and it's not right. These people need a trial of clozapine. Work with a colleague who's prescribed clozapine if you don't feel entirely comfortable. Once you've started people on clozapine 10 or 12 times, you'll become very comfortable with initiating it, and you'll feel that sense of pride and accomplishment that you're now practicing the state of the art, and you're doing the best thing for these patients.

Again, individualizing care is just the hallmark of what we do as mental health clinicians. The only way you can find out what is on your patient's mind with regards to treatment and life goals is to have that conversation focused on those specific tasks and then work with them to try to come to a mutually satisfactory decision. Sometimes they're not always agreeable with what you want to do, for example, maybe trying an LAI, but the idea is the conversation should continue over time so that you can get them the tools they need from a medication perspective to eventually help them do what they want to do as human beings. This is Dr. Jonathan Meyer. Thank you very much.

Jonathan M. Meyer, MD, is a Voluntary Clinical Professor of Psychiatry at University of California, San Diego, and a Distinguished Life Fellow of the American Psychiatric Association. Dr. Meyer is a graduate of Stanford University and Harvard Medical School, finished his adult psychiatry residency at LA County-USC Medical Center and completed fellowships there in Consultation/Liaison Psychiatry and Psychopharmacology Research. Dr. Meyer has teaching duties at UC San Diego and the Balboa Naval Medical Center in San Diego, and is a psychopharmacology consultant to the California Department of State Hospitals, and to the first episode psychosis programs at Balboa Naval Medical Center in San Diego and in the State of Nevada.

Dr. Meyer has lectured and published extensively on psychopharmacology, and is the sole author of the chapter on the "Pharmacotherapy of Psychosis and Mania" for the last 3 editions of Goodman & Gilman's The Pharmacological Basis of Therapeutics. Along with Dr. Stephen Stahl he is co-author of the Clozapine Handbook published by Cambridge University Press in May 2019, and The Clinical Use of Antipsychotic Plasma Levels released in September 2021 by Cambridge University Press.