Clozapine is often effective for patients with treatment-resistant schizophrenia; proactive and co-ordinated management,
however, is required. In particular, patients should not necessarily be relied on to report symptoms of adverse effects.
The primary care team can improve safety through monitoring and management of constipation, neutropenia, metabolic effects
and cardiac toxicity, and being aware of medicines which may interact with clozapine or exacerbate its adverse effects.
Constipation is an under-recognised and under-reported consequence of clozapine treatment. The need for increased awareness
of clozapine-related constipation has been highlighted recently with reports of avoidable fatalities.
- Do you prescribe clozapine or provide care for a patient taking clozapine? If so, do you feel confident in managing
the monitoring requirements and wide range of adverse effects associated with its use?
- Constipation due to clozapine can be severe and have fatal consequences. After reading this article would you now
feel more confident in preventing and if required, managing constipation in a patient taking clozapine?
- In your experience, do you feel that there is good communication and co-ordination between mental health teams
and primary care regarding the care of patients with mental health problems? Can you think of any particular
strategies that could be put in place to assist?
Part 1: Diagnosis and non-pharmacological treatment
Adults with insomnia have difficulty initiating or maintaining sleep, with adverse effects on their daytime functioning.
A sleep diary can help with diagnosis and tracking improvements. A non-pharmacological approach is initially preferred;
primarily cognitive behavioural therapy for insomnia (CBTi), which includes sleep hygiene and bedtime restriction. Evidence
shows that CBTi can be effective and provide greater long-term benefits than pharmacological measures.
- How realistic is it to suggest that general practitioners address lifestyle factors and use CBTi techniques as
first-line measures in patients with insomnia? In your experience does this work in practice or do
patients expect a “quick fix”?
- Sleep hygiene has been shown to improve sleep in approximately 30% of patients. Discussing the many lifestyle
steps that patients can take to improve sleep can be difficult to manage in a time limited consultation.
What strategies have you found to be helpful to accomplish this? Do you find patient information
sheets on sleep hygiene a useful tool?*
One key factor that can impact on sleeping habits is our reliance on modern technology such as cellphones,
laptops and tablet devices. What strategies have you found useful when advising patients about limiting
screen time if it is contributing to insomnia?
- Bedtime (or sleep) restriction can be a valuable technique for improving sleep. Have you used this technique with
patients? If so, what were the results? If this technique is new to you, do you think you would be
more likely to use sleep restriction after reading the article?*
* Printable PDF handouts for sleep hygiene and sleep restriction are available at:
Part 2: Pharmacological approaches for improving sleep
Pharmacological approaches to managing insomnia are a second-line option for adults who do not improve sufficiently
with cognitive and behavioural measures alone. For some patients with severe symptoms, medicines to help sleep can be
used for a short time initially, while non-pharmacological measures are optimised. The assessment and management of insomnia
in general practice can be difficult, especially in relation to managing patient expectations about pharmacological treatments.
- Do you find patients expect to be routinely prescribed sleeping tablets? If so, what strategies have you found
effective in your practice to counteract this expectation?
- An “exit strategy” is recommended at the time of prescription of a hypnotic medicine – a discussion about the intended
length of treatment and a plan for withdrawal. Is this something that you routinely do?
- Do you have many patients who continue on benzodiazepines (and similar medicines) long term? Does your practice
have a policy for reviewing the use of pharmacological treatments for sleep?
- Do you attempt to withdraw benzodiazepines in patients who have been taking them long term? What have you found
to be the best methods for this?
Non-pharmacological interventions are the mainstay of treatment for patients with depression. Antidepressants should
not be routinely prescribed for patients with mild depression as they will often respond to psychological interventions
alone, especially in the early stages of illness. A selective serotonin reuptake inhibitor (SSRI) is usually the first-line
pharmacological treatment for patients with moderate to severe depression who have not responded sufficiently to non-pharmacological
interventions, e.g. citalopram, escitalopram, sertraline or fluoxetine.
There are no guidelines for selecting a particular SSRI as there is little clinical trial data separating the SSRIs
in terms of efficacy and the results of meta-analyses have been contentious. The adverse effect profile,
potential for medicine interactions, ease of withdrawal and prescriber experience can be used to guide discussions regarding
medicine choice. Other medicines may be considered in some cases, e.g. mirtazapine, bupropion, venlafaxine or tricyclic
Patients should be followed–up in the first weeks after initiating an antidepressant to assess treatment response and
any adverse effects. If there has been no response to a therapeutic dose of an antidepressant after at least three weeks
consider switching to another medicine. Consider withdrawing antidepressants from patients who are coping well one year
after recovery from a single episode of depression or at least three years after recovery from multiple episodes.
- Non-pharmacological interventions are the mainstay of treatment for patients with depression. Online patient resources
have become relied upon as access to counselling and other support services are often limited. Which online
resources have you found to be most helpful for patients and why?
- The literature regarding antidepressant use is increasingly questioning the effectiveness of medicines for mild
to moderate depression and the role of the placebo effect. Has this recent information changed your prescribing
- At this stage, data from randomised controlled trials does not clearly determine which SSRI should be prescribed
over another. Do you have one SSRI that you use more than another? If so, for what reasons?
- In your experience, have you found that patients with severe depression respond well to a tricyclic antidepressant?
Or do you no longer prescribe these medicines for patients with depression?
- In what clinical circumstances would you consider prescribing a non-SSRI antidepressant such as mirtazapine, bupropion