Thursday, March 21, 2024

Social Determinants of Health Do Not Fully Account for Black-White Clozapine Gap

Even after accounting for variables such as access to care and social determinants of health, Black patients with schizophrenia are less likely than their White counterparts to receive a clozapine prescription, according to a study published this week in Psychiatric Services. Clozapine is considered the gold-standard medication for treatment-resistant schizophrenia, but data show it remains underused.

Spenser Barry, B.S., of the University of North Carolina Wilmington, L. Fredrik Jarskog, M.D., of North Carolina Psychiatric Research Center, and colleagues analyzed electronic health record (EHR) data from University of North Carolina Health, which comprises 16 hospitals and more than 500 clinics throughout North Carolina. They looked for adults (aged 18 to 64) diagnosed with schizophrenia between October 1, 2015, and November 30, 2021. The EHRs provided information on how long participants were in treatment, the number of antipsychotics other than clozapine they received, whether they received clozapine during the study period, and their recorded race.

To quantify participants’ social determinants of health, the authors used the 2018 census tract-level social vulnerability index (SVI), which measures the relative vulnerability of every U.S. Census tract. SVI uses four census variables: socioeconomic status; household composition and disability; minority status and language (English fluency); and housing and transportation (access to a vehicle). Higher scores indicate greater social vulnerability.

Among 2,857 participants (70% men), 14% received at least one clozapine prescription during the study period. Overall, 10% of all Black participants (159 of 1,521) received a clozapine prescription, compared with 19% of all White participants (206 of 1,091). After controlling for other demographic variables, SVI scores, and treatment history, White patients were 71% more likely to receive a clozapine prescription compared with Black patients. No other demographic variable analyzed in the study (gender, rurality, age at first diagnosis, or ethnicity) influenced participants’ likelihood of receiving clozapine.

SVI scores were higher among participants who did not receive clozapine compared with those who did. The authors noted that this finding was expected since initiating and maintaining clozapine treatment does require more resources than other antipsychotics.

“The reasons for the underprescription of clozapine among Black patients with schizophrenia are multifactorial and may include concerns about benign ethnic neutropenia, prescriber bias, prescribers’ anticipation of patients’ nonadherence to the treatment, and the notion that the medication is less effective for Black patients,” the authors wrote. “[N]ovel comprehensive approaches must be formulated that actively involve providers, patients, and health care systems (including payers) to address the many barriers that limit clozapine use.”

For related information, see the Psychiatric News article “FDA Reviewing Clozapine REMS to Determine if Monitoring Requirements Can Be Modified.”

(Image: Getty Images/iStock/simonkr)

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