Competence and confidence of health care professionals in using clozapine: a qualitative systematic review and thematic synthesis

Background:

Clozapine is the only licensed medication for treatment-resistant schizophrenia, although it is underused. Healthcare professionals (medical and non-medical professionals) play a crucial role in the management of clozapine. Consultant psychiatrists are accountable for the initiation of clozapine, whereas non-medical professionals are often responsible for the monitoring, the management of side effects and patient education. It appears that healthcare professionals‘ (HCPs) competence and confidence may have an effect on clozapine underutilisation.

Aim:

To synthesise the most pertinent literature examining the factors influencing HCPs competence and confidence in the management of clozapine and how these factors influence variation in prescribing practice.

Methods:

A review of the literature focusing on these elements was conducted. The Population, Context, Outcome (PCO) framework was adopted to support the literature search. The databases Medline, Psychinfo, Scopus, Cinahl, Pubmed, Embase, British Library, Ethos e-thesis, Google Scholar, Dart Europe e-thesis were consulted; the search was completed in January 2025. Screening, selection, data extraction and quality assessment were conducted independently by two researchers. Thematic analysis was used to investigate and compare the data emerging from the studies.

Results:

Thirty-four articles were included in the review. Six themes were identified: attitude toward and knowledge about clozapine, misconceptions (regarding side effects, monitoring and co-morbidities), guidelines, education, training and experience. HCPs self-reported as competent with guidelines (local and national), yet they expressed less confidence in their ability to adhere to them and were uncertain about managing side effects. Lack of education, training and insufficient exposure to clozapine management were significant factors impacting competence and confidence, resulting in clozapine underuse and variance in prescribing practice. The review highlighted a gap in the literature, as only a few studies involving non-medical professionals were found.

Conclusions:

A general lack of education and training related to clozapine use was identified amongst all professionals.

The impact of educational programmes on improving competence and enhancing confidence was considered positive, however when integrated with clinical practice.

The studies identified in this review were lacking in the involvement of non-medical professionals. Given their crucial role in managing side effects and educating patients and carers, it is evident that their inclusion in future research is imperative.