CPCP: Clozapine and Seizure Risk by Medical Student Arvinder Jandu

Arvinder Jandu M4
Arvinder Jandu M4

We owe  many thanks to senior medical student Arvinder Jandu for today’s Clinical Problems in Consultation Psychiatry (CPCP) presentation on the risk of seizures in patients taking clozapine. Arvinder will be heading to a residency in Emergency Room Medicine–I envy the ER which will be enhanced by his drive, talent, and tenacity. It’s another example of practice-based learning and improvement that actually helped me modify my position on this issue. I still think it’s an important adverse effect of clozapine, but the evidence is not as clear-cut as I thought it was about whether and when to add prophylactic anticonvulsant.

Using clozapine is a tricky proposition because of the important medical issues psychiatrists need to remain aware of. In fact, the potential for medical complications from clozapine are important enough that a paper was recently published with the interesting title, “Medical management of patients on clozapine: A guide for internists.”

Lundblad, W., et al. (2015). “Medical management of patients on clozapine: A guide for internists.” Journal of Hospital Medicine 10(8): 537-543.
Clozapine was approved by the US Food and Drug Administration in 1989 for the management of treatment-resistant schizophrenia, and has since proven to reduce symptom burden and suicide risk, increase quality of life, and reduce substance use in individuals with psychotic disorders. Nevertheless, clozapine’s psychiatric benefits have been matched by its adverse effect profile. Because they are likely to encounter medical complications of clozapine during admissions or consultations for other services, hospitalists are compelled to maintain an appreciation for these iatrogenic conditions. The authors outline common (eg, constipation, sialorrhea, weight gain) and serious (eg, agranulocytosis, seizures, myocarditis) medical complications of clozapine treatment, with internist-targeted recommendations for management, including indications for clozapine discontinuation. Journal of Hospital Medicine 2015;10:537–543. © 2015 Society of Hospital Medicine

Some psychiatrists might be a little intimidated by the problem, although consultation psychiatrists might be more comfortable with it. Neurologists probably have an opinion about it, and I’d like to hear from them. Still, I consider the paper a sort of crossroads for doctors regarding who has ownership of clozapine. Arvinder represented ER docs very well.

It was Arvinder’s idea to summarize the major issues for the “smokejumpers” out there because I’ve often characterized myself that way, trying my best to put out fires around the general hospital as a consultation-liaison psychiatrist. Notice I didn’t use the term “Psychosomatic Medicine” specialist. This reminds me of the recent poll from the Academy of Psychosomatic Medicine (APM) about whether we ought to consider again changing the specialty’s name (this has happened in the past).

I just got a new message and a new poll from APM. It turns out that about 68% of the members (a clear majority) agree we should consider a name change. Now they’re asking for our thoughts about what name we would prefer–and “Consultation-Liaison Psychiatry” once again may not be allowed as a choice. Dang. And we even got a new name choice from my poll: “Psychiatry-for-all-the-patients-that-most-psychiatrists-don’t-want-to-work-with.” Don’t forget Ergasiology!

However, we’re coming to a crossroads again, just like APM came to a crossroads about the Janus head logo a few years ago, and there was a crossroads about the subtitle to the Academy of Psychosomatic Medicine name as well. It used to be The Organization for Consultation-Liaison Psychiatry until 2013. It then suddenly became Psychiatrists Providing Collaborative Care Bridging Physical and Mental Health in 2014. Some of us are less than enthusiastic about certain elements of the collaborative care model.

I tried to find out the history of why the Janus head was used from an APM contact, but he couldn’t trace it, even after reviewing old journal covers. He did discover the APM logo wasn’t introduced to the cover until the 2010s. As many know, Janus is the god of beginnings, gates, transitions, passages–crossroads, if you will. And my contact also educated me about the history of APM. Did you know it was started by internists, not psychiatrists? There was even a New Yorker Talk of the Town article about it published in 1954, “The New Style GPs.”

“We went to the Plaza the other afternoon to visit the annual meeting of the Academy of Psychosomatic Medicine, and found the progressive medicos, some seventy-five strong, in perfectly splendid fettle.” 

“…we fell in with Dr. William Kaufman…   We asked him what’s new in psychosomatic medicine.  He replied that the Academy is, for one thing.  It was founded a year ago, by a group of doctors who felt that an existing organization, the American Psychiatric Society, was too Freudian…”

“…The Academy now has nearly a hundred members, including surgeons, internists, pediatricians, obstetricians, and a sprinkling of psychiatrists.  ‘We’re not anti-Freudian; we just don’t want to be doctrinaire.’ ”

William Kaufman was the first APM president. And the conflict between the so-called Freudian membership of the American Psychosomatic Society and the Academy of Psychosomatic Medicine was moderated by Dr. T.N. Wise, past president of both organizations, in “Presidential Address: A Tale of Two Societies:”

Wise, T. N. (1995). “A tale of two societies.” Psychosom Med 57(4): 303-309.
Although consultation-liaison psychiatry grew out of the general hospital psychiatry movement, the American Psychosomatic Society has played a vital role in nurturing the discipline. Through the Society’s journal, Psychosomatic Medicine, and its meetings, consultation psychiatry continues to stay in the mainstream. The subspecialty has developed in both content and strength to merit a focused organization, the Academy of Psychosomatic Medicine. The role of both organizations in the development of consultation-liaison psychiatry is discussed and recommendations for future collaborative activities are suggested.

I hope we weather the next crossroads–all of them.

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