Treating Unmet Needs in Psychiatry (TUNE-UP): targeted service increases out-patient initiations of clozapine

Background In the UK, clozapine is the only licensed treatment for treatment-resistant schizophrenia (TRS). However, it is underused because initiation is often limited by the need for in-patient admission, which is costly and unattractive to patients. Community clozapine services may address this. Aims To describe a targeted out-patient clinic (Treating Unmet Needs in Psychiatry (TUNE-UP)) for TRS management and assess its impact on community clozapine initiation rates. Method We reviewed clozapine titrations of patients under four community mental health teams from September 2021 to January 2025, recording whether titration occurred as in- or out-patient. The TUNE-UP clozapine clinic operated for 12 months (September 2023 to September 2024). Initiation rates during the TUNE-UP period were compared with those when the service was unavailable, using Poisson regression. Clinical outcomes were assessed using scales including the Positive and Negative Syndrome Scale (PANSS). Results Fifty-one individuals commenced clozapine during the study period. There was a significant increase in the rates of community initiation in the TUNE-UP period (11.0 per year) compared with those outside of this period (1.71 per year; incidence risk ratio 6.42 95% CI 2.04–20.2, P = 0.0015). Patients seen by TUNE-UP showed significant improvements in PANSS ( n = 6, median improvement 21.5 95% CI 7.0–33.0, P = 0.03). Conclusions A specialist service was associated with a significant increase in community clozapine initiations. This approach offers a strategy to improve TRS treatment in the community.