Yes it should

Bhattacherjee et al ask ‘Should intramuscular clozapine be adopted into mainstream clinical practice?’ The answer is ‘yes’. As they point out, clozapine is the only treatment likely to work for people with treatment-resistant schizophrenia (TRS) and has a number of other benefits. However, concerns about long-term compliance, side-effects, and safety are misguided and not supported by evidence. Rather, there is ample evidence to the contrary.¹ Intramuscular clozapine has only been used in the UK since 2017, and initial use was not confined to high-security or other forensic sites. I was co-author of the first UK case series.² We reported the use of 188 doses in a mixture of both secure settings and a rehabilitation unit, and the SLaM study included only one patient on a forensic unit. It has been used elsewhere in the world on many occasions. None of the cases series of intramuscular clozapine report significant side-effects other than injection-site pain, which as any recipient of the recent COVID vaccinations will know, is normal for even a small-volume intramuscular injection. I am confused that Bhattacherjee prefaces the observation that most of the patients prescribed intramuscular clozapine opted for oral instead with a ‘however’. This is fantastic; the usual number of intramuscular doses of clozapine was nil. That does not seem like a problem to me and perhaps on reflection, we have all observed that when medication is enforced, this is what most patients do. For me a problem is waiting for years to prescribe clozapine for spurious reasons, while patients remain distressed and detained. I agree that intramuscular clozapine should be administered carefully, with training, clinical governance, and legal and ethical safeguards, as is required with the use of any medical treatment. That intramuscular clozapine is an unlicensed preparation is correct. Many unlicensed ‘specials’ are used throughout medical practice including, for example, melatonin oral solution as available in the Cumbria, Northumberland, Tyne and Wear NHS FT Pharmacological Therapy Policy. Obviously, the incorrect or even the correct administration of any medication can have untoward consequences, and the right medication should always be given to the right patient at the right time, with the right dose and route. Availability problems are common with drug supply, and initiating clozapine with the option of the intramuscular route is always a carefully planned out process; sadly, there may already have been delays of a decade or more prior to an assertive approach.³ Since clozapine is reserved for TRS, it is a conflation to suggest the use of intramuscular olanzapine, which is also not readily available in the UK, or haloperidol. As for expense, the usual cost of intramuscular clozapine is £0.00 (for international readers, $0.00).