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Melissa C. Palmer, PharmD, BCPS, BCPP
Clinical Assistant Professor
University of Missouri-Kansas City School of Pharmacy

“From March 2003 until January 2006, I maintained a deceptive life living in libraries and abandoned buildings.”1 Thus began Bethany Yeiser’s description of her own lived experience as a homeless person with untreated schizophrenia. This journey was presented live as the opening keynote to virtual attendees of the CPNP 2020 Annual Meeting. Bethany’s story, unfortunately, is one that psychiatric pharmacists are accustomed to hearing. A 2019 systematic review and meta-analysis found a high prevalence of schizophrenia in the homeless population, at 10.29% (95% CI 6.44-16.02).2 Many factors contribute to homelessness; deinstitutionalization, reduced mental health treatment access, and lack of support services have all been implicated.3

Bethany’s path to homelessness started with the emergence of what she now recognizes as the prodromal symptoms of schizophrenia. Delusions appeared, followed by hallucinations. In 2007, Bethany was first psychiatrically hospitalized. What followed was a second hospitalization and twelve months of medication trials.1 During this time, a psychiatrist sat down with Bethany and laid out the facts: she was at risk of becoming ever more treatment-resistant. Finally, clozapine was trialed. Bethany reports improvement began within a few days, and she was able to complete a college degree approximately two years later. Bethany also wrote a memoir entitled “Mind Estranged: My Journey from Schizophrenia and Homelessness to Recovery.”

Bethany credits her successful treatment in large part to clozapine, the first atypical antipsychotic. Clozapine has undergone a colored history since its discovery in 1959, even described as “a blend of medical misconceptions, public health scares and accusations of company profiteering.”4 At the time of clozapine’s introduction, it was widely believed that extrapyramidal symptoms were indicative of true antipsychotic effect. Thus, clozapine was not commonly utilized, and trials in the United States were not in development until the 1970s. In 1975, the deaths of 8 patients secondary to agranulocytosis were published. This stymied clinical trials in the United States until the 1980s, with clozapine finally entering the national market in early 1990. Now, clozapine is generally reserved for patients with treatment-resistant schizophrenia despite significant evidence that clozapine should be and is the gold standard pharmacologic treatment.5 It has been estimated that only 5-20% of clozapine-eligible patients receive the drug.6 Bethany is one of those patients, and through management of clozapine’s side effects with agents such as armodafinil for fatigue, she considers herself fully recovered.

Bethany is President of the CURESZ Foundation, a nonprofit dedicated to schizophrenia research and education. Bethany advocates for early use of clozapine and shares her story at events nationwide. We thank her for her powerful presentation at the 2020 Annual Meeting. You may visit her website at http://www.bethanyyeiser.com/ for more information.

References

  1. Yeiser B. My Triumph Over Psychosis: A Journey From Schizophrenia and Homelessness to College Graduate. SCHBUL. 2016;:sbw073. DOI: 10.1093/schbul/sbw073. PubMed PMID: 27217267; PubMed Central PMCID: PMC5581912.
  2. Ayano G, Tesfaw G, Shumet S. The prevalence of schizophrenia and other psychotic disorders among homeless people: a systematic review and meta-analysis. Bmc Psychiatry. 5th ed. 2019;19(1). DOI: 10.1186/s12888-019-2361-7. PubMed PMID: 31775786; PubMed Central PMCID: PMC6880407.
  3. Foster A, Gable J, Buckley J. Homelessness in Schizophrenia. Psychiatric Clin North Am. 2012;35(3):717- 734. DOI: 10.1016/j.psc.2012.06.010. PubMed PMID: 22929875.
  4. Crilly J. The history of clozapine and its emergence in the US market: a review and analysis. Hist Psychiatry. 2007;18(1):39-60. DOI: 10.1177/0957154X07070335. PubMed PMID: 17580753.
  5. Siskind D, McCartney L, Goldschlager R, Kisely S. Clozapine v. first- and second-generation antipsychotics in treatment-refractory schizophrenia: systematic review and meta-analysis. Br J Psychiatry. 2016;209(5):385-392. DOI: 10.1192/bjp.bp.115.177261. PubMed PMID: 27388573.
  6. Olfson M, Gerhard T, Crystal S, Stroup TS. Clozapine for schizophrenia: state variation in evidence-based practice. Psychiatr Serv. 2016;67(2):152. Doi: 10.1176/appi.ps/201500324
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