Adult psychiatrists’ views on clozapine prescribing for schizophrenia in Germany-an online survey

Ther Adv Psychopharmacol. 2026 Apr 17;16:20451253261434380. doi: 10.1177/20451253261434380. eCollection 2026.

ABSTRACT

BACKGROUND: Clozapine remains the only effective antipsychotic drug for treatment-resistant schizophrenia (TRS), yet it continues to be markedly underused in most industrialized countries including Germany. Previous studies have identified prescriber-related factors such as concerns about adverse drug reactions, the burden of mandatory monitoring, and limited experience with clozapine use and TRS recognition as major contributors to this persistent underutilization. However, these issues have not been studied for the German healthcare system.

OBJECTIVES: To investigate prescriber attitudes toward clozapine use for schizophrenia in Germany and identify related treatment barriers.

DESIGN: Cross-sectional, web-based survey study.

METHODS: We conducted a web-based cross-sectional survey using PsyToolkit. Our questionnaire assessed clinicians’ demographics, familiarity with relevant national guidelines, practical experience with clozapine and formalized training in its use, perceived treatment barriers, and presumptions about patients’ attitudes toward clozapine. Data were predominantly analyzed descriptively.

RESULTS: A total of 155 psychiatrists-most of them board-certified and nearly all regular clozapine prescribers for schizophrenia-completed the survey. Most participants were familiar with guideline recommendations for clozapine initiation. However, even among them, most preferred to attempt at least one trial of antipsychotic polypharmacy before starting clozapine. Formalized training had a positive impact on knowledge regarding clozapine’s effectiveness in reducing negative symptoms, aggressive behavior, and suicidality. While most participants acknowledged clozapine’s effectiveness in reducing all-cause mortality, only a small proportion of participants acknowledged its effectiveness in reducing cardiovascular mortality. Notably, three quarters of participants presumed that patients would prefer standard antipsychotics over clozapine. Monitoring requirements and concerns regarding weight gain and blood dyscrasia were ranked as the main barriers impeding clozapine use.

CONCLUSION: We identified several modifiable prescriber-related factors limiting clozapine use for schizophrenia in Germany. Implementing mandatory targeted training programs during residency and regular use of shared decision-making to emphasize the patients’ perspective might facilitate a timelier and widespread use of clozapine.

PMID:42028371 | PMC:PMC13100437 | DOI:10.1177/20451253261434380