Trainee psychiatrists’ views on clozapine prescribing in Ireland

Abstract Background: Clozapine is the only licensed medication with established efficacy for treatment-resistant schizophrenia (TRS), yet it remains underutilised internationally. Delayed initiation is associated with poorer clinical outcomes, and clinician-related factors contribute to underuse. Limited research has examined trainee psychiatrists’ knowledge and experience of clozapine prescribing. Methods: A cross-sectional online survey was distributed via the College of Psychiatrists of Ireland to approximately 500 psychiatry trainees between June 2024 and January 2025. The questionnaire assessed clinical experience, knowledge, confidence in clozapine management and perceived barriers to initiation. Results: Seventy-four trainee psychiatrists completed the survey (response rate 14.8%). Most respondents had clinical exposure to clozapine; but fewer than one-third reported receiving specific clinical training. Knowledge regarding the indication for clozapine in TRS was strong, while knowledge relating to therapeutic drug monitoring, dosing and agranulocytosis risk was more variable. Respondents reported positive attitudes towards clozapine’s effectiveness and safety. Confidence was highest in identifying TRS and monitoring mental health during treatment, but was lower for physical health monitoring, managing adverse-effects, discontinuation and rechallenge. Perceived barriers included concerns regarding adherence, blood monitoring requirements, adverse effects, and delays associated with hospital admission. Most respondents reported insufficient training in clozapine prescribing. Conclusions: Respondents reported positive perceptions of clozapine and good knowledge of its indication for TRS, although practical prescribing knowledge appeared more variable. Most reported limited formal training and low confidence in several practical aspects of clozapine management. Structured clozapine education and supervised clinical experience may improve trainee confidence and preparedness for clozapine prescribing.