Underprescription of Clozapine: A Narrative Review Regarding 'Clozaphobia'

This review aims to examine the appropriateness of the term 'clozaphobia' to characterise the obstacles contributing to the underprescription of clozapine (CLZ). English-language, peer-reviewed studies addressing clinicians', patients' and/or carers' attitudes toward CLZ were considered eligible for full-text review. In May 2025, a search was conducted using the keywords clozapine, clozaphobia, fear*, underus*, underprescri*, underutiliz*, and barrier*, restricted to titles and abstracts on PubMed, Web of Science, Scopus, and Cochrane. A total of 362 records were retrieved, and 30 records were identified through backward citation searching. After screening, 53 studies were eligible for review. This review identified several barriers to CLZ use, which were grouped into three broad domains: clinician-related, medication- and patient-related, and administrative-related barriers. Key barriers included difficulties in recognising Treatment-Resistant Schizophrenia (TRS) and identifying candidates for CLZ, lack of training and confidence, negative attitudes toward CLZ, variability in treatment pathways, concerns about CLZ's adverse effects, and challenges in convincing carers of the need for CLZ, insufficient resources, unclear professional roles, and fragmentation of services. The vast majority of identified barriers stem from misconceptions or negative attitudes toward CLZ, which unjustifiably limit patient access to this effective treatment, and can be addressed through the implementation of existing facilitating strategies. In such contexts, the term clozaphobia seems appropriate and its use may help to raise awareness and promote critical reflexion on this subject. With the end of the clozapine risk evaluation and mitigation strategy, it is now time to push society to start producing higher dose pills and a long-acting injectable version of clozapine.