Recent research and guidelines’ recommendations favour clozapine use, probably more than ever, but even though most clinicians remain reluctant prescribing it.

To assess the mismatch between clozapine's treatment indications and prescription rates, discuss the underlying motives for such a discrepancy and possible interventions to reduce the gap.

Promote clozapine use when indicated and raise awareness of the impact in terms of patients’ health and healthcare costs.

A qualitative review of the evidence on clozapine's use.

The response rate to clozapine is approximately 50%, irrespective of non-response to prior treatment and has unique anti-suicidal, anti-aggressive and comorbid substance abuse properties. About one third of schizophrenia patients have treatment-resistant schizophrenia, however only one third are prescribed clozapine and its initiation is 5 years delayed. Doctor's reluctance in prescribing clozapine may be related to its perceptions regarding clozapine's serious side effects and patient's satisfaction. Nevertheless, monitoring serious side effects such as agranulocytosis considerably reduces fatalities and one year after treatment initiation such risk is comparable to other drugs like haloperidol; despite feared side effects with clozapine use, studies showed that clozapine is associated to reduced premature death even compared with those not taking regular medication; most patient's claim to feel better on clozapine, prefer to remain on clozapine and express that the advantages of clozapine outweigh disadvantages.

Clozapine remains the only antipsychotic licensed to treatment-resistant schizophrenia. Despite its clinical superiority, lower costs associated to treatment, patient's preferences and overestimated safety concerns, clozapine remains considerably underused.