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Review

A comprehensive review of the clinical utility of and a combined analysis of the clozapine/norclozapine ratio in therapeutic drug monitoring for adult patients

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Pages 603-621 | Received 28 Mar 2019, Accepted 08 May 2019, Published online: 31 May 2019

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Read on this site (5)

Carlos De Las Cuevas, Emilio J. Sanz, Alejandro G. Villasante-Tezanos & Jose de Leon. (2023) Respiratory aspiration during treatment with clozapine and other antipsychotics: a literature search and a pharmacovigilance study in vigibase. Expert Opinion on Drug Metabolism & Toxicology 19:2, pages 57-74.
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Ian McGrane, Edoardo Spina, Christoph Hiemke & Jose de Leon. (2022) Pharmacokinetic drug interactions with oral haloperidol in adults: dose correction factors from a combined weighted analysis. Expert Opinion on Drug Metabolism & Toxicology 18:2, pages 135-149.
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Espen Molden. (2021) Therapeutic drug monitoring of clozapine in adults with schizophrenia: a review of challenges and strategies. Expert Opinion on Drug Metabolism & Toxicology 17:10, pages 1211-1221.
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Renato de Filippis, Pau Soldevila-Matías, Pasquale De Fazio, Daniel Guinart, Inmaculada Fuentes-Durá, Jose M. Rubio, John M. Kane & Georgios Schoretsanitis. (2020) Clozapine-related drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome: a systematic review. Expert Review of Clinical Pharmacology 13:8, pages 875-883.
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Articles from other publishers (56)

Carlos De las Cuevas, Emilio J. Sanz, Jason A. Gross, Christoph U. Correll, Hélène Verdoux, John Lally, Renato de Filippis, Peter F.J. Schulte, Espen Molden, Manuel Arrojo-Romero, Adrian D. Bostrom, Georgios Schoretsanitis, Emilio Fernandez-Egea & Jose de Leon. (2023) Revealing the reporting disparity: VigiBase highlights underreporting of clozapine in other Western European countries compared to the UK. Schizophrenia Research.
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Sara Jiménez-Fernández, Manuel Gurpegui, Christoph U. Correll, Jose de Leon & Georgios Schoretsanitis. (2023) A Systematic Review of Clozapine Concentration–Dose Ratio from Therapeutic Drug Monitoring Studies in Children and Adolescents Treated with Clozapine for Mental Disorders. Therapeutic Drug Monitoring.
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Jonathan M. Meyer. (2023) Making sense of norclozapine levels: 3 clinical axioms. Schizophrenia Research.
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Bojana Panić, Marija Jovanović, Vera Lukić, Katarina Vučićević, Branislava Miljković & Srđan Milovanović. (2023) Association of clozapine and norclozapine levels with patient and therapy characteristics—focus on interaction with valproic acid. European Journal of Clinical Pharmacology 79:11, pages 1557-1564.
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Seonghyeon Ryu & Gyeonghyeong Cho. (2023) Clozapine Dose-Concentration Relationship and Other Factors Associated With Clozapine Plasma Concentration in Korean Schizophrenia Patients. Korean Journal of Schizophrenia Research 26:2, pages 46-51.
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Jose de Leon, Georgios Schoretsanitis, Robert L. Smith, Espen Molden, Anssi Solismaa, Niko Seppälä, Miloslav Kopeček, Patrik Švancer, Ismael Olmos, Carina Ricciardi, Celso Iglesias-Garcia, Ana Iglesias-Alonso, Edoardo Spina, Can-Jun Ruan, Chuan-Yue Wang, Gang Wang, Yi-Lang Tang, Shih-Ku Lin, Hsien-Yuan Lane, Yong Sik Kim, Se Hyun Kim, Anto P. Rajkumar, Dinora F. González-Esquivel, Helgi Jung-Cook, Trino Baptista, Christopher Rohde, Jimmi Nielsen, Hélène Verdoux, Clelia Quiles, Emilio J. Sanz, Carlos De las Cuevas, Dan Cohen, Peter F.J. Schulte, Aygün Ertuğrul, A. Elif Anıl Yağcıoğlu, Nitin Chopra, Betsy McCollum, Charles Shelton, Robert O. Cotes, Arun R. Kaithi, John M. Kane, Saeed Farooq, Chee H. Ng, John Bilbily, Christoph Hiemke, Carlos López-Jaramillo, Ian McGrane, Fernando Lana, Chin B. Eap, Manuel Arrojo-Romero, Flavian Ştefan Rădulescu, Erich Seifritz, Susanna Every-Palmer, Chad A. Bousman, Emmanuel Bebawi, Rahul Bhattacharya, Deanna L. Kelly, Yuji Otsuka, Judit Lazary, Rafael Torres, Agustin Yecora, Mariano Motuca, Sherry Kit Wa Chan, Monica Zolezzi, Sami Ouanes, Domenico De Berardis, Sandeep Grover, Ric M. Procyshyn, Richard A. Adebayo, Oleg O. Kirilochev, Andrey Soloviev, Konstantinos N. Fountoulakis, Alina Wilkowska, Wiesław Jerzy Cubała, Muhammad Ayub, Alzira Silva, Raphael M. Bonelli, José María Villagrán-Moreno, Benedicto Crespo-Facorro, Henk Temmingh, Eric Decloedt, Maria Rosel Pedro, Hiroyoshi Takeuchi, Masaru Tsukahara, Gerhard Gründer, Marina Sagud, Andreja Celofiga, Dragana Ignjatovic Ristic, Bruno Bertolucci Ortiz, Helio Elkis, António José Pacheco Palha, Adrián Llerena, Emilio Fernandez-Egea, Dan Siskind, Abraham Weizman, Rim Masmoudi, Shamin Mohd Saffian, Jonathan G. Leung, Peter F. Buckley, Stephen R. Marder, Leslie Citrome, Oliver Freudenreich, Christoph U. Correll & Daniel J. Müller. (2023) Guía internacional para una dosificación más segura de la clozapina en adultos mediante el uso de 6 titulaciones personalizadas de dosis basados en la etnicidad, la proteína C reactiva y los niveles de clozapina. Psiquiatría Biológica 30:3, pages 100415.
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Can-Jun Ruan, Ismael Olmos, Carina Ricciardi, Georgios Schoretsanitis, Philippe D. Vincent, A. Elif Anıl Yağcıoğlu, Chin B. Eap, Trino Baptista, Scott R. Clark, Emilio Fernandez-Egea, Se Hyun Kim, Hsien-Yuan Lane, Jonathan Leung, Olalla Maroñas Amigo, Mariano Motuca, Susanna Every-Palmer, Ric M. Procyshyn, Christopher Rohde, Satish Suhas, Peter F.J. Schulte, Edoardo Spina, Hiroyoshi Takeuchi, Hélène Verdoux, Christoph U. Correll, Espen Molden, Carlos De Las Cuevas & Jose de Leon. (2023) Exploring low clozapine C/D ratios, inverted clozapine-norclozapine ratios and undetectable concentrations as measures of non-adherence in clozapine patients. Schizophrenia Research.
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Georgios Schoretsanitis, A. Elif Anıl Yağcıoğlu, Can-Jun Ruan, Chin B. Eap, Espen Molden, Trino Baptista, Scott R. Clark, Emilio Fernandez-Egea, Se Hyun Kim, Hsien-Yuan Lane, Jonathan Leung, Olalla Maroñas Amigo, Mariano Motuca, Ismael Olmos, Susanna Every-Palmer, Ric M. Procyshyn, Christopher Rohde, Suhas Satish, Peter F.J. Schulte, Edoardo Spina, Hiroyoshi Takeuchi, Hélène Verdoux, Christoph U. Correll & Jose de Leon. (2023) Clozapine ultrarapid metabolism during weak induction probably exists but requires careful diagnosis. A literature review, five new cases and a proposed definition. Schizophrenia Research.
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Carlos De las Cuevas, Emilio J. Sanz & Jose de Leon. (2023) Adverse drug reactions and their fatal outcomes in clozapine patients in VigiBase: Comparing the top four reporting countries (US, UK, Canada and Australia). Schizophrenia Research.
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Carla Lou Morgenroth, Philipp Kleymann, Stephan Ripke, Swapnil Awasthi, Elias Wagner, Tatiana Oviedo-Salcedo, Cynthia Okhuijsen-Pfeifer, Jurjen J. Luykx, Marte Z. van der Horst, Alkomiet Hasan, Felix Bermpohl, Stefan Gutwinski & Stefanie Schreiter. (2023) Polygenetic risk scores and phenotypic constellations of obsessive–compulsive disorder in clozapine-treated schizophrenia. European Archives of Psychiatry and Clinical Neuroscience.
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Suzanne Reeves, Julie Bertrand, Stephen John Obee, Samora Hunter, Robert Howard & Robert James Flanagan. (2023) A population pharmacokinetic model to guide clozapine dose selection, based on age, sex, ethnicity, body weight and smoking status. British Journal of Clinical Pharmacology.
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Robert James Flanagan, Samora Hunter, Stephen John Obee & Suzanne Reeves. (2023) Clozapine. Journal of Clinical Psychopharmacology 43:2, pages 131-138.
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Jonathan G. Leung. (2023) Part II : Interactive case—Clinical pearls of clozapine . JACCP: JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 6:3, pages 312-318.
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Jonathan F. Lister & Kara R. Wong. (2023) Part I: Interactive case—Precision medicine in psychiatry. JACCP: JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 6:3, pages 307-311.
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Mishal Qubad & Robert A. Bittner. (2023) Second to none: rationale, timing, and clinical management of clozapine use in schizophrenia. Therapeutic Advances in Psychopharmacology 13, pages 204512532311581.
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Filippo Pennazio, Claudio Brasso, Vincenzo Villari & Paola Rocca. (2022) Current Status of Therapeutic Drug Monitoring in Mental Health Treatment: A Review. Pharmaceutics 14:12, pages 2674.
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Jonathan G. Leung, Jose de Leon, Mark A. Frye, Balwinder Singh, Robert O. Cotes & Susan L. McElroy. (2022) The Modernization of Clozapine. Journal of Clinical Psychopharmacology 42:6, pages 565-580.
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K.N. Roy Chengappa, Jane Thomas, Charles E. Kahn, Kimberly Clinebell, Kelly K. Mullen, Lori Arbutiski & Emil Ivanov. (2022) COVID-19 infection, fluctuations in the clozapine/norclozapine levels and metabolic ratio and clozapine toxicity: An illustrative case-report. Schizophrenia Research 244, pages 66-68.
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Pasindu Wickramarachchi, Jessica M. Boyd & Dennis J. Orton. (2022) Biological variation in clozapine and metabolite reporting during therapeutic drug monitoring. Clinica Chimica Acta 531, pages 183-187.
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Deepak K. Sarpal, Annie Blazer, James D. Wilson, Finnegan J. Calabro, William Foran, Charles E. Kahn, Beatriz Luna & K.N. Roy Chengappa. (2022) Relationship between plasma clozapine/N-desmethylclozapine and changes in basal forebrain-dorsolateral prefrontal cortex coupling in treatment-resistant schizophrenia. Schizophrenia Research 243, pages 170-177.
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Jose de Leon. (2022) Precision psychiatry: The complexity of personalizing antipsychotic dosing. European Neuropsychopharmacology 58, pages 80-85.
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Jose de Leon, Georgios Schoretsanitis, Robert L. Smith, Espen Molden, Anssi Solismaa, Niko Seppälä, Miloslav Kopeček, Patrik Švancer, Ismael Olmos, Carina Ricciardi, Celso Iglesias-Garcia, Ana Iglesias-Alonso, Edoardo Spina, Can-Jun Ruan, Chuan-Yue Wang, Gang Wang, Yi-Lang Tang, Shih-Ku Lin, Hsien-Yuan Lane, Yong Sik Kim, Se Hyun Kim, Anto P. Rajkumar, Dinora F. González-Esquivel, Helgi Jung-Cook, Trino Baptista, Christopher Rohde, Jimmi Nielsen, Hélène Verdoux, Clelia Quiles, Emilio J. Sanz, Carlos De Las Cuevas, Dan Cohen, Peter F.J. Schulte, Aygün Ertuğrul, A. Elif Anıl Yağcıoğlu, Nitin Chopra, Betsy McCollum, Charles Shelton, Robert O. Cotes, Arun R. Kaithi, John M. Kane, Saeed Farooq, Chee H. Ng, John Bilbily, Christoph Hiemke, Carlos López-Jaramillo, Ian McGrane, Fernando Lana, Chin B. Eap, Manuel Arrojo-Romero, Flavian Ş. Rădulescu, Erich Seifritz, Susanna Every-Palmer, Chad A. Bousman, Emmanuel Bebawi, Rahul Bhattacharya, Deanna L. Kelly, Yuji Otsuka, Judit Lazary, Rafael Torres, Agustin Yecora, Mariano Motuca, Sherry K.W. Chan, Monica Zolezzi, Sami Ouanes, Domenico De Berardis, Sandeep Grover, Ric M. Procyshyn, Richard A. Adebayo, Oleg O. Kirilochev, Andrey Soloviev, Konstantinos N. Fountoulakis, Alina Wilkowska, Wiesław J. Cubała, Muhammad Ayub, Alzira Silva, Raphael M. Bonelli, José M. Villagrán-Moreno, Benedicto Crespo-Facorro, Henk Temmingh, Eric Decloedt, Maria R. Pedro, Hiroyoshi Takeuchi, Masaru Tsukahara, Gerhard Gründer, Marina Sagud, Andreja Celofiga, Dragana Ignjatovic Ristic, Bruno B. Ortiz, Helio Elkis, António J. Pacheco Palha, Adrián LLerena, Emilio Fernandez-Egea, Dan Siskind, Abraham Weizman, Rim Masmoudi, Shamin Mohd Saffian, Jonathan G. Leung, Peter F. Buckley, Stephen R. Marder, Leslie Citrome, Oliver Freudenreich, Christoph U. Correll & Daniel J. Müller. (2021) An International Adult Guideline for Making Clozapine Titration Safer by Using Six Ancestry-Based Personalized Dosing Titrations, CRP, and Clozapine Levels. Pharmacopsychiatry 55:02, pages 73-86.
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Shiri Kamhi-Nesher, Sharon Taub, Shikma Halimi, Maria Frenkel, Mahmud Azam, Gil Bormant, Helena Isakov, Dikla Radzinsky, Abraham Weizman & Amir Krivoy. (2022) Clozapine blood level assessment using a point-of-care device: feasibility and reliability. Therapeutic Advances in Psychopharmacology 12, pages 204512532210944.
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Robert Løvsletten Smith, Birgit M. Wollmann, Lennart Kyllesø, Thu Thuy Anh Tran, Marit Tveito & Espen Molden. (2022) Effect of Valproic Acid on the Metabolic Spectrum of Clozapine in Patients With Schizophrenia. Journal of Clinical Psychopharmacology 42:1, pages 43-50.
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Sandeep Grover, Kripa Shanker Kasudhan, Naveen Murali, Amol N. Patil, Smita Pattanaik, Subho Chakrabarti & Ajit Avasthi. (2022) Pharmacometabolomics-guided clozapine therapy in treatment resistant schizophrenia: Preliminary exploration of future too near. Asian Journal of Psychiatry 67, pages 102939.
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Kenneth H. Wills, Stephen J. Behan, Michael J. Nance, Jessica L. Dawson, Thomas M. Polasek, Ashley M. Hopkins, Madelé van Dyk & Andrew Rowland. (2021) Combining Therapeutic Drug Monitoring and Pharmacokinetic Modelling Deconvolutes Physiological and Environmental Sources of Variability in Clozapine Exposure. Pharmaceutics 14:1, pages 47.
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David M. Taylor, Thomas R. E. Barnes & Allan H. Young. 2021. The Maudsley Prescribing Guidelines in Psychiatry. The Maudsley Prescribing Guidelines in Psychiatry 833 864 .
Yasin BezSindhura KompellaFelicia GallucciAdam AwerbuchBarbara J. Coffey. (2021) Clinical Use of Clozapine Serum Level and Management of Adverse Effects in an Adolescent with Difficult to Treat Schizophrenia. Journal of Child and Adolescent Psychopharmacology 31:10, pages 699-703.
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F. Martini, M. Spangaro, M. Bechi, M. Buonocore, G. Agostoni, F. Cuoco, M. Bosia & R. Cavallaro. (2021) P.0782 Clozapine to N-Desmethylclozapine ratio in treatment resistant schizophrenia: clinical implications from psychopathology to cognition. European Neuropsychopharmacology 53, pages S571.
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Jonathan M. Meyer & Stephen M. Stahl. 2021. The Clinical Use of Antipsychotic Plasma Levels. The Clinical Use of Antipsychotic Plasma Levels 249 266 .
Georgios Schoretsanitis, Maxim Kuzin, John M. Kane, Christoph Hiemke, Michael Paulzen & Ekkehard Haen. (2021) Authors’ Reply to Suhas et al.: Comment on: “Elevated Clozapine Concentrations in Clozapine-Treated Patients with Hypersalivation”. Clinical Pharmacokinetics 60:8, pages 1077-1079.
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Hitoshi Watanabe, Kyoji Ishida, Masanori Yamamoto, Tomokazu Nakako, Masakuni Horiguchi & Yoshiaki Isobe. (2021) Identification of 2-fluoro-8-methyl-11-(1-methyl-1,2,3,6-tetrahydropyridin-4-yl)-5H-dibenzo[b,e][1,4]diazepine with clozapine-like mixed activities at muscarinic acetylcholine, dopamine, and serotonin receptors. Bioorganic & Medicinal Chemistry Letters 40, pages 127911.
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Maxim Kuzin, Ekkehard Haen, Christoph Hiemke, Benjamin Bochon, Karolina Bochon, Gerhard Gründer, Michael Paulzen & Georgios Schoretsanitis. (2021) Body mass index as a determinant of clozapine plasma concentrations: A pharmacokinetic-based hypothesis. Journal of Psychopharmacology 35:3, pages 273-278.
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Georgios Schoretsanitis, Robert L. Smith, Espen Molden, Anssi Solismaa, Niko Seppälä, Miloslav Kopeček, Patrik Švancer, Ismael Olmos, Marta Vázquez, Celso Iglesias-Garcia, Ana Iglesias-Alonso, Edoardo Spina & Jose de Leon. (2021) European Whites May Need Lower Minimum Therapeutic Clozapine Doses Than Those Customarily Proposed. Journal of Clinical Psychopharmacology 41:2, pages 140-147.
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Georgios Schoretsanitis, Maxim Kuzin, John M. Kane, Christoph Hiemke, Michael Paulzen & Ekkehard Haen. (2020) Elevated Clozapine Concentrations in Clozapine-Treated Patients with Hypersalivation. Clinical Pharmacokinetics 60:3, pages 329-335.
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Madeleine S. A. Tan, Faraz Honarparvar, James R. Falconer, Harendra S. Parekh, Preeti Pandey & Dan J. Siskind. (2021) A systematic review and meta-analysis of the association between clozapine and norclozapine serum levels and peripheral adverse drug reactions. Psychopharmacology 238:3, pages 615-637.
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Domenico De Berardis, Gabriella Rapini, Luigi Olivieri, Agostina Giardini, Ida De Lauretis, Nicola Serroni, Laura Orsolini, Michele Fornaro, Felice Iasevoli, Sabatino Trotta, Paolo Cottura, Federica Vellante, Marco Alessandrini & Massimo Di Giannantonio. (2021) Cariprazine Add-on in Inadequate Clozapine Response: A Report on Two Cases. Clinical Psychopharmacology and Neuroscience 19:1, pages 174-178.
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Niels TioPeter F.J. SchulteHarrie J.M. Martens. (2021) Clozapine Intoxication in COVID-19. American Journal of Psychiatry 178:2, pages 123-127.
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Amir Krivoy, Eromona Whiskey, Henrietta Webb-Wilson, Dan Joyce, Derek K. Tracy, Fiona Gaughran, James H. MacCabe & Sukhwinder S. Shergill. (2021) Outcomes in treatment-resistant schizophrenia: symptoms, function and clozapine plasma concentrations. Therapeutic Advances in Psychopharmacology 11, pages 204512532110371.
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Shirlee Daniela Solomon, Valerie Powell, Marcos Sanches, Carol Borlido, Leah Burton, Vincenzo De Luca, Tarek Rajji & Gary Remington. (2021) Reliability of the Clozapine: N -Desmethylclozapine (CLZ:NDMC) Ratio . Schizophrenia Bulletin Open 2:1.
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Royun Park, Seoyoung Kim & Euitae Kim. (2020) Relationship of Change in Plasma Clozapine/N-desmethylclozapine Ratio with Cognitive Performance in Patients with Schizophrenia. Psychiatry Investigation 17:11, pages 1158-1165.
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Rajendra P. Shukla, Crystal Rapier, Matthew Glassman, Fang Liu, Deanna L. Kelly & Hadar Ben-Yoav. (2020) An integrated electrochemical microsystem for real-time treatment monitoring of clozapine in microliter volume samples from schizophrenia patients. Electrochemistry Communications 120, pages 106850.
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Hitoshi Watanabe, Kyoji Ishida, Masanori Yamamoto, Masakuni Horiguchi & Yoshiaki Isobe. (2020) Synthesis and pharmacological evaluation of 11-(1,6-dimethyl-1,2,3,6-tetrahydropyridin-4-yl)-5H-dibenzo[b,e][1,4]diazepines with clozapine-like receptor occupancy at dopamine D1/D2 receptor. Bioorganic & Medicinal Chemistry Letters 30:21, pages 127563.
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Maxim Kuzin, Georgios Schoretsanitis, Ekkehard Haen, Florian Ridders, Christoph Hiemke, Gerhard Gründer & Michael Paulzen. (2020) Pharmacokinetic interactions between clozapine and sertraline in smokers and non‐smokers. Basic & Clinical Pharmacology & Toxicology 127:4, pages 303-308.
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Tiffany Buckley, Christopher Kitchen, Gopal Vyas, Nathan A. Siegfried, Eshetu Tefera, Shuo Chen, Bethany A. DiPaula & Deanna L. Kelly. (2020) Comparison of Novel Immunoassay With Liquid Chromatography/Tandem Mass Spectrometry (LC-MS/MS) for Therapeutic Drug Monitoring of Clozapine. Therapeutic Drug Monitoring 42:5, pages 771-777.
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Y. W. Francis Lam. (2020) Oral contraceptives and clozapine. The Brown University Psychopharmacology Update 31:8, pages 2-3.
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Jose Leon, Georgios Schoretsanitis, John M. Kane & Can‐Jun Ruan. (2020) Using therapeutic drug monitoring to personalize clozapine dosing in Asians. Asia-Pacific Psychiatry 12:2.
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Ebenezer Oloyede, Olubanke Dzahini, Eromona Whiskey & David Taylor. (2020) Clozapine and Norclozapine Plasma Levels in Patients Switched Between Different Liquid Formulations. Therapeutic Drug Monitoring 42:3, pages 491-496.
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Georgios Schoretsanitis, John M. Kane & Jose de Leon. (2020) Adding Oral Contraceptives to Clozapine May Require Halving the Clozapine Dose. Journal of Clinical Psychopharmacology 40:3, pages 308-310.
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Jose de Leon. (2020) Personalizing dosing of risperidone, paliperidone and clozapine using therapeutic drug monitoring and pharmacogenetics. Neuropharmacology 168, pages 107656.
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Can-Jun Ruan & Jose de Leon. (2020) Is there a future for CYP1A2 pharmacogenetics in the optimal dosing of clozapine? . Pharmacogenomics 21:6, pages 369-373.
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Georgios Schoretsanitis, Alan Mendelowitz, Chitra Malur, Raphael J. Braga, Nina R. Schooler, Majnu John, Jose de Leon, John M. Kane & Georgios Petrides. (2020) Lack of ECT effects on clozapine plasma levels in patients with treatment-resistant schizophrenia: Pharmacokinetic evidence from a randomized clinical trial. Schizophrenia Research 218, pages 309-311.
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Jose de Leon. (2020) Future Studies on the Interaction Between Clozapine and Valproic Acid Should Aspire to Include Longitudinal Designs and Free Valproate Concentrations, and Should Consider that Inducer and/or Inhibitory Effects May Vary With Time, the Individual, and the Auto-Induction of Valproic Acid. Therapeutic Drug Monitoring 42:1, pages 159-161.
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Jose de Leon, Can-Jun Ruan, Georgios Schoretsanitis & John M. Kane. (2020) Dose and safety concerns of clozapine: Worldwide package inserts need revisions. Schizophrenia Research 216, pages 2-4.
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Jose de Leon, Can-Jun Ruan, Georgios Schoretsanitis & Carlos De las Cuevas. (2020) A Rational Use of Clozapine Based on Adverse Drug Reactions, Pharmacokinetics, and Clinical Pharmacopsychology. Psychotherapy and Psychosomatics 89:4, pages 200-214.
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