Aggressive and delusional about his alien origins, but refusing treatment
Mr. C, age 23, has persistent hallucinations and delusions, despite 4 trials of antipsychotic medication. He refuses clozapine because of the required weekly blood draws. What would you do next?
The authors’ observations
At times we have instituted all of the methods noted in Table 2. We have most often used dissolving tablets and plasma monitoring.
OUTCOME Improvement, transfer
Mr. C gradually improves over 6 months. The voices, delusions, and aggression resolve. He remains mildly disorganized and has poor insight, with unrealistic goals. Approximately 3 years after admission and 1 year after clozapine was initiated, Mr. C is transferred to a minimum-security facility.
The authors’ observations
Overall, our experience has been successful with the approach we have described. Patients often do not resist the treatment plan once they see our commitment to their well-being. When they do resist, it has been only for 1 to 3 doses of medication, and 1 or 2 blood draws. Of 6 recent cases under this protocol, we have discharged 3; 1 is approaching discharge; 1 has had minimal improvement to date; and 1 required discontinuation because of neutropenia. We recommend considering involuntary clozapine therapy for refractory patients who have a poor prognosis.
Bottom Line
Clozapine is an underutilized treatment for refractory schizophrenia, often because of patient refusal. In a case presentation format we review the barriers to clozapine therapy. We discuss clinical and legal issues for administering clozapine to an unwilling patient.
Related Resources
• Hill M, Freundenrich O. Clozapine: key discussion points for prescribers. Clin Schizophr Relat Psychoses. 2013;6(4):177-185.
• Nielsen J, Correll C, Manu P, et al. Termination of clozapine treatment due to medical reasons: when is it warranted and how can it be avoided? J Clin Psychiatry. 2013;74(6):603-613.
Drug Brand Names
Aripiprazole • Abilify
Polyethylene glycol • MiraLax
Clozapine • Clozaril, FazaClo
ropranolol • Inderal LA
Desmopressin • DDAVP
Quetiapine • Seroquel
Divalproex sodium • Depakote
Risperidone • Risperdal
Haloperidol • Haldol
Sertraline • Zoloft
Lithium • Eskalith, Lithobid
Terazosin • Hytrin
Olanzapine • Zyprexa
Topiramate • Topamax
