Elsevier

International Journal of Law and Psychiatry

Volume 30, Issue 6, November–December 2007, Pages 539-545
International Journal of Law and Psychiatry

Compulsory treatment with clozapine: A retrospective long-term cohort study

https://doi.org/10.1016/j.ijlp.2007.09.003Get rights and content

Abstract

Background

Clozapine is the gold standard in treatment of treatment-resistant psychotic patients. We know little about the effects of compulsory treatment in patients unwilling to accept the necessary treatment.

Aims

To assess the effectiveness, tolerability and safety of compulsory treatment with clozapine (CTC).

Method

A cohort of 17 consecutive patients given compulsory treatment with clozapine were rated retrospectively by their treating psychiatrists on the basis of their case notes.

Results

CGI-S decreased significantly over time until last observation after a mean of more than 15 months. No patient deteriorated as measured by CGI-I. At last observation as many as ten of the 11 patients still on clozapine were classified as much to very much improved. The degree of custodial restriction at last observation showed improvement in 11 patients and no change in six. No serious adverse events were observed.

Conclusion

A trial of compulsory treatment with clozapine showed this treatment to be feasible, effective, safe and well tolerated.

Introduction

Even after the advent of the new atypical antipsychotics, clozapine is still the gold standard in treatment of treatment-resistant and partially responsive schizophrenia and schizoaffective disorder (American Psychiatric Association, 2004, Schulte, 2001). It shows a superior effect on aggression and suicidality (Meltzer et al., 2003, Volavka et al., 2004). Clozapine should therefore always be offered to patients with serious treatment–refractory psychotic illness. Unfortunately lack of insight leading to rejection of antipsychotic medication is a frequent phenomenon amongst psychotic patients, especially under the most seriously affected. A literature search revealed only two publications on compulsory restart of clozapine after refusal (Lokshin et al., 1999, McLean and Juckes, 2001).

We intended to investigate the effectiveness, tolerability and safety of CTC in patients without earlier treatment with clozapine. A prospective randomised trial in this severely ill, uncooperative and often incapable patient group with a high risk for violence and suicide did not seem feasible and would have been open to severe ethical objections. Even an active control group with a nonclozapine antipsychotic seemed impracticable since clozapine was judged the only appropriate drug in these patients, mainly because of refractory psychotic illness. We therefore decided to evaluate a cohort of CTC patients retrospectively, by chart review.

Section snippets

Design and inclusion criteria

All psychiatrists of the ClozapinePlusCollaborationGroup (CPCG), a Dutch group for study and consultation with regard to clozapine and therapy–refractory psychotic patients, were asked whether they had treated patients compulsorily with clozapine. Under Dutch legislation, compulsory treatment can be administered when patients pose a serious threat to themselves, others or their environment. These patients are normally assaultive or suicidal, mutilate themselves or are seriously deteriorating

Results

Seven psychiatrists reported on 17 patients who had been treated compulsorily with clozapine in the period from January 1998 to July 2003. There were no other psychiatrists in the CPCG who had had experience with this situation. The seven reporting psychiatrists stated that they were quite sure that they remembered all patients to whom they had given compulsory treatment with clozapine during the above-mentioned period and had evaluated the effects of this treatment. Therefore the patient group

Good effect of CTC in the majority of patients

The results of this naturalistic long-term study show that in a clozapine naive cohort of 17 patients with serious chronic psychotic disorders a compulsory trial with clozapine turned out to be feasible, effective, safe and well tolerated.

The amount of coercion was rather low. Seven patients never needed to be given an injection. Only three patients required physical constraint to administer the clozapine injection. Eight out of 17 patients (47%) were considered responders at the end of the

Conclusion

In assessing the long-term efficacy of medication, randomised placebo-controlled trials are generally considered the most robust method. In a population like our cohort of severely ill, uncooperative and often incapable patients with a high risk for violence and suicide, it is not very probable that such a study will be conducted in the near future. Even a prospective naturalistic study will be hampered by difficulties in obtaining informed consent for a study of compulsory treatment. While a

Acknowledgments

We would like to thank Mrs M.A. Nugter, M.A., Ph.D., for her help and advice with statistical calculations and Mr R. Jokhoe, M.D., for registration of data for one patient.

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