International Journal of Law and Psychiatry
Compulsory treatment with clozapine: A retrospective long-term cohort study
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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