TREATMENT Involuntary clozapine
Mr. C continues to believe that he is an alien. He also thinks he is involved in a mission for God. He has physically assaulted staff on occasion. Overall, his mood shows no persistent abnormality and his sleep and appetite are normal. Family history reveals that Mr. C’s brother has schizophrenia. Because of Mr. C’s refractory illness, we seek the guardian’s consent for a trial of clozapine and ask for permission to give backup medication and lab testing involuntarily if necessary.
We obtain informed consent and orders are written. Mr. C refuses the first 2 doses of clozapine (12.5 mg at bedtime) and receives a backup order of IM olanzapine, 5 mg. He initially refuses baseline and 1-week hematology profiles, which then are obtained involuntarily by manual hold. Subsequently, Mr. C no longer refused medication or lab tests. His clozapine dosage is titrated to 400 mg/d, guided by clinical response and plasma level.
The authors’ observations
We work in a public forensic psychiatry facility, where the average length of stay is 680 days. In a public psychiatry facility there may be pressure to reduce the length of stay by moving patients to a less restrictive setting and thereby reducing the overall census. Many patients at our facility likely would benefit from clozapine. In an effort to provide this important therapy to patients who refuse it despite refractory symptoms, chronic hospitalization, and dangerous behaviors, we have developed an option of involuntary clozapine administration. When efforts to convince the patient to agree to clozapine treatment fail, approval for the involuntary administration of medication and laboratory testing can be requested.
Involuntary clozapine treatment may be an important option for patients who have a guardian (as do approximately one-half of patients at our facility). It also might be an option for patients who have a court order or other legal document approving a trial of involuntary clozapine. When seeking approval from a guardian, explain the benefits and risks of treatment. Some guardians are public administrators, such as elected officials who serve as conservators and guardians, and may be familiar with clozapine and successes with other patients, and quickly support the request. In other cases, the guardian is a family member and might require more education and time to make a decision.
After obtaining approval from a guardian, inform the patient of the plan to initiate clozapine, with the goal of gradually reducing some or most of the other psychotropics. Describe to your patient why weekly hematology profiles are necessary. In collaboration with the treatment team, a convenient time is scheduled for the baseline lab draw. If lab results meet the baseline requirements, clozapine is initiated, usually using the orally disintegrating formulation. The patient is informed about the lab results, medication orders, and potential side effects. If the patient refuses medication, an IM backup of another atypical antipsychotic may be ordered in place of the missed clozapine dose, after obtaining the guardian’s permission. Employing physical restraint such as a manual hold to obtain laboratory testing or to administer medication triggers restraint and seclusion policies.
How do you ensure compliance with clozapine therapy in an unwilling patient?
a) mouth check
b) medication watch (sitting in a public area for 30 minutes after a dose)
c) dissolving clozapine tablets
d) monitoring therapy with clozapine/norclozapine plasma levels