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Evaluating the use of enforced clozapine in an Australian forensic psychiatric setting: two cases


To evaluate the administration, outcomes and ethical issues of enforced clozapine in two patients with treatment-resistant schizophrenia/schizoaffective disorder in a forensic psychiatric setting, who were refusing oral clozapine.


"Enforced clozapine" implied that if a patient refused oral clozapine they received intramuscular clozapine at half the expected oral dose. The case series involved 12 months follow-up. Baseline and monthly measures included the Brief Psychiatric Rating Scale (BPRS), Clinical Global Impressions (CGI), Global Assessment of Functioning (GAF), Insight and Treatment Attitudes Questionnaire (ITAQ) and Quality of Life Self-Assessment Inventory (QLS-100). Routine haematological, metabolic and cardiac monitoring was informed by established clinical guidelines. Statistical analysis utilized t-Tests and Pearson's correlation coefficient.


Enforced clozapine was reasonably well tolerated with rapid acceptance of oral clozapine. By 12 months, statistically significant improvements were seen in BPRS (p = 0.05), CGI (p = 0.04) and GAF (p = 0.03). Improvements in ITAQ and QLS-100 were not statistically significant. BPRS and CGI were strongly negatively correlated with the length of time on enforced clozapine, clozapine dose and clozapine serum levels. GAF, QLS-100 and to a lesser extent ITAQ were positively correlated with those factors.


Enforced clozapine is a viable short-term treatment option in treatment-resistant patients who are refusing oral clozapine. It resulted in significantly reduced psychotic symptoms, reduced dangerousness, a better quality of life, improved insight into their illness and long-term acceptance of oral clozapine. Unfortunately recent global non-production of parenteral clozapine means that this promising intervention in selected treatment-resistant patients cannot be further evaluated and judiciously implemented.

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Open Access This article is published under license to BioMed Central Ltd. This is an Open Access article is distributed under the terms of the Creative Commons Attribution 2.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Kasinathan, J., Mastroianni, T. Evaluating the use of enforced clozapine in an Australian forensic psychiatric setting: two cases. BMC Psychiatry 7 (Suppl 1), P13 (2007).

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  • Clozapine
  • Clinical Global Impression
  • Brief Psychiatric Rate Scale
  • Psychiatric Rate Scale
  • Monthly Measure