To the Editor: In our statewide pharmacology training program, cliicians frequently ask how to deal with patients who won’t swallow clozapine or allow venipunctunes. Administration of clozapine is complicated because weekly white blood counts are necessary and the intramuscular form of clozapine, long in use in
Europe, is not approved in this country. This case illustrates the use of force in a therapeutic manner to overcome such resistance. The patient was a 3 1 -year-old unmarried woman with paranoid schizophrenia. She had a long history of serious assaults on family members, caregivers, and other patients and had experienced multiple hospitalizations since age 16. Hen mental status was characterized by disturbing auditory hallucinations (“mean and sexual things”) from a device “planted in her ear.” Her delusions were that her blood was used to create a clone who lived her life and that medications kept hen ill. These belicf caused hen to refuse treatment. The patient had been ruled incompetent by several courts, which had authorized many medications, all found to be ineffective. Because of hen impulsivity and assaultiveness, she had spent one year in seclusion and several months in wrist and ankle restraints. During that time, she was treated with fluphenazinc without significant improvement. Her only expressed wish was to be free to live in the community (1). After obtaining court authority to administer clozapine, the psychiatnist and milieu staff discussed the new medication with the patient. Although initially compliant, she soon refused medication and weekly blood tests, partly because of side effects but primarily because of delusional beliefs. It was clear that a full trial of clozapine provided hen only chance to leave the hospital, but some staff members were reluctant to force her to have venipunctunes, fingersticks, on drug delivery via nasogastnic tube. After several meetings, however, staff eventually developed hope that the patient’s illness would respond to clozapine, and as a result they felt that getting her to take the medication was worth the extra effort. As hen condition improved, the patient could move toward the increased freedom she desired. The successful use of force requined a therapeutic approach and psychoeducation. Force was never employed in anger, yet there was no doubt about whether it would be
Hospital
January
component ofthe American Psychological Association to seek prescribing privileges, an action that has generated interdisciplinary tensions. While I actively support psychologists’ involvement in psychopharmacology, I am very concerned about proposals to separate prescribing privileges from a broad medical background, which is essential for monitoring agents like clozapine. Moreover, phanmacothenapy does not just complement psychosocial training or case management.
For many
persons
with
severe
and
chronic mental illness, psychosocial training and case management may not be needed when medication is truly efficacious. Yet time and time again psychosocial and other appnoaches of lesser proven efficacy for severely mentally ill persons compete successfully for scarce public funding for treatment ofpaticnts who arc not as ill. Increasing the availability of agents like clozapine will increase the number of severely mentally ill pensons who can benefit from psychosocial approaches. The reasons I gave as to why physicians (and psychologists as well) do not seek work in the public sector were based on surveys by the state of Tennessee. Many of the reasons stated by Mr. Marchant also apply to the Veterans Affairs system. Nevertheless, the VA has had relatively more success than other public facilities in recruiting psychiatrists despite widespread use of nonphysicians. It has also been more consistent in adhering to a medical model and maintaining academic linkage. Cleanly more public facilities need to adopt models that encompass a stronger medical onientation. WILLIAM B. LAWSON, M.D., PH.D.
Clozapine
Refusal
and Community
Psychiatry
1992
Vol.
43
No.
used. On several occasions, force on a show offonce was necessary to obtain blood. The patient was usually willing to take clozapine, and her cornpliance was reinforced by pointing out practicaland immediate ways her behavior had changed (1-3). Staff believed their therapeutic approach helped this reluctant patient to have enough hope to coopcrate with, and gain confidence in, clozapine treatment-an essential step in her rehabilitation program (1,4). Over a period of nine months the patient improved dramatically. Her hostility, grandiosity, agitation, and suspiciousness decreased. Hen delusions remained but lost both their emotional charge and their promincnt impact on her day-to-day behavion. She became friendly and sociable, attended occupational therapy offthe ward, and left the hospital for visits with family members. This treatment-resistant, dangerous, and actively psychotic patient who wanted an alternative to hospitalization improved as a result of stafFs hope, conviction, teamwork, and perseverance. Clozapine (and other antipsychotics soon to come) challenge us to reevaluate patients whose chronicity has caused us to give up hope (1). CuRTIsSJ. DuRAND, M.D. NANCYJ. JARETZ, R.N. ANDREAS LADDIS, M.D. ILEANA BERMAN, M.D. ALAN I. GREEN, M.D The authors are associatedwith Harvard Medical School at the Massachusetts Mental Health Center in Boston. References 1. Satir V, Baldwin M: Satir Step by Step: A Guide to Creating Change in Families. Palo Alto, Calif, Science and Behavior Books, 1983 2. Jaretz N, Flowers E, Millsap L: Clozapine: nursing care considerations. Perspectives in Psychiatric Care, in press 3. Corrigan PW, Liberman RP, Engel JD: From noncompliance to collaboration in the treatment of schizophrenia. Hospital and Community Psychiatry 41:12031211,1990 4. Meltzer HY, Burnett 5, Bastani B, et al: Effects of six months of clozapine treatmeat on the quality of life of chronic schizophrenic patients. Hospital and Cornmunity Psychiatry 41:892-897, 1990
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Europe, is not approved in this country. This case illustrates the use of force in a therapeutic manner to overcome such resistance. The patient was a 3 1 -year-old unmarried woman with paranoid schizophrenia. She had a long history of serious assaults on family members, caregivers, and other patients and had experienced multiple hospitalizations since age 16. Hen mental status was characterized by disturbing auditory hallucinations (“mean and sexual things”) from a device “planted in her ear.” Her delusions were that her blood was used to create a clone who lived her life and that medications kept hen ill. These belicf caused hen to refuse treatment. The patient had been ruled incompetent by several courts, which had authorized many medications, all found to be ineffective. Because of hen impulsivity and assaultiveness, she had spent one year in seclusion and several months in wrist and ankle restraints. During that time, she was treated with fluphenazinc without significant improvement. Her only expressed wish was to be free to live in the community (1). After obtaining court authority to administer clozapine, the psychiatnist and milieu staff discussed the new medication with the patient. Although initially compliant, she soon refused medication and weekly blood tests, partly because of side effects but primarily because of delusional beliefs. It was clear that a full trial of clozapine provided hen only chance to leave the hospital, but some staff members were reluctant to force her to have venipunctunes, fingersticks, on drug delivery via nasogastnic tube. After several meetings, however, staff eventually developed hope that the patient’s illness would respond to clozapine, and as a result they felt that getting her to take the medication was worth the extra effort. As hen condition improved, the patient could move toward the increased freedom she desired. The successful use of force requined a therapeutic approach and psychoeducation. Force was never employed in anger, yet there was no doubt about whether it would be
Hospital
January
component ofthe American Psychological Association to seek prescribing privileges, an action that has generated interdisciplinary tensions. While I actively support psychologists’ involvement in psychopharmacology, I am very concerned about proposals to separate prescribing privileges from a broad medical background, which is essential for monitoring agents like clozapine. Moreover, phanmacothenapy does not just complement psychosocial training or case management.
For many
persons
with
severe
and
chronic mental illness, psychosocial training and case management may not be needed when medication is truly efficacious. Yet time and time again psychosocial and other appnoaches of lesser proven efficacy for severely mentally ill persons compete successfully for scarce public funding for treatment ofpaticnts who arc not as ill. Increasing the availability of agents like clozapine will increase the number of severely mentally ill pensons who can benefit from psychosocial approaches. The reasons I gave as to why physicians (and psychologists as well) do not seek work in the public sector were based on surveys by the state of Tennessee. Many of the reasons stated by Mr. Marchant also apply to the Veterans Affairs system. Nevertheless, the VA has had relatively more success than other public facilities in recruiting psychiatrists despite widespread use of nonphysicians. It has also been more consistent in adhering to a medical model and maintaining academic linkage. Cleanly more public facilities need to adopt models that encompass a stronger medical onientation. WILLIAM B. LAWSON, M.D., PH.D.
Clozapine
Refusal
and Community
Psychiatry
1992
Vol.
43
No.
used. On several occasions, force on a show offonce was necessary to obtain blood. The patient was usually willing to take clozapine, and her cornpliance was reinforced by pointing out practicaland immediate ways her behavior had changed (1-3). Staff believed their therapeutic approach helped this reluctant patient to have enough hope to coopcrate with, and gain confidence in, clozapine treatment-an essential step in her rehabilitation program (1,4). Over a period of nine months the patient improved dramatically. Her hostility, grandiosity, agitation, and suspiciousness decreased. Hen delusions remained but lost both their emotional charge and their promincnt impact on her day-to-day behavion. She became friendly and sociable, attended occupational therapy offthe ward, and left the hospital for visits with family members. This treatment-resistant, dangerous, and actively psychotic patient who wanted an alternative to hospitalization improved as a result of stafFs hope, conviction, teamwork, and perseverance. Clozapine (and other antipsychotics soon to come) challenge us to reevaluate patients whose chronicity has caused us to give up hope (1). CuRTIsSJ. DuRAND, M.D. NANCYJ. JARETZ, R.N. ANDREAS LADDIS, M.D. ILEANA BERMAN, M.D. ALAN I. GREEN, M.D The authors are associatedwith Harvard Medical School at the Massachusetts Mental Health Center in Boston. References 1. Satir V, Baldwin M: Satir Step by Step: A Guide to Creating Change in Families. Palo Alto, Calif, Science and Behavior Books, 1983 2. Jaretz N, Flowers E, Millsap L: Clozapine: nursing care considerations. Perspectives in Psychiatric Care, in press 3. Corrigan PW, Liberman RP, Engel JD: From noncompliance to collaboration in the treatment of schizophrenia. Hospital and Community Psychiatry 41:12031211,1990 4. Meltzer HY, Burnett 5, Bastani B, et al: Effects of six months of clozapine treatmeat on the quality of life of chronic schizophrenic patients. Hospital and Cornmunity Psychiatry 41:892-897, 1990
1
85
