Clozapine and urinary incontinence

Overcoming clozapine's adverse events: a narrative review of systematic reviews and meta-analyses

INTRODUCTION

Clozapine is the gold standard treatment for treatment-resistant schizophrenia, however adverse events remain a clinical challenge.

AREAS COVERED

This review presents a narrative synthesis of systematic reviews and meta-analyses that have reported the onset, incidence, prevalence, and management of clozapine's adverse events. We conducted a systematic literature search using PubMed, Embase, PsycINFO, OvidMEDLINE, CINAHL, and the Cochrane Database of Systematic Reviews from inception to April 2024.

EXPERT OPINION

Effective management of clozapine's adverse events necessitates multi-faceted, individualized, and shared-decision strategies. Despite a lack of high-quality systematic evidence, expert inter-disciplinary solutions are provided to help address a critical need for clinical guidance. This 35-year update offers an evidence-based framework to assist clinicians, patients, and caregivers navigate the adverse events associated with clozapine therapy.

A Case of Risperidone-Induced Urinary Incontinence

Schizophrenia spectrum disorders are psychiatric conditions associated with an increased risk of all-cause mortality; patients with these conditions have a shortened average lifespan compared to the general population. First-line treatment for schizophrenia spectrum illness consists of atypical antipsychotics, which are associated with well-understood side effects, including metabolic syndrome, anticholinergic effects, and extrapyramidal symptoms. We are presenting a case of a 36-year-old patient treated with the atypical antipsychotic risperidone who experienced treatment-associated urinary incontinence. In the current literature, atypical antipsychotic-induced urinary incontinence is not well-documented in patients with schizophrenia spectrum disorder. Incontinence is often a topic of societal shame for many patients, and as a side effect, it may influence medication compliance. In the treatment of schizophrenia spectrum disorders, compliance is essential to prevent psychosis relapse in patients, so prescribers must be aware of this potential side effect and how to manage it. Upon a patient presenting with incontinence suspected to be due to atypical antipsychotics, other more common causes of incontinence must first be ruled out. Then, further management can consist of stopping the offending medication or adding a medication to address the incontinence. In this case, our patient had an extended history of suboptimal treated schizoaffective disorder, and risperidone was providing significant improvement; therefore, to ensure continued improvement, we initiated oxybutynin to manage urinary incontinence.

The association of lower urinary tract symptoms with schizophrenia and its treatments: A narrative review

BACKGROUND

A higher incidence of lower urinary tract symptoms (LUTS) in people with schizophrenia compared to the general population is often suggested. However, it is not clear whether this is a genuine association, and whether it is a direct result of schizophrenia itself, or a side-effect of certain antipsychotics.

METHODS

We undertook a narrative review evaluating how the published literature reports the relationship between LUTS and schizophrenia and its treatments. We searched Embase, Ovid Emcare, and Ovid MEDLINE(R) ALL to August 2022, limited to the English language. We selected the following search terms: schizophrenia, schizophrenic, LUTS, overactive bladder, urinary urgency, urinary incontinence, overactive bladder, enuresis, nocturnal enuresis, and voiding dysregulation. We identified seven domains for assessment in advance of commencing the review. These were the categorization, description, and treatment status of schizophrenia; evaluation of LUTS; categorization of LUTS confounders; recapturing of the disease states of both schizophrenia and LUTS after therapies; assessment of the association between LUTS and schizophrenia and/or antipsychotics.

RESULTS

The association between LUTS and schizophrenia was poorly described. The evidence was low quality and focused predominantly on urinary incontinence as an antipsychotic side effect, neglecting other LUTS. The status of schizophrenia was often incompletely characterized, and no papers made use of a bladder diary or LUTS-specific questionnaires to assess symptoms. No papers collected information about LUTS in patients not on antipsychotics, nor did any thoroughly evaluate the influence of confounding variables. Despite the tendency of symptoms and severity of both conditions to fluctuate over time, no studies fully assessed the status of both schizophrenia and LUTS at baseline, therapy initiation, and follow-up.

CONCLUSIONS

It is not possible to state whether there is an association between LUTS and schizophrenia or its treatments. This review highlights the need to improve research and clinical management of the urinary tract in schizophrenia, with meticulously designed longitudinal studies.

Treatment strategies for clozapine-induced nocturnal enuresis and urinary incontinence: a systematic review

BACKGROUND

Clozapine is the most effective medication for treatment-refractory schizophrenia but is associated with significant adverse drug reactions, including nocturnal enuresis and urinary incontinence. This side effect can be burdensome and lead to medication nonadherence and psychotic relapse. Evidence to guide treatment of clozapine-induced nocturnal enuresis and urinary incontinence is sparse. We therefore aimed to synthesize the evidence base to guide management for clinicians, patients, and their carers.

METHODS

We systematically searched PubMed, Embase, PsycInfo, CINAHL, and the Cochrane Trial Registry databases from inception to May 2021 for publications on management of clozapine-induced nocturnal enuresis and urinary incontinence using a PROSPERO preregistered search strategy.

RESULTS

We identified 22 case reports and case series describing 74 patients. Interventions included clozapine dose reduction, nonpharmacological treatment, and pharmacological treatments. Among pharmacological treatments, desmopressin, oxybutynin, trihexyphenidyl, tolterodine, imipramine, amitriptyline, ephedrine, pseudoephedrine, aripiprazole, and verapamil were associated with complete resolution of nocturnal enuresis and urinary incontinence. Balancing evidence for effectiveness against risk of adverse effects, we developed a management framework for clozapine-induced nocturnal enuresis and urinary incontinence.

CONCLUSIONS

Following assessment of urological, psychiatric, pharmacological, and common comorbid medical issues, first-line treatments should be nonpharmacological, including bathroom alarms, voiding before bedtime, and nocturnal fluid restriction. If these interventions do not provide adequate relief, aripiprazole should be trialed. Desmopressin may be considered for severe refractory cases, but monitoring for hyponatremia is essential.

[Urinary incontinence: a good diagnosis as a basis for treatment]

Urinary incontinence: a good diagnosis as a basis for treatment Abstract. Abtract: Everyone has experienced incontinence at an early age. However, it also affects approximately 200 million people worldwide at the adult age. This common condition is frequently underreported by patients but can dramatically limit their social life. Subject to appropriate differential diagnosis, urinary incontinence is a condition that can be treated with good results in the majority of patients. This article provides a review of the essential symptomatology and current treatments, so that clinicians confronted with the problem may adopt the appropriate management.

Risperidone-associated enuresis—a case report

Background

Risperidone has been reported to be effective in treating both the positive and negative symptoms of schizophrenia, aggression, and behavioral disorders. While the metabolic side effect profile of this medication has been broadly studied, studies related to this medication’s bladder effects are relatively rare. We present a case of risperidone-induced enuresis in an adult male with schizophrenia that resolved upon discontinuation of the offending medication.

Case presentation

We describe a case of a 32-year-old man with a primary psychotic disorder who developed debilitating enuresis secondary to taking risperidone. Enuresis resolved upon switching to Seroquel.

Conclusion

Enuresis secondary to risperidone is not commonly discussed prior to initiation by the treating psychiatrist however can be debilitating. Discussing this potential side effect is critical to informed decision making on the patient’s part.

Verapamil treatment in clozapine-induced sleep-related enuresis: a case report

Enuresis is an embarrassing rare side effect of clozapine treatment. Using single-blind placebo-control design, the antienuretic activity of the calcium channel blocker verapamil (up to 80 mg/day per os, at 21.00 hours) was evaluated in a schizophrenic patient with comorbid obsessive-compulsive disorder (OCD) who developed nocturnal functional enuresis during clozapine treatment. Verapamil (80 mg/day) displayed antienuretic activity. No correlation between the bradycardiac effect and the antienuretic activity of verapamil was detected.

Nocturnal Enuresis is an Under-recognised Side Effect of Clozapine: Results of a Systematic Review

Objectives

Clozapine is an effective antipsychotic medication licenced for the management of treatment resistant schizophrenia. Due to its non-selective pharmacology, it has a broad range of side effects. Nocturnal enuresis secondary to the use of clozapine has been documented in the literature but may be overlooked, the link between drug and symptom being clinically unnoticed. Patients may not mention urinary symptoms due to supervening psychosis, co-existing symptomatology, embarrassment or shame. By raising awareness of the phenomenon, early recognition and patient support may improve compliance with clozapine medication, and consecutively, overall mental health. Consequently, this systematic review investigates the prevalence of nocturnal enuresis secondary to clozapine use.

Methods

A literature search on clozapine and nocturnal enuresis was used to identify the relevant papers. Papers providing the prevalence data on Clozapine associated nocturnal enuresis were selected for data extraction.

Results

47 papers were initially identified. Eight papers focused on the prevalence of clozapine associated nocturnal enuresis (CANE). Point prevalence (nocturnal enuresis at the time of assessment), 1-month prevalence and episode prevalence (nocturnal enuresis since beginning of clozapine) were given. Papers included patients with schizophrenia, schizoaffective disorder, bipolar affective disorder and psychotic depression, taking clozapine medication. The prevalence of CANE ranged from 10–42%. Point prevalence was 21–27%, 1-month prevalence was 10–39% and episode prevalence was 15–42%. Clozapine was more likely to cause nocturnal enuresis compared to other psychotropic medication.

Conclusion

The prevalence of CANE may be greater than previously thought. However, in order to determine an accurate prevalence of clozapine associated nocturnal enuresis, larger studies with strict inclusion criteria, common definition of diagnosis and prevalence are required. By establishing an accurate prevalence, physician awareness can be improved, and patients can becounselled on the risk of developing the side effect, thus improving early identification and reducing discontinuation rates.

Clozapine-induced nocturnal enuresis: diagnostic and treatment issues

Aims and Method

To report the management of three cases of clozapine-induced enuresis, by description of these cases and literature review.

Results

Heavy sedation, generalised epilepsy and diabetes mellitus induced by clozapine are some of the mechanisms that underlie the emergence of this side-effect.

Clinical Implications

These cases illustrate several different pathophysiological mechanisms necessitating further diagnostic investigations before adequate treatment can be started. Clozapine-induced enuresis is probably under-reported owing to the embarrassing nature of this side-effect.

Implications of infection and trends of antibiotic prescribing in hospitalized patients diagnosed with serious mental illness

Hospital-acquired infections have been recognized as a significant factor in increased morbidity and mortality across our health system. Unique to infections associated with inpatient psychiatric hospitalization is the additional hypothesized association of the role that antipsychotic agents and/or underlying disease may play in an increased risk for infection. In this paper, we explore the types of infections diagnosed in an inpatient psychiatric hospital, the demographics of the patients infected, and whether or not the patient was on antipsychotic agents at the time of infection.

Association between schizophrenia and urinary incontinence: A population-based study

BACKGROUND

Urinary incontinence (UI) is defined as the involuntary loss of urine and can constitute a hygiene or social problem for affected patients. Whether the UI incidence is higher in patients with schizophrenia than in the general population remains undetermined.

METHODS

The patients were selected from the Taiwan National Health Insurance Research Database, using claims data from 2005 to 2011. We compared the risk of UI between schizophrenia and nonschizophrenia groups. Logistic regression models were employed for analyzing the risk of UI after adjustment for sex, age, and comorbidities.

RESULTS

The adjusted odds ratio for UI in the schizophrenia group was 1.78-fold higher than that in the nonschizophrenia group. Furthermore, male patients with schizophrenia were more susceptible to UI than their female counterparts, and a higher risk of UI was observed among younger patients with schizophrenia.

CONCLUSION

Compared with the general population, the risk of UI was higher among the patients with schizophrenia. Early diagnosis and intervention can increase the quality of life among patients with schizophrenia.

Screening for incontinence in a secure psychiatric service for women

Incontinence is associated with mental illness and neuroleptic medications but diagnosis and treatment is often poor or non-existent. Problems of incontinence are compounded in secure psychiatric services for women by poor health, obesity, and a sedentary lifestyle. Addressing the physical health of this group necessitates a more accurate picture of the nature, incidence, and management of incontinence. A point-in-time survey of 108 women who agreed to be interviewed (93%) covered presence, frequency, and nature of incontinence, and information on management case note data was used to gather demographic and previous medical history, comparisons were made between patients with and without problems of incontinence. Findings indicate a problem of incontinence in 48% of women with a dominance of problems of stress and urge enuresis. Of modifiable factors that contribute to enuresis, the current study highlighted the contribution of obesity, smoking and clozapine medication. A further finding was the preference for managing rather than treating problems of incontinence. Actions to improve the detection and treatment of this problem are described.

Rare and very rare adverse effects of clozapine

Clozapine (CLZ) is the drug of choice for the treatment of resistant schizophrenia; however, its suitable use is limited by the complex adverse effects' profile. The best-described adverse effects in the literature are represented by agranulocytosis, myocarditis, sedation, weight gain, hypotension, and drooling; nevertheless, there are other known adverse effects that psychiatrists should readily recognize and manage. This review covers the "rare" and "very rare" known adverse effects of CLZ, which have been accurately described in literature. An extensive search on the basis of predefined criteria was made using CLZ and its combination with adverse effects as keywords in electronic databases. Data show the association between the use of CLZ and uncommon adverse effects, including ischemic colitis, paralytic ileus, hematemesis, gastroesophageal reflux disease, priapism, urinary incontinence, pityriasis rosea, intertriginous erythema, pulmonary thromboembolism, pseudo-pheochromocytoma, periorbital edema, and parotitis, which are influenced by other variables including age, early diagnosis, and previous/current pharmacological therapies. Some of these adverse effects, although unpredictable, are often manageable if promptly recognized and treated. Others are serious and potentially life-threatening. However, an adequate knowledge of the drug, clinical vigilance, and rapid intervention can drastically reduce the morbidity and mortality related to CLZ treatment.

Treatment considerations in clozapine induced enuresis or incontinence

Antipsychotic related urinary symptoms are recognised and they remain a potential treatment-limiting sideeffect of clozapine. This article reports the incidence and management of two cases of clozapine-associated incontinence in psychiatrically stable patients. Both cases occurred during treatment and appear to have a similar pathophysiology, which may be related to the atypical nature of clozapine therapy. We searched the PubMed and MEDLINE databases for articles published from 1980 to 2008 that contain the keywords 'clozapine and enuresis, ‘clozapine and incontinence,’ ‘clozapine and seizures’. We also manually searched the bibliographies of these articles for related sources, and explored the reported treatment options to this side-effect of clozapine therapy. Both patients gave an informed consent.

Nocturnal enuresis with antipsychotic medication

Nocturnal enuresis can be discomfiting and troublesome. There is increasing evidence that as a side-effect of second-generation antipsychotics, particularly clozapine, it may be underrecognised. Direct but sensitive questioning may be required to elicit this side-effect. We briefly review possible mechanisms of this problem, and management and treatment options.

Nocturnal enuresis in patients taking clozapine, risperidone, olanzapine and quetiapine: comparative cohort study

BACKGROUND

Nocturnal enuresis has been reported in patients taking clozapine, but the incidence has not been accurately established. The incidence of enuresis in patients taking risperidone, olanzapine or quetiapine is unknown. Aims To compare nocturnal enuresis in patients taking clozapine with that in patients taking risperidone, olanzapine or quetiapine.

METHOD

Observational cohort study using prescription event monitoring methods. Patients prescribed atypical antipsychotic medicines were followed up by questionnaires that were sent to their medical practitioner. Practitioners were asked to directly ask their patients about bed-wetting.

RESULTS

Nocturnal enuresis was reported by 17 of 82 (20.7%) patients taking clozapine, 11 of 115 (9.6%) taking olanzapine, 7 of 105 (6.7%) taking quetiapine and 12 of 195 (6.2%) taking risperidone. Compared with clozapine, the risk of nocturnal enuresis was significantly lower in patients taking olanzapine (odds ratio, OR = 0.43, 95% CI 0.19-0.96), quetiapine (OR = 0.33, 95% CI 0.13-0.59) or risperidone (OR = 0.27, 0.12-0.59), with odds ratios adjusted for age, gender and duration of treatment.

CONCLUSIONS

Approximately one in five patients prescribed clozapine experienced bed-wetting. This was significantly higher than the rate of nocturnal enuresis in patients taking olanzapine, quetiapine or risperidone.

Use of aripiprazole in clozapine induced enuresis: report of two cases

This report describes the efficacy of combined use of aripiprazole in the treatment of a patient with clozapine induced enuresis. Aripiprazole acts as a potential dopamine partial agonist and the dopamine blockade in the basal ganglia might be one of the causes of urinary incontinence and enuresis. We speculate that aripiprazole functioned as a D2 agonist in hypodopaminergic state of basal ganglia caused by clozapine and maintained dopamine level that would improve enuresis ultimately.

A 2-year prospective follow-up study of lower urinary tract symptoms in patients treated with clozapine

Urinary incontinence and enuresis are well-known side effects of clozapine. However, clinical experience has shown that patients also suffer from diverse lower urinary tract symptoms (LUTS). The natural course of clozapine-related LUTS is unclear. Thus, a longitudinal follow-up study is needed. A total of 101 subjects who were taking clozapine initially participated. Their LUTS were evaluated using the International Prostate Symptom Score (IPSS), other questionnaires, and a medical records review. After 2 years, 87 of the original subjects could be contacted, and the status of their LUTS was re-evaluated. The average IPSS total was 7.4 +/- 5.9 at the initial evaluation. Although only 11 subjects (10.9%) reported actual incontinence, 42 subjects (41.6%) were found to have clinically significant LUTS (IPSS total score > or =8). No influencing factors could be found among the demographic and clinical variables. At the follow-up, the average IPSS total (7.9 +/- 6.0) and the percentage of subjects with clinically significant LUTS (43.7%) had both increased, although the change was not statistically significant. The prevalence of LUTS in clozapine-medicated patients was higher than in the general population of the same age. However, the prevalence of incontinence was only a quarter of that of LUTS. If clinicians focus only on incontinence, distress from LUTS will not receive appropriate attention. Furthermore, contrary to literature observations, clozapine-related LUTS did not remit easily but rather persisted even into the long-term maintenance phase. More concern should be directed at these troublesome and often neglected side effects.

Urinary incontinence in schizophrenic patients treated with atypical antipsychotics: urodynamic findings and therapeutic perspectives

Objective The present study was a urodynamic evaluation of schizophrenic patients with urinary incontinence occurring during treatment with atypical antipsychotics Methods A total of 12 schizophrenic patients (mean age = 30.7 years, SD = 6.5) presenting urinary incontinence during treatment with atypical antipsychotics at stable doses underwent urodynamic evaluations. Clinical assessment included the administration of Positive and Negative Syndrome Scale (PANSS) Results Four patients out of 12 presented urodynamic patterns consistent with an overactive bladder, while five patients presented reduced bladder compliance; only three patients showed normal urodynamic patterns Conclusion Detrusor overactivity is a condition associated with urinary incontinence in schizophrenic patients treated with atypical antipsychotics. Urodynamic evaluations can improve our knowledge of the mechanisms that subtend atypical antipsychotic-induced incontinence, an invalidating side-effect with strong repercussion on compliance and rehabilitation in schizophrenic patients.

Serum antimuscarinic activity during clozapine treatment

This study attempts: (1) to verify that serum antimuscarinic activity is related to clozapine dose, and more importantly to clozapine plasma concentrations; (2) to explore whether norclozapine has serum antimuscarinic activity; (3) to explore whether antimuscarinic activity is related to clozapine side effects; and (4) to compare the serum antimuscarinic activities of clozapine with those of antiparkinsonian drugs and other antipsychotics. In 39 patients participating in a double-blind clozapine study, the [3H]QNB assay was used to measure serum antimuscarinic activity: (1) on baseline medications; (2) after a 4-week haloperidol trial; (3) after a 16-week clozapine trial of either 100, 300, or 600 mg/d; and (4) after 1 or 2 consecutive 16-week clozapine trials with remaining doses in nonresponders. Clozapine levels predicted serum antimuscarinic activity better than clozapine dose. At the end of the 1st clozapine trial, the correlation with the levels explained 69% of the variance of serum antimuscarinic activity (r = 0.83, P < 0.001, N = 34). Clozapine levels were good predictors of serum antimuscarinic activity only in patients taking 300 or 600 mg/d. After correcting for clozapine levels, the within-subject correlation between norclozapine levels and serum antimuscarinic activity was relatively high and significant (r = 0.54, F = 26.7, df = 1.65, P < 0.001). Constipation was significantly associated with higher serum antimuscarinic activity during the 1st clozapine trial. Clozapine was associated with clearly higher antimuscarinic activity than other antipsychotics or low doses of antiparkinsonians. In vitro studies and new clinical studies are needed to verify whether norclozapine may significantly contribute to antimuscarinic activity during clozapine treatment.

Effects of the atypical neuroleptic clozapine on micturition parameters in anesthetized rats

Clozapine, an atypical antipsychotic, has resulted in a number of reports of urinary disturbances in the clinical literature. We examined the effects of clozapine on urodynamic parameters in the anesthetized rat and compared the effects to those of the typical antipsychotic haloperidol and the selective D2 and D4 antagonists, raclopride and L-745,870, respectively. Clozapine abolished high-frequency oscillations (HFO) during the expulsion phase, and profoundly altered a number of other parameters (e.g., intercontraction interval and resting pressure). Clozapine did not affect the peak contraction pressure during cystometrograms but displayed peripheral inhibition of bladder contractions elicited by electrical stimulation of the pelvic nerve (possibly mediated via clozapine's anti-muscarinic effects). Haloperidol had less potent effects than clozapine since it reduced the amplitude of HFO to 25% of control and also affected several other parameters but without peripheral bladder inhibition. Raclopride only resulted in a modest decrease (approximately 70% of control) in the HFO and no alteration in other parameters. L-745,870 was effective only at highest dose tested suggesting that it might not be acting selectively at D4 receptors. Therefore, we propose that clozapine primarily interferes with the function of the external urethral sphincter. These effects can only be partly explained through antagonism of D2 receptors. Since both clozapine and haloperidol have interactions with other transmitter systems beside dopamine, we suggest that central antagonism of D2 receptors, coupled to central antagonism of another receptor system and peripheral muscarinic receptor blockade, may account for clozapine's potent effects on micturition.

Clozapine inhibits micturition parameters and the external urethral sphincter during cystometry in anesthetized rats

Clozapine therapy has been associated with a high degree of urinary disturbances. The purpose of this study is to examine the effect of clozapine on urodynamic parameters and on the activity of the external urethral sphincter in anesthetized rats. Single cystometrograms (CMG) were performed on urethane-anesthetized female Sprague-Dawley rats, while also recording the EMG from the external urethral sphincter. Clozapine (0, 0.1, 1, 10 mg/kg) was administered intravenously. In addition, the peripheral end of the pudendal nerve was stimulated in order to determine if clozapine was exerting peripheral effects directly on the external urethral sphincter. Clozapine increased the bladder capacity while reducing the micturition volume thus resulting in a marked increase in the residual volume. The pressure threshold was increased but the peak pressure during contraction remained unchanged. The expulsion time and contraction time were decreased and the amplitude of the high frequency oscillations (HFO) seen during the expulsion phase were markedly reduced and even abolished. The EMG from the external urethral sphincter also showed marked decreases after clozapine, and the bursting pattern seen during HFO was abolished. Clozapine had no effect on the activity elicited from electrical stimulation of the pudendal nerve. Clozapine inhibits several urodynamic parameters and inhibits the activity of the external urethral sphincter in anesthetized rats. These effects may help explain the urinary disturbances reported in the clinical literature.

A retrospective study of clozapine and urinary incontinence in Chinese in-patients

OBJECTIVE

This study investigated the incidence of clozapine-associated urinary incontinence (UI) in schizophrenic patients, the percentage of these patients with persistent urinary incontinence (PUI), and the possible factors affecting the occurrence of UI.

METHOD

A total of 61 Chinese in-patients with schizophrenia (according to DSM-IV) treated with clozapine for more than 3 months were assessed retrospectively for the occurrence of UI. Patients who still had UI at the time of assessment were classified as having PUI. Patients whose UI had resolved at the time of assessment were classified as having self-limited urinary incontinence (SUI). We compared the characteristics of UI and non-UI cases and of PUI and SUI cases.

RESULTS

The results showed that urinary incontinence developed at some time in 27 of 61 patients (44.3%), and that it was persistent in 15 of 61 patients (25%). There were no statistically significant differences in age, sex, clozapine dose, duration of clozapine use, duration of index admission, duration of illness, age at onset of schizophrenia, or concurrent treatment with other psychiatric medications between the UI and non-UI groups and between the PUI and SUI groups.

CONCLUSION

Clozapine-associated urinary incontinence may be persistent in some patients, and it should be cautiously monitored in every patient taking clozapine.

Characteristics of the new long-stay population in an inner Melbourne acute psychiatric hospital

OBJECTIVE

There has been an accumulation of so-called 'new long-stay' (NLS) patients in psychiatric hospitals. To date, no Australian studies have characterised this patient group. We aimed to study the demography, and clinical and social functioning of the NLS population at Royal Park Hospital (RPH) together with patients' attitudes to treatment and views on future placement.

METHOD

All 30 NLS patients at RPH were identified. Twenty-seven consenting patients were assessed using the following standardised instruments: Manchester Scale for psychopathology, Life Skills Profile (LSP), Physical Health Index and Patient Attitude Questionnaire. Information on past psychiatric history, past treatment and current treatment was collected. Insight and compliance were assessed.

RESULTS

The majority of patients were single men with a diagnosis of schizophrenia. Forty-one percent were detained in hospital involuntarily and 56% were considered dangerous to themselves or others. The patients were characterised by high levels of positive and negative symptoms. They were most impaired with respect to 'social contact' relative to the other subscales of the LSP. While 10 (48%) patients expressed a desire to leave hospital, only one patient considered that anyone would cohabit with them. Over two-thirds considered they had been unwell and that medication had helped. Staff rated one-third as having major problems with compliance. About two-thirds of patients had disability secondary to comorbid physical illnesses.

CONCLUSION

Like other NLS patients studied in the United Kingdom and Ireland, this group had significant handicaps secondary to psychiatric illness, concomitant physical illness and disability and behaviour unacceptable in community settings. They were also characterised by significant social isolation. These factors may be important determinants of rehabilitation failure and need to be addressed in the process of de-institutionalisation as well as in longitudinal studies examining these and other factors predicting NLS status.

Management of treatment resistant schizophrenia unresponsive to clozapine

A recent challenge in schizophrenia has been the management of patients who have failed to respond not only to standard therapeutic regimes but also to trials of atypical neuroleptics such as clozapine and risperidone. This article focuses on the further psychological and pharmacological management of such patients.

Drug strategies and treatment-resistant schizophrenia

OBJECTIVES

The aims of the paper are to review the notion of treatment resistance in schizophrenia and consider the factors important in determining non-responsiveness to standard neuroleptic treatment, and to review the strategies currently available in the treatment of such patients, including an evaluation of recently-introduced, novel drug treatments.

METHOD

A selective review of the literature relating to treatment resistance was undertaken using medline searches, followed by cross-checking for further articles identified in these references.

RESULTS

The various treatment approaches available are considered, including adjunctive treatment with lithium or carbamazepine. The risks and benefits of high dose antipsychotic treatment are discussed. The possible benefits and side-effects of new treatments, particularly the atypical neuroleptics, are also reviewed.

CONCLUSIONS

The reasons why a proportion of patients with schizophrenia fail to respond to standard neuroleptic treatment are ill-understood. Nevertheless, initial assessment should include identification of any factors that may be related to a patient's poor response, such as poor compliance, substance use or epilepsy. This may help to determine an appropriate treatment strategy. There is a need to be systematic and to ensure that patients be given an adequate trial of each treatment tested in terms of duration and dosage. The available evidence does not support the use of high doses of neuroleptics for the majority of patients. Adjunctive treatments, such as lithium, carbamazepine or benzodiazepines may be beneficial in non-responsive patients, particularly if certain target symptoms are present. Atypical neuroleptics, particularly clozapine, have proved particularly effective in non-responsive patients as well as those sensitive to the motor side-effects of standard drugs. However, the high risk of agranulocytosis with clozapine is a problem; also the drug and the necessary haematological monitoring are expensive. There are hints that some of the other, new, atypical neuroleptics have some benefit in non-responsive patients, but controlled studies are required.