Background Clozapine remains the cornerstone of treatment for treatment refractory schizophrenia. Clozapine has been shown to improve quality of life and cognitive functioning and to reduce hospital days in psychiatric patients. The impact of clozapine in a forensic population of psychiatric patients has not been studied. Methods This study is a naturalistic, retrospective database analysis of forensic patients hospitalized at the Northwest Missouri Psychiatric Rehabilitation Center from January 1, 1990 to August 1, 1999 who were treated with clozapine or haloperidol. Patients were either court ordered for hospitalization as having been found not guilty by reason of insanity or as incompetent to proceed to trial. Results Data from 84 patients (69 male, 15 female) were included in the analysis. The primary Axis I diagnoses were substance abuse (n = 61) and schizophrenia (n = 46). Patients had been treated with haloperidol (n = 78) and clozapine (n = 21), and some had received each agent as monotherapy during their course of treatment (n = 15). Assault (n = 22), armed criminal action (n = 18), and burglary (n = 18) were the primary forensic reasons for admission. Of those eligible to obtain a conditional release, 33% of haloperidol-treated patients and 38% of clozapine-treated patients obtained their conditional release on those medications. Haloperidol-treated patients were more likely to have their conditional release revoked (58.8%) versus those treated with clozapine (0%). Clozapine-treated patients were also more likely to stay on conditional release for longer periods of time. Global Assessment of Functioning (GAF) scores improved in both treatment groups; however, of 15 patients converted from haloperidol to clozapine, 93% (n = 14) saw improvements in GAP scores. Conclusions Clozapine and haloperidol effectively reduce psychosis and aggression. In our study, clozapine-treated patients were more likely to obtain a conditional release and stayed on conditional release for longer periods of time. Although the need exists to study this patient population more closely from a longitudinal standpoint, one may suspect that these findings represent a potential decrease in healthcare costs for the treatment of forensic psychiatric patients.

In spring 2000, the Missouri Department of Mental Health mandated that its psychiatric inpatient facilities convert patients from trade-name to generic clozapine. The pharmacy department at our facility was encouraged to develop a conversion program to oversee and assess the efficacy and tolerability of the change. A protocol to monitor the conversion of patients to generic clozapine hospitalwide was developed. The primary objective was to determine whether therapeutic response and level of tolerability were the same with generic versus trade-name clozapine. The secondary objective was to determine whether changes in monitoring white blood cell and absolute neutrophil counts were necessary after conversion. Our results showed that most patients did not experience changes greater than a mean of 5 points in their scores on the Brief Psychiatric Rating Scale (BPRS). However, a statistically significant difference was seen in 22 patients who had a mean reduction or an increase of less than 5 points (p=0.0139) in BPRS scores compared with two patients who had a mean increase greater than 5 points. Assessment of percentage change in BPRS scores indicated that 14 (58%) converted patients had a 1-50% decrease in mean BPRS scores, and 10 (42%) had a 1-40% increase. However, of those with a mean BPRS increase, five (50%) had an increase of 10% or less. Our clozapine conversion program resulted in the successful conversion of all 24 patients.

Patients receiving atypical antipsychotic drugs had a perceived high quality of life and were satisfied with a variety of aspects of their lives. However, metabolic disturbances had a significant, detrimental effect on patients' perceived quality of life.

This preliminary investigation suggests that patients receiving delayed-release divalproex sodium for mood lability can be converted successfully to extended-release divalproex sodium. Moreover, these findings imply that this transition is associated with a reduction in some of the adverse effects associated with divalproex sodium.