ObjectiveA number of studies have demonstrated the anti-aggressive properties of clozapine in schizophrenia and its positive effect in borderline personality disorder. There is no published literature on the treatment of antisocial personality disorder (ASPD) with clozapine. We present a case series of 7 patients with primary ASPD and high psychopathic traits treated with clozapine, having a significant history of serious violence and currently detained in a UK based high-security hospital.MethodsA retrospective review of case notes was carried out to formulate Clinical Global Impression (CGI) scores and record incidents of violence and aggression. Effect on specific symptom domains (cognitive-perceptual, impulsive-behavioural dyscontrol, affective dysregulation) was also noted. Metabolic parameters and serum clozapine levels were also sampled.ResultsAll 7 patients showed significant improvement on clozapine. It was shown to benefit all symptom domains, especially impulsive behavioral dyscontrol and anger. The number of violent incidents committed by 6 of the 7 patients reduced significantly, and all patients’ risk of violence reduced. Clozapine serum levels for 6 of the 7 patients were in the range 150–350 ng/mL.ConclusionClozapine is of benefit in reducing the clinical severity of ASPD. It improved all symptom domains, especially impulsive-behavioral dyscontrol and anger, and reduced levels of aggression and violence, especially at lower doses (serum levels <350 ng/m). To our knowledge, this is the first account of clozapine treatment in patients with ASPD and high psychopathy.

Background Security needs among patients referred to forensic mental health services have rarely been systematically studied. Aims To ascertain security needs among patients referred to a high secure hospital, Broadmoor High Secure Hospital, England. We also aimed to compare the security needs for those referred to mental illness services with those referred to personality disorder services in the hospital. Method A retrospective complete cohort study of all referrals to Broadmoor Hospital over a 2-year period was conducted. All referred patients (n = 204) were assessed for need for high secure care by two Broadmoor clinicians. The final decision on need for admission was taken by a multidisciplinary admission panel. Independent of the panel, researchers rated need for security using the DUNDRUM-1 triage security scale. Results Those admitted to Broadmoor Hospital had higher triage security scores than those declined (F = 4.209, d.f. = 1, P = 0.042). Referrals to the personality disorder pathway had higher security needs than those referred to the mental illness pathway high secure service (F = 6.9835, d.f. = 1, P = 0.0089). Overall security needs among referrals to Broadmoor were extremely high, both by comparison with previous needs identified in UK medium secure services and international medium and high secure services. Conclusions High secure patient cohorts represent a uniquely vulnerable group within mental health services, with extremely high security needs identified in this study. This has significant implications for services given the high levels of resources needed to provide therapeutically safe and secure care and treatment to this group.

The findings of this study are important in showing that all patients who responded to olanzapine pamoate also showed a decrease in violent behaviour. The potential anti-aggression effects of olanzapine pamoate may represent a very promising area for further work. A depot antipsychotic medication that reduces violence could have significant implications for management of high-security patients.