Previous research demonstrated that alcohol and drug misuse prior to admission to special (high and medium) security psychiatric care in Scotland was high. Evidence from clinical practice subsequently suggested that the situation was worsening. In response, a three-pronged strategy was implemented: staff were trained in alcohol and drug issues in mentally disordered offenders, an admission screening programme was introduced to detect those at risk, and specific interventions were developed. This paper presents data on the admission screening programme and on a specific intervention. Study 1 describes the admission data on 86 male patients admitted to the State Hospital, Carstairs. It confirmed that alcohol (81%) and drug (75%) misuse were rising in this population. Combined drug and alcohol abuse was common resulting in the development of joint treatment interventions. Study 2 describes an eight-week drug and alcohol education and awareness programme. An evaluation of this intervention showed that subjects' knowledge of alcohol and drug issues rose significantly pre to post-intervention. However no difference was found in the stage of change or locus of control measures. A number of possible explanations for this finding are discussed, including the validity of the instruments and the effect of detainment in a high security psychiatric environment on the opportunity to change. In spite of the limitations of the environment, the prevalence of alcohol and drug misuse and its association with violence emphasise the need for specific programmes.

Patients may fail to respond to clozapine treatment despite use of the maximum licensed UK dosage (900 mg/day) because of ultra-rapid metabolism of the drug. We present the findings of a study of a national clozapine/norclozapine assay service for the period 1997-2005 and three individual case studies of patients treated with clozapine in doses greater than 900 mg/day. Clinicians should be alert to the possibility of treatment failure because of rapid clozapine clearance secondary to genetic factors and heavy cigarette consumption. This may necessitate the use of clozapine in doses up to 1400 mg/day, notably in young male smokers. Doses of greater than 900 mg/day are rarely justified in women. Anyone given relatively high-dose clozapine (600 mg/day or more) should be monitored regularly for adverse events and changes in smoking habit.