A large proportion of patients with treatment-resistant schizophrenia continue to have persistent symptoms and psychosocial impairment despite adequate treatment with clozapine. This group of patients with clozapine resistant schizophrenia (CRS) constitutes about 40%-70% of those with treatment-resistant schizophrenia. These patients represent the most severely ill among those with schizophrenia with higher levels of symptom severity and disability, and greater socioeconomic burden. A large body of evidence has shown that when clozapine fails, augmentation of its response with antipsychotics or other medications is of little or no benefit for these patients. Augmentation with electroconvulsive therapy seems to hold some promise, but the evidence is limited. The benefits of psychosocial interventions in augmenting clozapine response in these situations has not been explored fully. A few trials of cognitive-behavioural therapy (CBT) have been undertaken, and their results do not seem to support the effectiveness of adjunctive psychosocial therapies in augmenting the efficacy of clozapine in these patients. Nevertheless, this chapter attempts to re-evaluate the evidence for the effectiveness of psychosocial interventions in CRS, by conducting a brief review of the area followed by illustrative histories of patients with CRS who benefitted from adjunctive psychosocial therapies. The results suggest that adjunctive psychosocial treatments could still have a role in potentiating clozapine response in CRS. However, psychosocial treatment modules that combine CBT with other treatment strategies such as individual support, stress management, and family interventions are more likely to be successful in augmenting clozapine response in CRS than CBT alone. Therefore, there is much scope for further research in this area
Department of Psychiatry, Postgraduate Institution of Medical Education and Research (PGIMER), Chandigarh, India.