Clinical Case 6 of 15 · ~767 words
Clinical Case No. 6. Longstanding Schizophrenia, Clozapine and Admission with Pneumonia
Previous course and partial stabilization
David is 54. His psychotic disorder began in young adulthood; over thirty years, there have been remissions, repeated admissions, several moves and changes of physician. He now lives in a supported apartment in the Fraser region. His sister visits weekly. He enjoys radio programs about gardening and tends several boxes of herbs on the balcony.
For years, earlier records used the word "resistant," although some unsuccessful courses had been interrupted by adverse effects or irregular dosing. Later, the team reconstructed the treatment history and confirmed two trials of different antipsychotics that were adequate in dose, duration and actual use, without sufficient response. Only then did clozapine have a clear clinical basis. Verifying the adequacy of previous trials is an important part of Canadian recommendations for treatment-resistant schizophrenia. [124]
Clozapine reduced the intensity of the voices and the frequency of crises. David still sometimes believes his neighbours are discussing him, but he can set the thought aside and go shopping. He needs support with complex daily tasks, money and regular treatment.
Consultation is provided by Fraser Health's Psychosis Treatment Optimization Program, an outpatient service for optimizing antipsychotic treatment, including clozapine. The local team, pharmacy and family physician provide everyday follow-up. [125]
Monitoring treatment
David takes a stable, individually selected clozapine dose. The team monitors absolute neutrophil counts through the Canadian medication monitoring system and reviews bowel movements, orthostatic symptoms, drowsiness, weight and glycaemia at appointments.
When asked directly, David reports infrequent bowel movements with considerable straining. The physician prescribes constipation treatment, and the nurse agrees with David on tracking stools, pain, distension and other signs of deterioration. Clozapine-associated gastrointestinal hypomotility can cause severe complications. [126]
His family physician also manages type 2 diabetes; HbA1c is 7.2%. Cigarette consumption is recorded whenever there is a substantial change in condition: tobacco combustion products induce clozapine metabolism, and stopping smoking can increase its concentration. Nicotine replacement therapy does not have this inducing effect. [127]
Acute physical illness
In February 2026, David coughs for several days, becomes weaker and stops his usual shopping. A support worker notices drowsiness and calls for medical help. In hospital, his temperature is 38.6 °C, oxygen saturation 89% on room air and respiratory rate 26 per minute. Chest radiography shows a right lower lobe infiltrate. He is admitted to a general medical ward with pneumonia and hypoxaemia.
Attention and orientation fluctuate; David confuses day and night and responds slowly. His sister describes an abrupt departure from his usual state. Acute onset and impaired attention direct assessment towards delirium associated with pneumonia.
The internist treats pneumonia and assesses oxygenation, hydration and glucose. The consultation-liaison psychiatrist establishes baseline functioning and clarifies possible medication contributions. The pharmacist checks actual use, recent doses, interactions and changes in smoking. David stopped smoking at home when he became ill and does not resume in hospital.
Infection and smoking cessation can raise clozapine concentrations. Because of drowsiness, the psychiatrist orders a clozapine level and reviews the dose. The internist continues to correct hypoxaemia, dehydration and metabolic abnormalities, while the pharmacist checks interactions. The three professionals agree on one plan. [126, 127]
Why a missed dose matters
Because of drowsiness, David missed several doses before admission. The team establishes the duration of the interruption: according to the Canadian monograph, after at least two days, treatment resumes at a low dose to reduce the risks of hypotension, bradycardia and syncope. [126]
His sister brings the pharmacy packs. These are compared with actual use and pharmacy information; after assessing toxicity and physical stability, the team plans retitration. They also monitor for returning psychotic symptoms during the transition.
As the pneumonia resolves, attention improves. David begins reading short newspaper items, remembers his plants and asks his sister to water them. She recognizes the familiar rhythm of his conversation.
Discharge and return to the community
Before discharge, the team assesses walking, nutrition, daily-living skills and residual weakness. The occupational therapist finds that David needs help with several new prescriptions. Home support is temporarily increased.
The pharmacy receives the final clozapine regimen, blood-test plan and the clozapine prescriber's contact details. Changes in physical health treatment are sent to the family physician. Smoking cessation and a plan to reassess the dose if David resumes cigarettes are documented separately.
At the first follow-up, David wants to remain tobacco-free and accepts support. Actual smoking status continues to be reviewed alongside clozapine tolerability. Within several weeks, he is shopping again, and psychotic symptoms return to their previous controlled level.