Treatment-resistant schizophrenia — structured clinical viva

This is true TRS by TRRIP-style criteria: two adequate antipsychotic trials failed with adherence reasonably confirmed, pseudo-resistance reasonably excluded. Confirm ongoing risk, residual symptoms, smoking status, and psychosocial package. Measurement-based care continues.^[1][6]

Clozapine is the evidence-based next step — Kane established superiority in defined TRS. Consent must cover benefits (unique efficacy; InterSePT suicide signal in high-risk schizophrenia) and risks (neutropenia monitoring, early myocarditis vigilance, constipation/ileus, metabolic effects, seizures, sedation). Monitoring infrastructure is non-negotiable: no bloods, no drug; slow titration; smoking/CYP1A2 education.^[2][3][5][6]

LAI is not the primary next step here because adherence was already verified on the failed trials — explain that monthly injections address adherence-related pseudo-resistance, not true pharmacological TRS. LAI remains useful later for other reasons but does not replace clozapine once TRRIP is met.^[1][6]

ECT is not automatic next before clozapine; it becomes highly relevant if clozapine later fails adequately (ultra-TRS) — Petrides supports ECT augmentation of clozapine for persistent positives. Discuss consent, cognitive risks, and anaesthetic pathway calmly.^[4]