Restoring decision‐making capacity through ECT to enable clozapine initiation in treatment‐resistant schizophrenia: An ethical and clinical case report

Background: Treatment-resistant schizophrenia (TRS) is often accompanied by poor insight and impaired decision-making capacity (DMC), complicating the initiation of clozapine (CLZ) despite clear clinical indications. In Japan, CLZ utilization is markedly lower than in many foreign countries, partly due to concerns about adverse effects, mandatory blood monitoring, and difficulties in obtaining informed consent from patients with impaired DMC. Although CLZ can legally be initiated only with family consent, sustained treatment generally requires the patient's own agreement. Electroconvulsive therapy (ECT) may alleviate acute psychotic symptoms and temporarily improve DMC, thereby enabling informed participation in treatment decisions. Case Presentation: A woman in her late thirties with TRS persistently refused CLZ. On readmission, her Clinical Global Impression-Severity (CGI-S) score was 7. Pseudo-TRS was partly ruled out using a long-acting injectable antipsychotic (LAI). Following a multidisciplinary case conference in the psychiatric department and family proxy consent, ECT was initiated during involuntary hospitalization for medical care and protection in accordance with clinical practice recommendations for ECT endorsed by the Japanese Society of Psychiatry and Neurology (JSPN). After three ECT sessions, the patient's DMC improved sufficiently to allow voluntary consent to CLZ initiation. Twelve ECT sessions were administered while CLZ was titrated to 225 mg/day. The CGI-S score improved to 3, no serious adverse events occurred, and she was discharged approximately 120 days after admission with stable outpatient follow-up. Conclusion: This case demonstrates that ECT can function as a capacity-restoring intervention enabling voluntary CLZ initiation in selected TRS patients who initially lack DMC. In the context of low CLZ utilization in Japan, a staged approach combining acute stabilization and pharmacological consolidation may provide a clinically and ethically acceptable pathway when supported by multidisciplinary review and procedural safeguards.