Clozapine is used in combination with psychotropic medication and a wide variety of non-psychotropic medications. This article reviews the literature on clozapine drug interactions and the effect these have on serum level changes in clozapine. A total of 54 articles with a total of 109 individual case reports were obtained by manual and computerised literature search from January 1970 to May 2013. Psychotropic medications most likely to increase clozapine levels include: fluvoxamine, lamotrigine, aripiprazole and the discontinuation of levomepromazine and carbamazepine. Non-psychotropic medications associated with increase in clozapine levels include: erythromycin, ciprofloxacin, omeprazole, cimetidine, OCP containing ethinylestradiol, amiodarone, aluminum hydroxide and isoniazid. Rifampin and St John's wort resulted in low clozapine levels. Smoking cessation also increased clozapine levels. The role of routine clozapine monitoring in clinical practice requires further clarification. In the absence of recommendations for routine clozapine level monitoring, clinical judgment should always be used in addition to diagnostic testing. Clinicians must maintain increased clinical vigilance for adverse side effects when clozapine is combined with other medications.

Recent changes in the practice of inpatient psychiatry have minimized the emphasis on psychodynamic principles in the treatment of hospitalized patients. The concepts of transference and countertransference have taken a secondary role to rapid diagnosis, treatment and discharge. This paper explores the impact of countertransference on physician decision-making and clinical care through two case histories illustrating how countertransference can impact the assessment, treatment and management of the psychiatric inpatient. The authors discuss the concept of countertransference, its effect on physicians and hospital staff and strategies for recognizing and minimizing the impact of countertransference.