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A 34-year-old divorced man with a 16-year history of schizophrenia lived with his parents, but harboured persistent overvalued paranoid ideas towards his father.

When these ideas reached psychotic intensity, he was detained in a psychiatric hospital: he had bizarre thoughts in relation to telepathy via high power voltages and a belief that his father was forcing him to inhale chemicals to control his brain.

The patient was a heavy smoker, caffeine abuser and episodic binge drinker. His insight was poor, and he held his father responsible for both auditory and olfactory hallucinations. Treatment with oral neuroleptics was attempted but compliance (as in previous hospitalisation) was poor and depot haloperidol was introduced. His detention order was revoked by the State Guardianship Board but a community treatment order (enforceable like a detention order, allowing for return to detention if community treatment is not maintained) was conceded after much debate.

Given the man's residual paranoia and lack of insight, his general practitioner agreed to provide regular intramuscular depot medication.

The situation at the family home became increasingly tenuous due to the patient's lack of personal self-care and his father's intolerance of his son's lack of motivation and increased paranoid ideation. Although two attempts at inpatient rehabilitation were undertaken, the situation at home remained poor and response to antipsychotics and augmenting treatment strategies left the patient with persistent paranoid beliefs and olfactory hallucinations pertaining to the "chemicals".

Although the level of disability was endured by the parents, the situation reached crisis when the patient expressed clear homicidal ideation towards the father and thoughts of mass destruction with nuclear weapons.

Prolonged hospitalisation led to little improvement and clozapine therapy was instituted. The patient made a modest recovery and, although thought-disordered, developed sufficient insight to distinguish his illness-related experiences from reality.

After 10 weeks of clozapine therapy, however, he felt that he should return home. Due to the distance from the clozapine clinic, his general practitioner was contacted and agreed to partake in a cooperative prescribing and monitoring arrangement. The patient continued to improve at home and resumed work in the family business. The hostility between him and his father diminished as he became more active, his father became less critical and the paranoid ideation towards his father gradually abated. Compliance with clozapine therapy was confirmed by regular tests of serum clozapine levels.

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