Often the final pathway for psychosis is the forensic services. In many other cases the only options are prison or no care at all. Despite much research into the psychopharmacological approach many patients are either unresponsive or unable or unwilling to take medication. Many clinicians would support the early use of clozapine for these patients but despite the availability of clozapine in Europe for nearly 20 years the numbers who are treatment resistant are still highly significant. This affects patients, carers and indeed potential victims and staff who are increasingly vulnerable. The eclipse of the typical anti-psychotics and the fear of extra-pyramidal side effects has led to many patients being prescribed oral atypical agents which they do not actually take. The result of, in many cases years, of untreated or part treated psychosis is severe cognitive damage. This then contributes to difficulty in managing the patient and lack of engagement in the therapy process. The emergence of new depot preparations may be the answer but the degree of D2 blockade may still not be sufficient and the addition of 5HT blockade may be also useful. In the forensic settings there is much made of risk assessment but the most efficient predictor of future risk is a stable patient on an effective treatment regime. Several options are described including double depot, high dose olanzapine and clozapine enhancement.