We report a case of an 84 year old woman with lingual-facial-buccal TD, due to treament for 10 years with Haloperidol 2 mg/day, after a single psychotic episode. A decision to switch to aripiprazole 10 mg/day was made. Over the next month, her TD gradually disappeared, and re-emerged after three months when the patient gave up treatment against our advice. We also review four other cases reported in the last two years with similar findings. These properties may play a role in both prevention of the emergence of TD and the treatment of TD. Aripiprazole may provide alternate pharmacotherapy to treat psychoses and TD.

Psychotropic drugs including some of the new generation of antidepressants and antipsychotics can have important effects on the cardiovascular system including changes in blood pressure and effects on the QTc interval. It is good practice to check ECG and blood pressure (BP) before the administration of certain psychotropic agents. It has been suggested that Psychiatrists should be able to interpret ECG's.

The aim of our study was to assess the facilities available in the Psychiatric clinic to check blood pressure and arrange ECG's. We were also interested to find out whether psychiatrists were confident in interpreting ECG's and clarify any associated training requirements. So, we carried out an anonymous postal survey of 260 consultant psychiatrists in the North West of England. Data were analysed with the Statistical Package of Social Sciences (SPSS) version 13 for windows.

132 consultants returned the completed questionnaires giving a response rate of 50.7%. A majority of respondents (59%) felt that it was difficult to arrange for ECG in the clinic and worryingly an even higher percentage (61.4%) lacked facilities to check blood pressure. Only a small minority (12.9%) felt confident about identifying QT prolongation on ECG. An overwhelming percentage of respondents (81.8%) respondents felt that doctors working in psychiatry should have regular training in interpreting ECG's.

This survey highlights the lack of facilities in mental health clinics to check blood pressure and arrange simple medical procedures like ECG. It also highlights the need for regular ECG training for psychiatrists

Some clinicians consider depot antipsychotics to be stigmatizing and coercive. Former coercion studies have predominantly considered hospital admission rather than medication. This cross-sectional study investigated patients' perspectives of coercion for depot and oral antipsychotics.

72 participants, with schizophrenia or schizoaffective disorder on voluntary maintenance medication were randomly selected for further in-depth interviews as a sub-sample from an antipsychotic attitudinal study. The MacArthur Admission Experience (short form) was adapted to explore coercion regarding medication. Scores were compared for formulation groups (depot versus oral).

Only 9 (12.5%) had no concerns about coercion. Coercion scores were higher for depot than oral in terms of total score (mean 4.39 vs 2.80, p=0.027), perceived coercion (2.52 vs 1.73, p=0.041) and negative pressures subscales (1.17 vs 0.33, p=0.009). No significant differences were found for the “voice” subscale (0.70 vs 0.73) and affective reactions. Specifically, more participants on depot felt that people try to force them to take medication (30% vs 2%, p<0.001).

To our knowledge, this is study is unique in that it reports specifically on coercion regarding both depot and oral antipsychotics, using systematic quantitative methodology. Participants felt that treatment with depots was more coercive than with oral antipsychotics and was associated with a relative lack of true autonomy. One reason for this might be that depots are “given” rather than “taken”; thus the “power of others” may be seen as more potent. Greater perceived coercion may explain why some consider depots to be a more stigmatizing form of treatment.

To assess the effectiveness of long lasting risperidone (LLR) in the drug compliance and its impact on health assistance resources.

A retrospective revision was carried out with patients admitted to the acute unit of our hospital between 1st September 2004 and 31st August 2005, with one of the following diagnosis: schizophrenia, schizoaffective disorder, bipolar disorder and delusional disorder; Choosing from those under treatment with LLR, we obtained a sample of 44 patients.

Clinical and demographical relevant variables were taken into consideration.

The study has a “mirror image” design where we compared data before and after the introduction of LLR using Student t test for dependant samples.

We observed a statistically significant decrease in the incidence and length of hospitalization following treatment with LLR. An increase in the number of psychiatric casualties was observed, although it had no statistical significance and the data were subject to bias.

LLR may increase the drug compliance and therefore reduce number and length of hospitalizations.

Long-acting injectable risperidone (RLAI) is effective and well tolerated in maintenance treatment in patients with schizophrenia. This kind of formulations improves compliance, and it has been recently published that RLAI reduces relapse and hospitalizations.

To evaluate whether treatment with RILD for 6 months is able to improve hospitalization rates and length, compliance with treatment and polypharmacy.

Medical records of 52 patients who had been treated with RILD for at least 6 months were reviewed. Data referred to the 6 months previous to treatment start were compared to those from the 6 months after treatment initiation. The evaluated parameters were: sociodemographic characteristics, number and length of hospitalizations, compliance with pharmacological treatment, attendance to consultations, and polypharmacy rates.

Mean age was 32.2+_11.1 years. The most frequent diagnosis was paranoid schizophrenia (40%). The main reason for the start treatment with RLAI was non-compliance (65%). A reduction of 50% in the number of hospitalizarions was observed after 6 months of treatment with RLAI, as compared to the previous 6 months (36 vs 14). Moreover, length of inpatient stays was also reduced after treatment with RLAI (mean of 17 vs 13.7 days). Compliance with pharmacological treatment and attendance to psychiatric consultation were also improved.

RLAI seem to be able to reduce number and length of hospitalizations, and improves adherence to therapy, 6 months after the start of the treatment, in real life conditions.

The aim of this paper is womens needs assessment in the new organisational concept of psychiatric care-community mental health care, which started with its implementation in Bosnia and Herzegovina in 1996 immediately after the war.

This study is retrospective and analytical-descriptive. As research instrument was used the Questionnaire for womens needs assesment in mental health care, which was designed for the purpose of this study and which has been applied at two groups,homogenious according to gender. Each group was consisted from 50 female patients.

The results of this study indicated the womens needs for inovative forms of community mental health care-the opportunity to choose woman as psychiatrist and women as team members, as well as the opportunity to use separate community mental health services-for women only.

The results of this study, which are in accordance with new womens community mental health care trends in USA and some Western European countries, obviously indicates the womens needs in mental health care. According to the study results, womens needs should be met in the early stage of new psychiatric care concept implementation.In the same time that would present in Bosnia and Herzegovina inovation of community mental health care, and also assure that womens mental health needs would be met at optimal way.

Patients diagnosed with schizophrenia or bipolar disorder are at an elevated risk of suicide attempts and suicidal ideation. Although atypical antipsychotics are effective in treating psychotic symptoms, the risk of suicide attempts and suicidal ideation may differ across these agents. We conducted an analysis on reported rates of suicide-related events associated with the use of atypicals.

Proportional reporting rates (PRR) of suicide attempts from the World Health Organization (WHO) database (through June, 2006) were compared across atypical antipsychotics. Using additional information from FDA's AERS (Adverse Event Reporting System; through March, 2006), similar comparisons were made for suicidal ideation, suicide attempts, and completed suicides.

From the WHO database, the PRR for suicide attempts was lowest for clozapine (1.3) followed by aripiprazole (1.5), risperidone (3.3), quetiapine (4.2), ziprasidone (4.7), and olanzapine (5.2). For AERS, the respective PRRs for suicidal ideation, suicide attempts, and completed suicides were: 1.1, 3.3, and 1.9 for clozapine; 3.2, 4.3, and 2.7 for risperidone; 5.6, 2.9, and 5.4 for aripiprazole; 6.9, 4.4, and 6.4 for ziprasidone; 4.3, 4.5, and 7.2 for olanzapine; and 5.6, 4.2, and 9.3 for quetiapine.

AE reporting systems suffer limitations, which include having a problematic denominator and biased reporting. However, AE reporting is a primary tool used to identify a signal through pharmacovigilance. In the data analyzed, variability across atypical antipsychotics seemed evident, and inconsistencies between data were observed. The reasons for these findings are unclear, but these results warrant further investigation in controlled studies.

Clozapine is an atypical dibenzodiazepine antipsychotic used for resistant schizophrenia. Myocarditis and cardiomyopathy are rarely reported complications of clozapine treatment. The incidence of clozapine-related myocarditis has been variably reported at between 0.03% and 0.19% Myocarditis is a potentially life-threatening complication of clozapine.

We reported a case of a 30-year-old female patient who developed reversible myocarditis a few weeks after we began the treatment with clozapine for chronic resistant schizophrenia (as specified in DSM-IVTR), characterized by severe left ventricular systolic dysfunction that resulted in congestive heart failure.

After the immediate discontinuation of the clozapine, along with aggressive supportive care, resulted in almost complete recovery to baseline.

Patients taking clozapine who develop dyspnoea, fatigue, chest pain or collapse should be screened for myocarditis, especially during the first weeks of treatment. Health professionals should be aware of this uncommon but serious side effect of clozapine since failure to recognize the association may result in adverse clinical outcome. Myocarditis should be suspected when cardiac dysfunction appears suddenly, and appropriate diagnostic and therapeutic strategies must be undertaken promptly.

No psychotropic drug has been approved by FDA for usage during pregnancy. Data on safety of the second generation antipsychotics in pregnancy and lactation are limited. Quetiapine is in FDA category C and limited human studies reported no abnormality during pregnancy, delivery and in the postnatal period after using quetiapine throughout the pregnancy. The foregoing is a case presentation of high dosage of quetiapine use during pregnancy.

Ms. N, a 30-year-old gravida one-para one woman, who had been treated for a diagnosis of bipolar affective disorder since 1994, experienced her third manic episode at the 21th week of her pregnancy, 6 months after quitting her lithium (1500 mg/day) treatment. When she was hospitalized, her mental status examination was positive for grandiose delusions, psychomotor agitation and pressured speech. Quetiapine 400 mg/day had been given the patient and the dose increased to 1200 mg/day in 15 days and then haloperidole 15 mg added to the treatment. During her stay at hospital her obstetrical and perinathological examination had done by consultant obstetrician and had been followed after discharge. At the follow up detailed ultrasound examinations, fetal echocardiography and blood investigations showed no abnormality. This combination was continued for 4 weeks and then haloperidole had stopped. Quetiapine 1200 mg/day was reduced to 400 mg/day slowly in 4 weeks period and the patient had stopped taking medicine 10 days later. 4 weeks after that, she gave birth to a healthy boy at 39th week of her pregnancy with C/S.

Naturalistic data on acute psychiatric inpatient treatment is scarce, data from RCT's are less relevant due to exclusion criteria for more severelly ill inpatients and lack of capacity to give informed consent. Treatment recommendations are influenced more by data on less acutely ill psychiatric inpatients.

All inpatients admitted to PICU during one month were screened for diagnosis (ICD-10), severity of illness and symptoms (CGI and GAS), therapy and speed of significant clinical improvement (observation) at admission, in 24 hours and at discharge.

227 consecutive PICU admissions were included, gender ratio=1, average GAS 41, CGI 5. Median lenght of hospitalization was 2.5 days. Atypical to typical antipsychotics ratio was 4:1, rate of clinical improvement was 35%. Results were compared with results of similar study 7 years ago and the difference in the profile of antipsychotic drugs usage was significant and favoured atypicals.

Antipsychotics and benzodiazepins are most often used drugs to control acute psychopathology. The use of classical AP's is diminishing in recent years without the lost of efficacy. The CPZ equivalent dosages are however higher then recommended in the literature and reflect more the everyday clinical practice.

Aripiprazole is a new antipsychotic with a different mode of action to established second generation antipsychotics. We aimed to study patients who were prescribed aripiprazole in routine clinical practice, to identify patients who had a good clinical response.

From a data set of 21,000 electronic patient records (starting in 2002), we retrospectively identified all secondary care psychiatric patients started on aripiprazole (n=180). We assigned an improvement score of Clinical Global Impression to these records to measure the effectiveness of aripiprazole. We examined demographic and clinical correlates of patients who improved (CGI scores <5) versus those who did not improve (CGI≥5).

Adequate records for analysis were available for 120 patients. 77 patients (64%) had a CGI 1-4 (minimally to very much improved). 43 patients (36%) had a CGI≥5 (no change to very much worse). The discontinuation rates were 17% (improved group), and 43% (no change to worse group) Those who did well could not be distinguished in terms of age, sex, mean duration of record availability (approx 700 days), diagnosis (>80% psychosis), duration of contact with services, or initial dose of aripiprazole (10mg). Patients who improved with aripiprazole were less likely (p<0.01) to be treatment resistant (previous or subsequent treatment with clozapine). Discontinuation was primarily due to agitation (29%) followed by inefficacy (23%) and worsening psychosis (10%).

Aripiprazole was clinically effective in around two-third of patients. Favourable response was associated with lack of treatment resistance. Agitation followed by inefficacy were the commonest reasons for discontinuation.

Few studies are available comparing the effectiveness of Risperidone long-acting injection (RLAI) against conventional depot antipsychotics. We aimed to study patients who were prescribed the long-acting injections Risperidone and Zuclopenthixol decanoate in routine clinical practice, to identify predictors of continuing longer-term treatment.

From a data set of 11,250 electronic patient records, we retrospectively identified all secondary care psychiatric patients Risperidone and Zuclopenthixol depots during a three years period (2002-2005). We calculated the duration of treatment ratio (DoTR) (duration of mention of medication divided by total duration of psychiatric record) as a measure of effectiveness. We examined clinical and demographic variables associated with high and low DoTRs, i.e. patients likely to continue versus those likely to discontinue treatment.

98 records were identified for Risperidone LAI, 70 for Zuclopenthixol. Patients who continued longer-term treatment were similar for both compounds in terms of age, sex, diagnosis, length of contact with services, previous Clozapine treatment and co-prescription with other psychotropics. Individuals continuing on RLAI long-term were on a higher maximum mean dose (42 mg every 2 weeks) compared to those who discontinued early (30 mg every 2 weeks) p=0.0002. Discontinuation due to adverse effects was less with RLAI than with Zuclopenthixol (26% versus 63%, p=0.06).

Both RLAI and Zuclopenthixol depot are clinically effective in longer-term treatment of psychotic disorders. Patients established on higher dose RLAI (37.5 mg and 50 mg per fortnight) were more likely on to continue long-term treatment.

Purpose of this study was to investigate patients perspective on service quality and their satisfaction with services. Also to ensure that the standards relating to patient assessment and treatment are adhered to and to ensure that all patients have the opportunity to comment on the services and that patient opinions are considered in future service planning.

An 8 items patient satisfaction questionnaire was devised by the author and was distributed to residents on discharge from two rehabilitation wards. Fifteen questionnaires were completed in the 18 month period.

Out of total of 15 cases, 53% were female and 47% male patient. Their mean age was 37.5 years and their mean length of stay in the rehab ward was 23 months. All patients were satisfied with admission process and environment of the wards. Significant majority satisfied with treatment received. To 87% this was their first admission to the rehab unit and the 93% reported that they would recommend the rehabilitation ward to a friend or relative and that they would use this unit again in the future.

Central issue emerged whether the patient was satisfied or dissatisfied with the care they recieved but they all suggested that the quality of care between the patients and individual member of staff were central to the quality of the care. The high quality therapeutic relationship and caring environment is the essence of satisfaction and it may determine the outcome of psychiatric treatment.

That RLAI are prescribed appropriately and patients are monitored on an ongoing basis. An audit tool was sent to each psychiatrist, data were collected retrospectively on 28 patients.

Out of 28 patients 19 still taking RLAI. Data not available on one patient. All patients had received oral atypical prior to RLAI. 23 were exposed to oral Risperidone. 80% reported significant improvement only 5 experienced mild side effects. 21 suffered from Schizophrenia and 6 from Bipolar Affective Disorder. At the time of initiation, 25 in patients and 3 in community. Significant improvement noted 2 months and 7 months after initiation. All of them were monitored regularly.

RLAI appears well tolerated and markedly effective in vast majority of patients only 3 patients showed negative response. RLAI can offer considerable benefit to a significant number of patients suffering from Schizophrenia and Bipolar Affective Disorder with psychotic symptoms.

In the UK, Black and minority ethnic (BME) patients have been reported to be disproportionately detained under the Mental Health Act.

Systematic review of all UK literature on ethnicity and detention with meta-analysis of detention rates for BME patients, to determine range of explanatory hypotheses and examine the evidence for these hypotheses

Electronic data bases searched for all date-based studies (1984-2005). Meta-analyses performed where data available. Explanations offered for any excess categorised and evidence examined.

49 studies identified, 19 included in meta-analyses. Compared with White patients, Blacks were 3.83 times, BME patients 3.35 times and Asians 2.06 times more likely to be detained. Racial stereotyping and discrimination against BME patients was the most often cited explanation (53% studies); followed by alienation and mistrust of psychiatric services (28%); higher rates of psychosis (22%); delay in help seeking (18%); and misdiagnosis/ under recognition of illness (16%). There was no primary evidence provided by any study to confirm any of these explanations, while some papers presented data that contradicted these explanations.

BME patients experience higher rates of detention under the MHA than White patients. Available explanations offered for this excess are largely unsupported. Explanations such as ‘institutional racism’ in psychiatry neither accurately account for the excess, nor help find ways of reducing detention rates.