Delusional disorder is traditionally considered a treatment resistant disorder. Antipsychotics are considered to be the treatment of choice despite information in this area is limited.

Describe a sample of DD inpatients, which received routine treatment.

To perform indirectly an efficacy analysis of long-acting injectable risperidone (RLAI) compared to oral risperidone and to others atypical antipsychotics.

Prospective observational study including 80 inpatients on DD, according to DSM-IV-TR, consecutively admitted over a period of 10 years, and who were treated with atypical antipsychotics. The sample was divided into three groups according to which antipsychotic received: RLAI, oral risperidone and other oral atypical antipsychotics (OAP). Sociodemographic data and clinical features at the first admission and indirect efficacy variables at follow-up were registered. For comparison purposes, ANOVA, Chi-square and Mann-Whitney test were used.

Twenty-four patients received RLAI (30%), 30 oral risperidone (37.5%) and 26 (32.5%) OAP. No statistically significant differences were found among the three treatment groups regarding demographic data, reason for hospitalization and psychopathology at admission. RLAI group showed a greater adherence to follow-up (15/24 with> 75% of visits) and percentage of maintenance at the end of the period. In addition, the RLAI group required less frequently treatment with antidepressants (n = 5/24, 20.8%) and benzodiazepines (54.2% vs 65.4% in other oral atypical antipsychotics).

Treatment with RLAI in delusional disorder improves adherence to follow-up in these patients. On the other hand, patients treated with RLAI require less frequently use of other psychoactive drugs.

Unfortunately, many patients who remit fully or partially from an episode of major depression with regular antidepressants have difficulties in the first four weeks of the treatment.

Our report assesses whether agomelatine has more rapid onset of effect or not in a major depressive patient.

A 28-years-old man with current major depressive disorder defined using DSM-IV-TR criteria was started to treat with 25 mg/day agomelatine. He was evaluated by daily CGI-S, BDI, HAMD-17, PSQI, and ISI during the treatment course.

The significant response has occurred at the 5th day of the antidepressant treatment. The term of response represents a clinically meaningful degree of reduction in depressive symptoms here (i.e. ≥50% reduction in baseline severity assessed by HAMD-17).

Agomelatine has approved in October 2011 for the treatment of depression in Turkey. This new antidepressant might produce earlier symptom improvement than comparator traditional antidepressants with its novel pharmacological profile as an agonist at melatonergic (MT1 and MT2) receptors and antagonist at 5-HT2C receptors. And, early symptom relief may, in part, be related to its regulatory effects on circadian and sleep-wake cycles. Finally, this therapeutic benefit suggests that agomelatine can be considered a first-line treatment for patients with major depression.

Thromboxane (TX) A2 and the activation of its receptor have been shown to modulate vasoconstriction, platelet aggregation, but also dopaminergic and serotonergic signaling.

As dopaminergic and serotonergic systems play a crucial role in the pathophysiology of schizophrenia and as these systems are main targets of antipsychotics, we hypothesized that antipsychotics might also influence TXA2 production.

We measured levels of TXB2, the metabolite of the very unstable molecule TXA2, in the stimulated blood of 10 healthy female subjects in a whole blood assay using the toxic shock syndrome toxin-1 (TSST-1) and the monoclonal antibody against the surface antigen CD3 combined with the protein CD40 (OKT3/CD40) as stimulants. Blood was either supplemented with antipsychotics (chlorpromazine, clozapine, and its metabolite N-desmethylclozapine with four different concentrations each) or not.

Under TSST-1 as well as OKT3/CD40 stimulation, mean TXB2 concentrations were significantly (p < 0.05) decreased by clozapine over all of the applied concentrations. N-desmethylclozapine led to a decrease in TXB2 levels under TSST-1 stimulation only. Chlorpromazine did not show any significant influence on TXB2 production.

Clozapine might, complementary to serotonin and dopamine receptor binding, act on the dopaminergic and serotonergic system via a modulation of TXA2 production. Additionally, side effects of clozapine such as orthostatic hypotension may be a result of the reported TXA2 changes.

In schizophrenic patients the atypical antipsychotics are the first choice of treatment to avoid serious side effects of neuroleptics on D2 classic motor pathways, however, can cause a major disruption in weight, glucose homeostasis and lipid, resulting in the dreaded metabolic syndrome.

Showing that the combination of aripiprazole with clozapine is a very useful therapeutic option in patients with schizophrenia who have risk factors for developing metabolic disorders.

To increase the scientific literature to help the investigation of neuroleptic drugs free of metabolic risks.

We describe the case of a 22 year old male patient with paranoid schizophrenia affection of 3 years of evolution with the development of iatrogenic metabolic disorders.

The occurrence of overweight and diabetes incipient efforts aimed at minimizing the side effects of clozapine and improve neuropsychological performance. It starts with aripiprazole 5 mg/d up to 30 mg in 3 weeks. We maintain 250 mg dose of clozapine in the blood, decreasing the metabolic dysfunctions and improving the affective flattening.

Aripiprazole is a new generation drug that facilitates ad integrum restitution of premorbid function in psychotic patients.

We must continue research on this molecule and the like Receptor affinities which make them attractive to work in partnership with other antipsychotics with proven efficacy but devastating metabolic effects.

A large list of benefits have been atributed to the long-acting-risperidone-injection (LARI) when treating the mentally ill, such us; less side effects, tolerability improvement, and better medication compliance.

Description of a sample of patients in treatment at a Valencian Psychiatric Medical Center (Buñol), with LARI; diagnosis, reasons why LARI was introduced and document the evolution of oral treatment since LARI was introduced.

Observational descriptive study. 32 patients included, from a Buñol Psychiatric Medical Center, treated with LARI.

Assessments included sociodemographic data (sex. age, diagnosis, years illness, LARI dose, number of pills per day taken when LARI was introduced and at present time). SPSS (v15.0).

N=32 patients; 3 women, 29 men.

Diagnosis; 65% Psychotic Disorders (47% Schizophrenia, 15% Schizoafective disorder, 3%

Delusional Disorder) 12,5% Personality Disorders, 9,5%

Mentally Retarded, 12,5% Other

Reasons why LARI was introduced; 47% non compliance, 37% side effects with oral or other LAI treatment (long acting injection).

LARI treatment duration; 5 years (rank 1–14) and the LARI mean dose; 68 mg/14 days (rank 25–150 mg).

Mean number of pills/day when LARI was introduced; 5,5 pills/d (rank 1–13), and at present time; 4 pills/day (rank 0–11).

Oral antipsychotic treatment was retired in; 37,5%.

Non compilance is the main handicap physicians have to deal with; the CATIE study revealed that 74% abandoned treatment. Though it is difficult to reach monotherapy, a long acting injection antipsychotic (such us LARI), can help to simplify oral treatment, and therefore improve adherence, essential for an adequate clinical outcome.

Describe the possibility that medications without anticipated anticholinergic effects can have that type of side effect.

We would like to present a 57-year-old patient, admitted to hospital because symptoms of major depressive episode with psychotic features. The main symptoms were auditory delusions with imperative character, base diminished mood and unregulated restless sleep. Psychological testing is obtained and showed the difficulty in sustaining attention, confused thinking, a strong depressive shift, a drop of vital energy, hypersensitivity, which turned into projections.

At the beginning of hospitalization were corrected prescribed drugs before admission and transferred to fluvoxamine and at sixth day of hospitalization, quetiapine was added, with a gradual reduction until the termination of risperidon and promasinum. Within a week after taking fluvoxamine in dose of 200 mg per day patient allege the occurrence of dry mouth.

Regard that the quetiapine and fluvoxamine usually have tha side effect of dry mouth, We have decided to reduce the dose of fluvoxamine on the usual daily-defined dose of 100 mg and the dose of quetiapine keep the same, because at lower doses at patient were still present auditory hallucinations.

Regard that the reduction of dose of fluvoxamine showed also reduction of side effect, we believe that in the presented case fluvoxamine was drug responsible for the appearance of aforementioned side effect, although we do not exclude a synergistic effect.

Many patients with major depressive disorder fail to achieve remission with standard antidepressant therapy. Current options for the management of treatment resistant depression (TRD) comprise dose optimization, switching within or between drug classes, augmenting with other drugs and combination strategies. However, the application of combination treatment may be limited by adverse side effects.

From February 2010 to February 2011, twelve inpatients with TRD were retrospectively identified as being treated with a combination of agomelatine and bupropion after discontinuation of former antidepressant treatment. Mean doses of agomelatine at the end of treatment were 47.9 ± 7.2 mg/d, and bupropion 325 ± 86.6 mg/d. Intensity of depressive symptoms was routinely assessed using Beck's Depression Inventory-2. Response was defined as decrease of BDI sum score by 50%, and remission as BDI sum score below 13. Metabolic parameters and adverse side effects were routinely measured. Statistical analysis was performed using paired t-test and repeated measurements ANOVA with degree of TRD as covariate, and unpaired t-test for gender comparisons.

Eight patients showed response, and seven reached remission after 6–8 weeks of inpatient treatment. This effect was independent of the degree of TRD.

How to continue antidepressive treatment after an initially unsuccessful trial is a vital question. However, guidance as to which option is to be favoured remains limited. In particular, the use of antidepressant combinations to address TRD is understudied. We have shown that combination treatment with agomelatine/bupropion in TRD may lead to significant symptom relief. Future randomized controlled trials are needed to confirm our results.

Escitalopram(ESC) is a selective serotonin reuptake inhibitor(SSRI)which has been shown to be an effective treatment for major depressive.

We report a case of a 52-years old female patient who after approximately 1 month of therapy with ESC, progressively titrated up to 20mg/day developed a bilateral ankle oedema, which resolved completely within the first week following its discontinuation.

To prove the connection between ESC and cutaneous effects(oedema).

The patient was suffering from depressed mood most of the day, fatigue, diminished ability to think or concentrate, insomnia,feelings of worthlessness and periods of sweating, chest pain, dizziness and fear of losing control. Escitalopram was administered with a initial dose of 10 mg once a day that over a period of one week increased to 20 mg once a day. Three weeks later the patient's depressive symptoms improved a signifigantly. However she complained about a swelling in both her feet and she could hardly wear her shoes.The clinical examination revealed a bilateral ankle oedema. Clinical and laboratory evaluations (electrocardiogram, ultrasonography, blood tests, albumins, renal and thyroid function tests, serum electrolytes)didn’t reveal any pathological findings. There was also no history of areterial hypertension, and after repeated measurements her arterial pressure was within normal range.

Escitalopram was discontinued and the patient was treated with paroxetine 20 mg/day.The patient's oedema resolved completely within ten days after escitalopram discontinuation with no reappearing.

Bilateral ankle oedema it's a rare side effect during therapy with ESC.

To report about occurence of side effects of different antidepressants during treatment of a patient with depressive disorder.

Patient, 42 years old, was admitted to our Clinic for psychiatry due to worsening in her mental condition. At admission, the patient was anxious, depressed, and members of her family said that she stopped eating and isolated herself from her family and other people. Also, she spent most of the time in bed. After admission to the hospital the laboratory examination was performed and results were in referent ranges. Also, EEG and brain MRI were performed (normal findings). The patient was diagnosed with depressive disorder. The treatment with duloxetine in daily dosage of 30 mg, along with lorazepam in daily dosage of 2,5 mg was initiated, but vomiting occured and the treatment with duloxetine was discontinued. After that velafaxine was introduced in therapy. Soon after that headache occured and treatment with venlafaxine was discontinued. The therapy with tianeptine in daily dosage of 37,5 mg was initiated and after two weeks the symptoms of depression and anxiety were reduced. Also, the patient started communicating more with other people and showed interest in the environment. Gradually, daily dosage of lorazepam was reduced and treatment with lorazepam was discontinued. The patient was discharged from the hospital after six weeks of treatment. At control examinations that followed her mental condition remained stable and she started work again.

Pharmacologic treatments for nightmares are limited. Increased adrenergic hyperresponsiveness has been postulated as a mechanism in the pathophysiology of Post-Traumatic Stress Disorder (PTSD). Prazosin, a central alpha-1 adrenergic receptor antagonist, has been studied for PTSD-related nightmares.

To review evidence for prazosin to treat PTSD and non-PTSD nightmares.

A systematic review using MEDLINE/PubMed, EMBASE, EBM Review, Google Scholar, and Web of Science. Two authors reviewed abstracts and selected clinical reports of prazosin treatment.

Of 115 abstracts, 19 studies met criteria: 3 randomized, double-blind, placebo controlled trials; 3 open label case series; 5 retrospective chart reviews; and 8 case reports. 183 evaluable patients (135 veterans and 48 civilians; 163 males) were described. Only one study did not confirm a PTSD diagnosis, but commented that their patients had symptoms consistent with PTSD. Common outcome measures were the Clinician Administered PTSD Scale (CAPS) items B2 (“recurrent distressing dreams”) and D1 (“difficulty falling or staying asleep”), and the Clinical Global Impression of Change (CGI-C). The CAPS-B2 and CGI-C consistently showed improvement in patients treated with prazosin. There were reports of patients relapsing with nightmares when they discontinued prazosin. Effective dosages ranged from 1 mg to 16 mg. Common side effects included dizziness, and blood pressure changes were not significantly affected. Prazosin was well tolerated, even by elderly patients.

Despite small sample sizes, the evidence supports the use of prazosin for PTSD-related nightmares. However, there was no evidence for its use in non-PTSD nightmares. Future larger studies would be informative.

Clomipramine is a tricyclic antidepressant with potent serotonin reuptake blockade. It is one of a few antidepressant medications available in the intravenous form and is the only one available in Tan Tock Seng Hospital (TTSH), Singapore.

Studies have provided evidence that intravenous clomipramine is useful in the treatment of major depression and obsessive-compulsive disorders. Other possible indications include post-traumatic stress disorder and anxiety disorder.

Methods of delivering intravenous clomipramine varied in the literature, with starting doses ranging from 25 mg per day to 150 mg per day and final dosages ranging from 150 mg per day to 250 mg per day, either via pulse loading or gradual loading.

The study aimed to analyze the demographics, indications for treatment, dosage and frequency of administration, complications of treatment and co-morbid psychiatric conditions of patients who were treated with intravenous clomipramine in TTSH over the period from January 2007 to December 2011.

A retrospective study was performed on all inpatients admitted under the Department of Psychological Medicine in TTSH who were treated with intravenous clomipramine over the specified period.

The common indications for treatment include mood and anxiety disorders. The dosage given per day ranged from 25 mg to 150 mg. No mortality or severe adverse events resulted from the treatment.

The use of intravenous clomipramine may provide clinicians with a safe, fast-acting and efficacious therapy modality for acute management of several psychiatric disorders. Further large-scale studies will be useful in providing evidence to support its clinical use in psychiatry.

The main aim of this study is to investigate the capacity of a number of variables from four dimensions (clinical, psychosocial, cognitive and genetic domains) to predict the antidepressant treatment outcome, and combined the predictors in one integrate regression model with the aim to investigate which predictor contributed most.

In a semi-naturalistic prospective cohort study with a total of 241 fully assessed MDD patients, decrease in HAM-D scores from baseline to after 6 weeks of treatment was used to measure the antidepressant treatment outcome.

The clinical and psychosocial model (R2 = 0.451) showed that HAM-D scores at baseline and MMPI-2 scale paranoia was the best clinical and psychosocial predictor of treatment outcome respectively. The cognitive model (R2 = 0.502) revealed that combination of better performance on TMT-B test and worse performance on TOH and WAIS-R Digit Backward testes could predict decline in HAM-D scores. The genetics analysis only found median of percent improvement in HAM-D scores in G-allele of GR gene BclI polymorphism carriers (72.2%) was significant lower than that in non-G allele carriers (80.1%). The integrate model showed that three predictors, combination of HAM-D scores at baseline, MMPI-2 scale paranoia and TMT-B test, explained 57.1% of the variance.

Three markers, HAM-D scores at baseline, MMPI-2 scale paranoia and TMT-B test, might serve as predictor of antidepressant outcome in daily psychiatric practice.

Efficacy of antipsychotic medications is nowadays confirmed, but their effectiveness is biased by the generally low compliance to therapy associated to psychotic patients. Psychiatric intramuscular depot pharmacotherapy represents a good option to increase compliance and to improve the outcome.

We indirectly assessed compliance to oral antipsychotic therapy by psychopathological and clinical scores, and compared it to results obtained on patients who were assuming intramuscular antipsychotic therapies, whose compliance is assumed to be total.

Our purpose was to discriminate differences in outcome between clients who were provided a psychopharmacological oral treatment, and those who take a depot psychopharmacotherapy.

We collected psychopathological and clinical data on 100 schizophrenic patients attending our outpatient psychiatric services; we divided our sample in two subgroups according to the type of therapy (oral vs depot). We matched patients depending on sex, age, schizophrenia subtype and age at onset, and compared psychopathological variables (BPRS, PANSS, NRS, SWS and number of hospitalizations) on 32 couples.

We did not find any statistically significant difference between the two subgroups, as regards the outcome.

Efficacy to long-term oral antipsychotic therapy is similar to that shown by depot medications, suggesting that compliance between the two types of long-term therapies is high and comparable. We conclude that, balancing the pros and cons while choosing the typology of treatment, doctors should pay more attention to patient's needs and preferences and to a good therapeutic alliance rather than to potential side effects and general outcome.

Metabolic side effects of clozapine represent an important treatment limitation. Ziprasidone is a new atypical antipsychotic with low affinity to hystaminergic H1 and adrenergic alpha 1 receptors and few effects on body weight, metabolic parameters and cardiovascular system.

To confirm the efficacy and tollerability of ziprasidone as adjunctive therapy in Schizoaffective or bipolar patients partially responder to clozapine or with persisting negative symptoms, metabolic syndrome or overweight.

8 patients with psychotic Bipolar Disorder or schizoaffective disorder were tested with the BPRS, the HAM-D and the CGI at T0 and retested after 2 weeks (T1). Plasma clozapine and norclozapine levels, concomitant treatments, BMI, cholesterol and tryglicerides (in patients at cardiovascular risk) were tested at T0 and T1.

Ziprasidone was well tolerated by all the patients. BPRS and HAM-D scores were reduced in all patients. Concomitant antipsychotics and mood stabilizers were reduced. Patients at cardiovascular risk showed a reduction of total cholesterol, Cholesterol LDL and triglycerides. BMI was reduced in patients with a BMI at T0 higher than 25. Plasma levels of clozapine and norclozapine showed an irregular course.

The adding of ziprasidone consented a better control of metabolic parameters in patients with cardiovascular risk and a reduction of the severity of the disorder. Ziprasidone showed an efficacy on negative and depressive symptoms.

Antipsychotic monotherapy is recognized as the treatment of choice for patients with psychosis but concurrent use is increasingly common among both inpatients and outpatients.

Previous studies of the prescription patterns of psychotropic medications in psychotic patients have highlighted a high rate of antipsychotic polypharmacy, but data in Iran are sparse. This study seeks to analyze prescribing patterns of antipsychotic use and to estimate associated risks in this patient group.

The aim of this study was to investigate the prevalence and its determinants of Antipsychotic Use in patients with psychiatric disorders in the greatest psychiatric hospital (Razi) in Iran.

This study was on patients with psychiatric disorder that have discharged from the hospital during four months. We have assessed all patients with psychiatric interview and evaluation of their psychiatric documentations.

Results of this study indicated that the most prevalent of psychiatric diagnosis was schizophrenia (33.42%) and then Bipolar I Disorder, Schizoaffective Disorder, Mental Retardation and Amphetamine-Induced Psychotic Disorder. 90.7% of all of patients had taken antipsychotic medications and antipsychotic polypharmacy was in 27.2% of these patients. The most prevalent component of antipsychotic polypharmacy was consisting of Chlorpromazine, Halopreidol and Chlorpromazine, Risperidone and then Chlorpromazine, Olanzapine respectively. There were significant relations between pattern of antipsychotic use and gender, occupation status, type of psychiatric ward, duration of hospitalization and cost of treatment but no relationship with age, educational status and duration of illness.

This study suggests that prevalence of antipsychotic polypharmacy is high in in-patient psychiatric patients.

Case-report, Literature review and Discussion.

AB was a 29 year old transsexual admitted with a two week history of paranoid delusions and auditory hallucinations. He had recently reduced his Oestrogen tablets from 4 mg to 2 mg per day. He had also been taking Meizitang “a natural herbal” slimming pill, bought online. He presented with paranoid, persecutory delusions, first and third person auditory hallucinations and poor insight. He was treated with Quetiapine, recovered completely within 2 weeks and was discharged.

We propose that the reduction in Oestrogen levels, the intake of Meizitang and the cognitive dissonance associated with his gender identity contributed to the development of psychosis. Our literature review revealed several studies that implicated Sibutramine (which Meizitang is known to be adulterated with) as an aetiological factor for psychosis. We also report on studies that demonstrated the anti-psychotic effects of Oestrogen.

This case highlights the need for further studies on both the protective effects of Oestrogen in psychosis and the psychogenic effects of Meizitang. We recommend increased awareness amongst clinicians about the potential risk of psychosis associated with Meizitang.

Second-generation antidepressants dominate the medical management of major depressive disorder (MDD). Two published CERs provide conflicting evidence about the comparative efficacy and safety of second-generation antidepressants for the treatment of MDD.

To compare the benefits and harms of bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazodone, and venlafaxine for the treatment of MDD in adults.

We updated a CER published in 2007 by the Agency for Healthcare Research and Quality searching MEDLINE, Embase, The Cochrane Library, and the International Pharmaceutical Abstracts up to May 2010. Two persons independently reviewed the literature, abstracted data, and rated the risk of bias. If data were sufficient, we conducted meta-analyses of head-to-head trials of the relative benefit of response to treatment. In addition, we conducted mixed treatment comparisons to derive indirect estimates of the comparative efficacy among all second-generation antidepressants.

Overall, no substantial differences in efficacy could be detected among second-generation antidepressants. Statistically significant differences in response rates between some compared drugs are small and likely not clinically relevant. Differences exist in the incidence of specific adverse events and the onset of action. Venlafaxine leads to higher rates of nausea and vomiting, sertraline to higher rates of diarrhea, and mirtazapine to higher rates of weight gain than comparator drugs. Bupropion caused lower rates of sexual dysfunction than other antidepressants.

Our findings indicate that the existing evidence does not warrant the choice of one second-generation antidepressant over another based on greater efficacy and effectiveness.

Maintenance antipsychotic medication has a key role in the long term management of schizophrenia but in clinical practice its effectiveness is often reduced by poor adherence. Antipsychotic long acting injections (LAIs) can improve clinical outcomes in those who have adhered poorly with oral medication.

To compare patients’ attitudes, satisfaction and tolerability to their currently prescribed LAI, either a FGA-LAI or risperidone long-acting injection (RLAI), which was the only SGA-LAI at the time of this research.

Cross-sectional survey of a representative sample of patients prescribed a FGA-LAI (n = 39) or RLAI (n = 28) for a minimum of 6 months. Assessments comprised drug attitude inventory (DAI-30), tolerability measured by Liverpool university neuroleptic side effect rating scale (LUNSERS) and satisfaction with antipsychotic medication by the SWAM scale.

The DAI-30 score for patients on FGA depots was 16.18 and RLAI was 14.43, which indicated positive attitudes in both the groups. This difference did not reach statistical significance (p = 0.491). Further analysis, based on both the LUNSERS and SWAM scales, did not find any significant difference in tolerability and patient satisfaction.

There was no evidence of differences between FGA-LAIs and RLAI in terms of patient rated tolerability, attitudes and satisfaction. Both groups of patients had positive attitudes to their LAI and overall tolerability was good. This data is observational, and not from a randomised design, which may reflect selection bias. Randomised studies are needed to further investigate differences in tolerability and attitudes between specific LAIs.