Objective symptoms of akathisia in the absence of subjective symptoms is known as pseudoakathisia, more often diagnosed in older patients with long-term antipsychotic treatment.

To describe a case of pseudoakathisia in a patient with clotiapine abuse.

Pseudoakathisia management.

X is a 47-year-old male with chronic insomnia treated with clotiapine 40 mg/day for four years. He admits abusive neuroleptic consumption in the past eight months (160 mg/day), without any psychiatric control for years. In recent months he has experienced different organic complications, requiring multiple hospitalizations. During psychiatric examinations due to confusional states, repeated lower limbs movements were objectified. X reported he presented these movements for at least six months, without complaints of inner restlessness feeling. Neurological examination showed normal DAT-SCAN result. Clinical progression was evaluated using BARS scale (Barnes Akathisia Rating Scale).

Following the results of tests and statements of drug history, X was diagnosed with clotiapine-induced pseudoakathisia. Neuroleptic treatment was suspended, and clonazepam 6 mg/day and propranolol in ascending doses up to 80 mg/day were initiated. In subsequent evaluations, progressive decrease in movement intensity was observed. However, complete remission after four months from clotiapine suspension was not achieved.

Pseudoakathisia is a concept not well defined at this moment and different hypotheses about its nature are considered. It has been suggested that it is a form of delayed dyskinesia, or a clinical progression from akathisia, with acquired subjective discomfort tolerance. The most widely used treatment includes benzodiazepines, beta-blockers and anticholinergics, although their effectiveness is limited.

The authors have not supplied their declaration of competing interest.

1. Reduce overall medication expenditure while maintaining standard of care. 2. Develop a program to return unused medications for refund.

1. Monthly review of pharmacy cost by facility, patient and medication. 2. Development and legislative approval of a program to return drugs. 3. Collaborate with contracted pharmacy to explore ways to cut costs. 4. Train nurses and physicians to understand optimal ordering practice. 5. Demonstrate medications wasted with associated financial impact to the facility.

The expenditure to the facility over 11 years has gradually decreased despite increase in medication costs. In 2004, the facility spent $ 712,904 and in 2014, the expenditure was $ 584,022.

Awareness about costs and optimal ordering practices led to significant savings to the facility.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

The association venlafaxine-mirtazapine is currently known as California Rocket Fuel (CRF). Studies show advantage in terms of efficacy and rapid control of depressive symptoms compared to other associations. Venlafaxine is a selective serotonin-noradrenalin reuptake inhibitor and mirtazapine is a noradrenergic-specific serotonergic antidepressant: the result is a potent noradrenergic and serotonergic effect. Studies say that CRF should be performed only for drug-resistant depression; however, there are case reports of its use as a first line treatment, in selected patients.

To summarize the latest literature about this field and to present a case report.

To explore and critically review the controversies of venlafaxine-mirtazapine association as a first line antidepressants strategy.

A brief review of the latest literature was performed, using PubMed and the keywords “venlafaxine-mirtazapine association”. A case report about a depressed woman is presented.

Despite most studies are referent to its utility in drug-resistant depression, there are recent pilot studies that recommend CRF as a first line option.

M., a 64-year-old woman, had her first psychiatric consultation. She had been depressed for 2 years, she lost 10 kg, had total insomnia and suicidal thoughts. CRF was started up to 150/15 mg, daily. An improvement was noticed after two weeks of treatment and the stabilization of depressive symptoms were achieved by the fourth month.

CRF seems to be effective and useful. Patients with insomnia and weight loss may benefit from CRF as a first line option. However, more studies are needed.

The authors have not supplied their declaration of competing interest.

Smoking rate seems to be higher among patients with schizophrenia, comparing to other psychiatric entities, mainly in those who are on typical antipsychotics. Tobacco is known to have enzyme inducer properties, due to cytochrome P450 complex activity: CYP1A1, CYP1A2, CYP2E1 and CYP2D6. CYP2D6 and CYP1A2 play an important role in antipsychotics metabolism, mainly in the first generation ones, like haloperidol, despite its importance in risperidone metabolism.

To analyze the importance of tobacco smoking in patients taking long-action injections.

To investigate how sexual dysfunction varies with tobacco smoking, in patients taking long-action injections.

Individuals from both sexes, from 18 to 55 years old, taking antipsychotic long-action injections, answered the Arizona Sexual Experience Scale (ASEX).

In the studied population (n = 44), there were 20 individuals on haloperidol and 24 individuals on risperidone. In a total of 18 (40.9%) positive results for sexual dysfunction, 6 were on haloperidol (30%), 12 (50%) were on risperidone. Seventeen individuals of the 20 who were on haloperidol were smokers, but only 4 were considered to have sexual dysfunction, 35.3%; 12 of the 24 individuals who were on risperidone were smokers, but only 5 were considered to have sexual dysfunction, 41.7%.

Patients treated with haloperidol smoke more, comparing to risperidone. Sexual dysfunction is more frequent in patients taking risperidone than in patients taking haloperidol. This data supports that CYP2D6-CYP1A2 induction by tobacco, mainly interacts with haloperidol, which may be helpful for patients to try less side effects.

The authors have not supplied their declaration of competing interest.

Interferon combined with ribavirin is widely used to decrease the burden of Hepatitis C virus (HCV), but some serious side effects might limit its usefulness. There has been recently a growing awareness about neuropsychiatric complications of many drug treatments. Anecdotal case reports of HCV treatment induced psychosis were published but there seems to be no consensus about the causative relation and no systematic reviews were done to the date.

To describe a paradigmatic case that was managed as an iatrogenic psychotic episode following interferon associated with ribavirin.

Call attention to problems that interfere with the recognition, diagnosis and management of drugs induced psychosis.

Bibliographic research was conducted through the PubMed in the Medline library and clinical information was obtained through medical records and clinical interviews with the patient.

A 50-year-old Brazilian woman, with a previous episode of postpartum depression, presented with paranoid psychosis six months after initiating HCV antiviral therapy. Psychotic symptoms consisted of persecutory delusions and auditory hallucinations and developed together with agitation and aggressive behavior. Psychiatric hospitalization was required and psychosis resolved with discontinuation of therapy and initiation of risperidone. Laboratory tests and brain images were of no help in the etiologic investigation.

There are many drugs known to possibly cause neuropsychiatric symptoms. It is the job of every physician to be aware of this hypothesis especially in cases with acute onset and atypical presentations.

The authors have not supplied their declaration of competing interest.

There is evidence that supports the increased risk of developing psychosis or psychotic like symptoms in vulnerable populations after use of cannabis. Cannabis’ main psychoactive component, Δ9-tetrahydrocannabinol (THC), induces acute psychotic effects and cognitive impairment. But there is also evidence to suggest that molecules in the cannabis plant could have an antipsychotic affect.

In this review we are trying to explore the possibilities of cannabis use as a therapeutic agent in mental disorders.

Thorough research of the main databases, and web search engines for relevant studies, using appropriate keywords. We scrutinize them independently, before reaching consensus about appropriateness.

In animal models repeated treatment with cannabis constituent cannabidiol CBD or the atypical antipsychotic clozapine attenuates or reverses the schizophrenia-like behavioral disruption.

In humans there are data that CBD counteracts psychotic symptoms and cognitive impairment associated with cannabis use. Also CBD may lower the risk for developing cannabis use associated psychosis. There are opposite effects of CBD and THC on brain activity patterns in key regions implicated in the pathophysiology of schizophrenia, such as the striatum, hippocampus and prefrontal cortex.

The possible mechanism of action of GBD is not fully clarified, as it may involve anti-inflammatory or neuroprotective properties. These initial clinical studies with CBD treatment of psychotic symptoms argument the potential of CBD as an effective antipsychotic compound. Mechanisms responsible for these effects need to be further investigated.

The authors have not supplied their declaration of competing interest.

The plant that has as active ingredient nicotine was chewed or smoked for many years from American natives, for its therapeutic properties. Nowadays after the extensive negative attitude towards smoking, the main provider of nicotine, researchers are now pointing out the therapeutic possibilities of nicotine in mood disorders, as a substance that is acting in the acetylcholine receptors in the brain.

In this review we are trying to explore the possibilities of nicotine use as a therapeutic agent.

We did a detailed research of the main medical databases, and web search engines for relevant studies. We scrutinize them independently, before reaching consensus about appropriateness for inclusion in the study.

Diadermal administration of nicotine has a positive effect in depressive disorder in 3–8 days, an effect that in one study was reversed after cessation of nicotine. Patients with depression and/or healthy subjects show improvement of attention and working memory after diadermal use of nicotine. Research is not conclusive in the sustainability of these positive affects as other researchers emphasize their short effect in mood.

Nicotine presents as part of novel and promising therapeutic agents with complex interactions with other neurotransmitters in the brain. Before condemning nicotine along with smoking we should acknowledge the potential use of nicotine as a therapeutic compound since research shows that some of these positive effects appear not only to smokers after abstinence but also to non-smokers.

The authors have not supplied their declaration of competing interest.

Extrapyramidal symptoms are well known as side effects in therapy with antipsychotics. Explore this side effects is mandatory because they normally are a cause of treatment discontinuation or assess a change in medication. Some studies notice how long acting injectable antipsychotic cause less extrapyramidal symptoms than oral treatment, others does not find differences.

The aim of this study is to analyze the extrapyramidal symptoms presented on a group of patients treated with aripiprazole long acting injectable (ALAI) follow-up in a mental health care center.

Descriptive study of a group of patients treated with ALAI. To assess the possible extrapyramidal symptoms due to treatment we have used the Simpson-Angus Scale (SAS). The follow up was 3 months after initiation of treatment.

Six patients were included in the study, 2 women (33.3%) and 4 men (66.7%). The mean age of the sample was 37 years old. The different diagnoses of the group were 4 patients with psychotic disorder (66.7%; 2 schizophrenia, 1 schizoaffective disorder and 1 delusional chronic disorder) and the other 2 had an affective disorder (33.3%; both bipolar disorder). The average score for the SAS was 1.2 meaning normal results and therefore no significant extrapyramidal symptoms.

In our sample the average of the results obtained by applying the SAS is considered within normal limits. In our case as to extrapyramidal effects ALAI treatment has been well tolerated. A larger sample would be needed to obtain more reliable results.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

To examine the effects of asenapine on NO release and Ca2+ transients in H9C2, which were either subjected to peroxidation or not.

H9C2 were treated with asenapine alone or in presence of intracellular kinases blockers, serotoninergic and dopaminergic antagonists, and voltage Ca2+ channels inhibitors. Experiments were also performed in H9C2 treated with hydrogen peroxide. NO release and intracellular Ca2+ were measured through specific probes.

In H9C2, asenapine differently modulated NO release and Ca2+ movements depending on the peroxidative condition. The Ca2+ pool mobilized by asenapine mainly originated from the extracellular space and was slightly affected by thapsigargin. Moreover, the effects of asenapine were reduced or prevented by kinases blockers, dopaminergic and serotoninergic receptors inhibitors and voltage Ca2+ channels blockers.

On the basis of our findings we can conclude that asenapine by interacting with its specific receptors, exerts dual effects on NO release and Ca2+ homeostasis in H9C2; this would be of particular clinical relevance, when considering their role in cardiac function modulation.

The authors have not supplied their declaration of competing interest.

Johann Gottlieb Burckhardt-Heussler was a Swiss psychiatrist, who pioneered controversial psychosurgical procedures. Burckhardt-Heussler extirpated various brain regions from six chronic psychiatric patients under his care. By removing cortical tissue he aimed to relieve the patients of symptoms, including agitation, rather than effect a cure.

To present the scientific papers of Johann Gottlieb Burckhardt-Heussler on psychosurgery.

To review available literature and to show evidence that Burckhardt-Heussler made a significant contribution to the development of psychosurgery.

A biography and private papers are presented and discussed, followed by a literature review.

The theoretical basis of Burckhardt-Heussler's psychosurgical procedure was influenced by the zeitgeist and based on his belief that psychiatric illnesses were the result of specific brain lesions. His findings were ignored by scientists to make them disappear into the mists of time, while the details of his experiments became murky. Decades later, it was the American neurologist Walter Freeman II, performing prefrontal lobotomies since 1936, who found it inconceivable that the medical community had forgotten Burckhardt-Heussler and who conceded that he was familiar with, and probably even influenced by, Burckhardt's work.

It is partly thanks to Burckhardt-Heussler's pioneering work that modern psychosurgery has gradually evolved from irreversible ablation to reversible stimulation techniques, including deep brain stimulation.

The authors have not supplied their declaration of competing interest.

ECT outpatient program recently created in the Psychiatric Day Hospital in Ávila was designed to assess the safety and efficacy of continuation/maintenance electroconvulsive therapy (ECT) in patients after ECT remission.

Description of the activity and objectives of an ECT outpatient program in a Psychiatric Day Hospital.

Retrospective cross-sectional descriptive Study. The three patients who received the continuation/maintenance electroconvulsive therapy during the 10 months this unit has been opened were chosen as a sample.

From the opening of Psychiatric Day Hospital 10 months ago, 58 patients have been admitted; among them, three patients come to the hospital monthly to receive the electroconvulsive therapy, maintaining their psychopathological stability over time.

With the creation of this new program we considered three types of objectives:

– therapeutic: a therapy applied in a more comfortable and satisfactory for the patient and family regime. To prevent relapse and exacerbations;

– management: benefits on the best use of existing resources:

– reduction in hospital admissions and readmissions,

– decrease in the average stay,

– reduction in visits to Emergency Services,

– allow referrals from outpatient department,

– individual monitoring of patients that complements the check at their Mental Health Team;

– teaching, training and investigation.

The authors have not supplied their declaration of competing interest.

The aim of this study was to monitor the use of electroconvulsive therapy (ECT) in the Czech Republic for the purpose of harmonizing national practice.

A 13-item questionnaire was sent to all Czech inpatient psychiatric facilities. This questionnaire assessed technical background of ECT, indications for the treatment, procedure in detail, way of documentation and monitoring of side effects.

ECT is used 23 centers (10 psychiatric hospitals, 5 university psychiatric departments and 8 psychiatric wards) across the Czech Republic. There is no special legal act regulating the use of ECT in the CR, but there are guidelines issued by the Czech Psychiatric Society available. All centers use instruments delivering brief pulse stimuli. All patients have to be indicated for this treatment and have to sign inform consent form/excluding situation when patient's life is endangered/. Somatic state is assessed/EKG, blood tests, eye check-up regularly and other examinations in individual cases/. Thiopenthal and succinylcholine are used most often for anesthesia and myorelaxation. Bitemporal electrode placement is the preferred option in all centers. The ECT is provided 2–4 times a week in special ECT rooms in the presence of staff team/psychiatrist, anesthetist, psychiatric and anesthesiological nurses/. Continuation ECT and outpatient ECT is not used. The procedure including side effects is documented in individual patient's documentation, but summarizing documentation is conducted only in some centers.

ECT is widely used in the Czech Republic. Procedures in all centers follow national guidelines. There is need to improve documentation system to harmonize national practice.

The authors have not supplied their declaration of competing interest.

To find out how the use of ECT in psychiatry is perceived by the public in the Czech Republic.

The questionnaire (8 questions monitoring awareness, knowledge of ECT and its use in modern psychiatry) created for the purpose of this study was shared through internet and also distributed in paper version to public.

The sample consists of 365 respondents – age average 28.9 years, 62% of females, 53% of university graduates, 44% with secondary education, 3% other education, 27% of healthcare professionals outside the field of psychiatry, 20% of medical students before the start of the traineeship at psychiatry, 53% of the public. Among the respondents, 98% have heard about ECT, 7% of them think that ECT is no longer used. Among the respondents, 62% learned about ECT from the media (film, print). Among the respondents, 22% do not believe in the effectiveness of ECT, 30% think that ECT is abused by psychiatrists, 86% believe that ECT has side effects (personality changes, permanent memory disorders, brain damage, epilepsy). Among the respondents, 77% would agree with ECT, if it should be applied to their relative.

ECT is an effective method in treating of severe mental disorders. But until now the public view is influenced by media. Due to the negative stereotype of the method many people are afraid of this treatment. The interesting fact is that also health professionals and medical students are influenced by public stigma of ECT.

The authors have not supplied their declaration of competing interest.

The finding of prefrontal dysfunction in schizophrenia patients with negative symptoms (NS) has raised interest in using transcranial magnetic stimulation (TMS), which can modulate prefrontal function and dopamine release, as potential treatment for NS.

To briefly review current literature concerning the use of TMS as treatment for NS.

To assess whether current evidence supports the use of TMS for NS.

Narrative review of articles found through a PubMed database search using the keywords “transcranial magnetic stimulation”, “schizophrenia”, and “negative symptoms” between 1998 and 2015.

Up to date, reviews of randomized sham-controlled studies found positive effects of TMS in NS. However, they exposed several methodological difficulties. More recent studies, reviewed in this poster, tried to overcome these, using results from multiple centers, larger samples and blinding. Various TMS techniques were studied, differing in frequency, motor threshold (MT), stimulus location, and treatment duration. Overall, TMS continues to show promising results in reducing NS; particularly rTMS 10 Hz, for at least 15 sessions on the left dorsolateral prefrontal cortex (DLPFC) at a 110% MT.

TMS may be a useful treatment for NS for patients not responding to pharmacological treatment alone. Studies remain difficult to compare due to different measures of outcome (PANSS and SANS being the most commonly used) and techniques. Furthermore, possible modulators of response include duration of illness, cognitive symptoms amelioration, medication and their dose, and different NS may respond differently to TMS. More studies are needed to better understand the utility of TMS in NS.

The authors have not supplied their declaration of competing interest.

ECT can be a safe treatment choice in cases of PVD.

The authors have not supplied their declaration of competing interest.

It is not clear whether electroconvulsive therapy (ECT) is a safe procedure in depressed older adults with unrepaired abdominal aortic aneurysm (AAA). ECT is potentially incriminating to the cardiovascular system due to a transiently elevation of blood pressure and heart rate during the seizure.

To report a case of an older adult presenting a psychotic depression complicated by an unrepaired AAA.

To report a case study, describing the safety of ECT in patients with unrepaired AAA.

A case report and retrospective review was conducted.

A 75-year-old male was admitted to hospital for the treatment of a psychotic depression. Treatment was complicated since for one year he was diagnosed with an AAA (diameter 4.7 cm). In collaboration with vascular surgeons and anesthesiologists we decided to start ECT. After fourteen ECTs an improvement of mood was achieved. Post-ECT we noticed an AAA expansion of 0.1 cm.

Our findings indicate that ECT may be a safe procedure for patients diagnosed with unrepaired AAA. Published data suggest that the risk for aortic aneurysm rupture during ECT is low. However, multidisciplinary collaboration among psychiatrists, anesthesiologists and vascular surgeons is essential for a positive outcome.

The authors have not supplied their declaration of competing interest.

Repetitive Transcranial Magnetic Stimulation (rTMS), through modulation of cortical activity, has become an invaluable tool in experimental and clinical neurosciences. Although this form of noninvasive treatment is considered safer than other means of brain stimulation it has been associated with adverse effects (AE).

To make a brief review, concerning the AE of rTMS, their prevention and management.

To understand and be able to deal with the most common AE associated with rTMS.

A PubMed database search, using as keywords “Transcranial magnetic stimulation”, “Repetitive Transcranial magnetic stimulation”; “adverse effects”; “management” and “guidelines” between the year 1998 and 2015.

AE caused by rTMS are rare. They can be classified into severe (seizures) and mild (syncope, and transient hearing impairment, acute psychiatric changes, headache, local pain, neck pain, toothache, paresthesia and cognitive/neuropsychological changes) and into early and late AE. In order to obviate and avoid them, guidelines have been created; some state that to apply rTMS the technician needs to obtain the patient's informed consent and assess the risks/benefit ratio. To meet these criteria, screening tools have been created, and since then the number of AE has reduced.

Even though rTMS is considered safer than other forms of brain stimulation it is still associated with AE. In order to avoid them, screening tools have been created allowing the clinician to assess the risks and benefits of applying this technique.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.