Cycloserine is a highly effective second line anti-tuberculosis medication, the use of which has increased in recent times due to emergence of multi-drug resistance. One of the side-effects is psychosis characterized by paranoia, hallucinations and affective instability. These symptoms are usually reported within the first 2 weeks of therapy in 30–50% of patients receiving Cycloserine 500 mg. At a dose of 100mg and above it leads to a hyperdopaminergic state which in turn could lead to psychosis. However, as this is a very effective treatment in people with multi-drug resistant tuberculosis, it is not always possible to omit treatment due to remergence of life threatening illness. We present findings from few patients on this medication who were referred to us for management of psychotic symptoms.

To treat the psychotic symptoms with anti-psychotic which would enable patient to continue Cycloserine. Also to monitor the response to an anti-psychotic.

Data was collected from the patient’s case notes, full psychiatric assessment and interviewing the relative. Patient was followed up in the out-patient clinic to monitor response to anti-psychotic medication.

Patients were treated with both typical and atypical medication with good response and it was possible to continue with Cycloserine in one case.

Cycloserine induced psychosis can mimic any other psychotic illness and can be effectively treated with anti-psychotics.

Phenytoin used to prevent seizures linked to brain cancer neurosurgery has shown many undesirable side effects and drug interactions with chemotherapy.

To evaluate the incidence of depression, insomnia, mood instability and early post surgery seizures, after Phenytoin (PHE) vs. Levetiracetam (LEV) monotherapy in patients with brain tumour subjected to a supratentorial brain tumour resection.

A prospective study in patients with supratentorial cancer diagnosis subjected to neurosurgery of resection was done. Patients were consecutive randomized to be treated with PHE (n = 26) 15 ml/kg IV-bolus, 125 mg/8 h IV x48 h, 100 mg/8 h O x7 days or with LEV (n = 34) 500 mg/12 h IV x48 h, 500 mg/12 h O x 7 days. Clinical, histological, TAC, EEG, seizures and undesirable side effects were analyzed.

60 patients (53% male, aged 52.5 ± 20 years) with glioblastoma multiform 45%, meningioma 43%, Ewing's sarcoma 6.7%, others 5.3% (size between 3–6 cm, in the right brain site-65.2%, in the frontal lobe-56.2%) were subjected to followed for a week after tumour resection. Undesirable side effects (USE) were (%LEV/%PHE): total (7.3%/31.5%), somnolence (0%/32.8%), headache (6.1%/22.3%), dizziness (0%/25.6%), difficulty with coordination (0%/23.5%), depression (6.2%/18.7%), lack of energy/strength (12.5%/33.8%), insomnia (11.3%/37.9%), mood instability (12.5%/22,6%), leukopenia (0%/16.9%) after surgery (p < 0.05). None of the patients taking Levetiracetam vs. 4 of the patients taking Phenytoin (0% vs. 15.3%) had seizures after surgery (p < 0.05).

Levetiracetam showed lower depression, insomnia, mood instability and seizures incidence than Phenytoin after supratentorial tumour neurosurgery.

Involuntary Ambulatory Treatment (IAT) is a judicial measure existing in Spain. Its aim is to ensure the adherence to treatment of seriously ill patients, with poor insight and repeated hospitalization. This is done by means of the regular and involuntary administration of antipsychotic intramuscular medication.

To assess the treatment used in patients undergoing IAT in a local clinic, to assess the type of medicaments and their dosage and to verify adherence to treatment and evolution.

A revision was made of the clinical backgrounds of all the patients of a psychiatric outpatient clinic who have been submitted to IAT (n = 37). A note was made of socio-demographic variables as well as psychiatric diagnoses according to DSM-IV-TR criteria and the number of hospitalizations and treatments used.

All but one patient had been hospitalized and average of 3.53 times before IAT. Since undergoing IAT only 6 patients have been admitted (16%). Four of them relapsed having abandoned treatment.

In seven cases (19%) the patients gained insight and the antipsychotic treatment was changed from injectable to oral treatment at the patients’ request. In these cases IAT was ceased.

The antipsychotic prescribed in 59% of the cases was Long-Acting Injectable Risperidone. This percentage was higher in non- schizophrenic patients (84%).

In our environment IAT could be an effective tool for severe patients with nil insight, since it can bring about an improvement in treatment adherence and evolution, as well as insight.

Neuroleptic malignant syndrome (NMS) is a rare and potentially fatal idiosyncratic drug reaction usually defined as a complication of treatment with antipsychotics. It is manifested by altered mental status, hyperpyrexia, rigidity and autonomic instability. This syndrome occurs in response to administration of drugs that induce dopamine blockage.

Study the risk factors, diagnosis, treatment and complications of NMS, by performing a literature review.

Summarize the main aspects of NMS that may have importance in usual clinical practice.

PubMed was used to identify NMS articles published after 2000, associated with the MeSH terms “neuroleptic malignant syndrome” and “antipsychotic agents”.

NMS is not dose-related and its aetiology is still unknown. There are many risk factors associated with the syndrome, such as demographic, individual, genetic and environmental factors and medication. In order to evaluate the medical situation, an accurate clinical history and physical examination should be fulfilled. NMS is also characterized by changes in laboratory investigation. There are no patognomonic findings, thus other different diagnosis should be considered. Specific treatment remains controversial. Treatment should be individualized for each patient, regarding characteristics, duration and severity of the clinical signs and symptoms. Resolution is usually verified in one to two weeks. Though there are cases in which the symptoms persist and comorbid process may occur.

Although NMS is a rare complication of antipsychotic therapy, early diagnosis and treatment is essential to improve prognosis.

Because only 40 – 60% of all patients with obsessive-compulsive disorder (OCD) respond to selective serotonin reuptake inhibitors (SSRIs), the evaluation of alternative therapy methods in the presence of treatment resistance has high clinical relevance. In this context, many studies have examined additive medication with antipsychotics.

All double-blind randomised controlled trials (DBRCTs) that evaluated the efficacy of a combination therapy of antipsychotics and SSRIs in treatment-resistant OCD were covered by systematic literature searches.

A total of ten DBRCTs were identified (four for quetiapine, three for risperidone, two for olanzapine and one for haloperidol) with a participant collective comprising in total 316 treatment-resistant OCD patients. After the augmentation therapy, significantly more subjects in the intervention group (antipsychotic + SSRI), 32% of the patients, fulfilled the response criterion (reduction in the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) ≥ 35%) than in the control group (placebo + SSRI) (relative risk (RR) = 2.08; 95% CI: 1.3 – 3.32). The standardised mean difference (SMD) of the Y-BOCS reduction between the pooled two study-groups revealed an effect size of 0,62. The sub-group analyses showed significant efficacy only for haloperidol and risperidone. Further significant differences existed regarding the duration of SSRI medication before the augmentation phase.

Based on the favourable benefit-risk-ratio, risperidone can be regarded as the agent of first choice for augmentation treatment with an SSRI. Overall, about one third of patients benefit from this therapy option. However, further scientific studies are needed before sufficiently empirically secured pharmacological treatment recommendations can be expressed.

Determination of the best evidence involves a systematic, comprehensive review and synthesis of the research literature as performed in high-quality meta-analysis. In a recently published multiple-treatment meta-analysis by Cipriani and collegues (Lancet, 2009) the authors finally concluded to favour sertralin over escitalopram due to lower costs.

Based on the example published by Cipriani et al. we tried to highlight possible pitfalls, the clinican with limited time might not be able to spot easily whilst skimming the results of meta-analysis.

Escitalopram had the best efficacy and tolerability profile in the study. Sertraline was recommanded as first choice because of the most favourable balance between benefits, acceptability and acquisition costs. Analyzing study-design, statistical procedures and knowledge such as the early launching of generics of escitalopram lead to a different view of the interpretation by Cipriani and collegues.

We concluded that the findings of Cipriani et al. have limited generalizability due to problematic study design issues including statistical concerns. Despite the fact that meta-analysis might provide best evidence-based information, the findings of the latter should always be interpreted with caution as the quality of them can only be as good as the studies included and the study design implemented.

Psychosis is a mental condition characterized by the presence of hallucinations, delusions, and thought disorders. It spans diagnostic entities that respond to similar therapeutic approaches. Most patients who develop schizophrenia and related psychotic disorders are at very high risk of relapse in the absence of antipsychotic treatment. Yet, chronic psychosis is an entity that has not been well established until today.

Evidence indicates that sustained treatment is associated with fewer relapses than is targeted intermittent treatment; however guidelines do not give definite recommendations about treatment duration. Indefinite maintenance antipsychotic medication is recommended for patients who have had multiple prior episodes or two episodes within five years. Adjunctive medications are commonly prescribed for comorbid conditions.

The authors aim to study the therapeutic approach of patients with chronic psychosis.

Cross-sectional study and clinical records review of a sample of patients with the diagnosis of schizophrenia and other chronic psychotic disorders.

The sample consists of 154 psychotic patients, 71% males, with mean age of 45,9 years. 43, 5% of patients are under treatment with more than one antipsychotic agent, and 59% are treated with long-lasting antipsychotic medications (LLA).

The considerable decrease in hospitalization days, and the need to avoid covert non-compliance justifies the increased number of patients under LLA treatment. This sample presents with a high percentage of patients treated with more than one antipsychotic medication, despite the fact that there is minimal evidence supporting this therapeutic option.

Nonadherence is the Achilles heel of effective psychiatric treatment. The meaning of the term “adherence” has evolved over time and is now associated with a variety of definitions and measurement methods. This has resulted in a poorly operationalized and non-standardized term that is often interpreted differently by providers and patients.

This abstract aims to: 1) describe changes in the concept of adherence; 2) present a more comprehensive definition of adherence which recognizes the influence of patient-provider transactions; 3) introduce dynamic adherence, a six-phase model, which incorporates the influence of transactional processes and econometrics on patients’ adherence decisions; and 4) provide recommendations for providers to improve their relationships with patients and in turn, medication adherence.

A review of the scientific mental health literature.

Despite the prevalence, seriousness, and costs associated with medication nonadherence, the construct of adherence remains poorly operationalized and lacks cogent standardization. Drawing from psychiatric research, a dynamic model of medication adherence across six phases is presented.

This model of adherence highlights the importance of the patient-provider relationship and the transactional processes that comprise what is a dynamic developmental system. Dynamic adherence is intended to foster movement toward a more coherent and unified set of definitions and clinical strategies that will provide the potential to more fully elucidate the risk and protective mechanisms impacting adherence, and the subsequent development and refinement of best practices in increasing the odds of stable medication adherence.

Treatment of alcoholics is complex and difficult, very often it demands complex psychopharmacotherapy.

To investigate characteristics of psychopharmacotherapy of inpatients alcoholics with brain computerized tomography (CT) during hospitalization on Psychiatry Department in Tuzla.

We investigated 86 record files of inpatients that were treated from 01.01.2005 to 31.12.2009 year on Psychiatry Department, who had dismissed diagnosis Alcohol dependency F 10.2 according ICD-10, to whom computerized tomography of brain has been done durin hospitalization. Targeted variables were: age, marital status, working status, involvement in war fighting's, CT diagnosis, psychological findings, laboratory findings and characteristics of psychopharmacotherapy.

The mean age of observed patients was 50.1 ± 6.6 years. Age of inpatients was in positive correlation with duration of work, presence of silent ischemic stroke and brain cortex atrophy. Presence of PTSD was in positive correlation with involvement in the combatants, with cognitive disturbances, with depressiveness and somatic complains. Brain cortex atrophy positively correlated with silent stroke and glucose blood level.

There were 72 (83.7%) inpatients that treated with antidepressants, 45 (52.3%) with sedating antipsychotic drugs, 10 (11.7%) atypical antipsychotics 12 (13.0%) with typical antipsychotics, 53 (61.6%) with hypnotics, 37 (43.0%) tranquilizers, 23 (26.7%) vitamin B. There was the most frequent combinations of antidepressants SSRI with promazine in 41 (47.7%), with diazepam 25 (29.1%), with zolpidem 20 (23.3%) and nitrazepam in 17 (19.8%) patients.

SSRI antidepressants were the most frequent used psychopharmacotherapy drugs, then sedating neuroleptics and hypnotics. The most frequent drug combinations were antidepressants, sedating neuroleptic or tranquillisers and hypnotics.

Over the recent years, meta-analysis has become a very influential tool to synthesize information from multiple primary studies of similar design. Widespread use of increasingly complex statistical methods makes it ever more challenging to adequately assess the results reported and conclusions drawn in meta-analyses of psychopharmacological studies.

This study aimed to identify potential fallacies of meta-analytic reporting and interpretation by in-depth examination of recent publications on anti-depressant medication.

Published meta-analytic datasets were re-analysed and the results and possible interpretations obtained in this way were compared with the published results and interpretations.

Several widespread methodological problems were identified in the example studies. As most important among these appear the choice of effect size measures and modeling approaches, as well as the related risk of data dredging. Concerning the level of granularity, two pitfalls encountered were inappropriate aggregation of original data and lack of adequate subgroup analyses. Finally, a low level of transparency regarding data and methodology often hampers re-analysis and cross-checking of reported findings by peers.

The difficulty of replicating meta-analytic results on independent data leads to the often conclusive nature of meta-analytic findings, and therefore a realistic assessment of the limitations of the respective analysis is pertinent. To this end, practically relevant quality criteria for readers to bear in mind when dealing with meta-analytic publications are summarized in a ten point checklist for a rough assessment of the quality of meta-analyses by the reader.