Pregabalin is a gamma-aminobutyric acid analogue used for the treatment of neuropathic pain, partial-onset-seizures, fibromyalgia, and anxiety disorders. Mirtazapine is an atypical antidepressant used in major depression and often prescribed off-label for insomnia. Delirium, an acute confusional state, is a very rare adverse reaction of both medications.

We report a case of an elderly patient treated with low dose pregabalin and mirtazapine who developed drug-induced delirium which resolved rapidly upon withdrawal of both drugs

A 75-year-old woman was admitted for symptoms of anxiety, various bodily complaints (dysphagia, headache, tinnitus, weakness) and sleep-onset insomnia over the preceding 2 months. On admission, examination revealed an apparently anxious, uneasy and emotional looking patient. Mini mental state examination, as well as clock drawing and copying were normal, suggesting absence of cognitive impairment. Physical examination was unrevealing except for high blood pressure recordings (150/90 mmHg). Laboratory testing indicated creatinine at 1.19 mg/dl, with a creatinine clearance moderately decreased at 38 ml/min. Upon admission, she was placed on pregabalin 25 mg bid and mirtazapine 30 mg ¼ tablet qd.

Three days after admission, pregabalin was increased to 25 mg tid. On the same day and about 2 hours after the night dose, the patient acutely developed delirium: she presented confusion, disorientation, incoherence, restlessness and deterioration of her anxiety. On physical examination she was afebrile with no hypertonia or ataxia. An urgent brain magnetic resonance imaging was grossly unrevealing. Pregabalin and mirtazapine were discontinued, as a drug-induced delirium was suspected. She received as a symptomatic treatment lorazepam progressively up to 4 mg qd. Symptoms of delirium resolved rapidly, and she was discharged days later with full functional recovery

Cases of delirium have been described following treatment with pregabalin, but in significantly higher doses. Pregabalin relies heavily on renal clearance for its excretion and the dose should be adjusted in patients with creatine clearance below 60 ml/min. As our patient had a moderate decrease in renal clearance, we prescribed a dose within suggested limits, but in combination with mirtazapine led to the appearance of a drug-induced delirium. In conclusion, combined therapy with low-dose pregabalin and mirtazapine seems to account for the development of delirium in our patient as based on its temporal association with the initiation of this drug combination and its prompt resolution upon withdrawal of these two agents

None Declared

Valproic acid (VPA) has been used in clinical practice since the 60’s, with a relatively favourable safety and efficacy profile. Pancreatitis, hepatotoxicity and teratogenicity are the most significant adverse drug reactions. VPA is also known for causing hyperammonemia, which may be asymptomatic or can present with encephalopathy. VPA-induced hyperammonemic encephalopathy (VHE) is a serious but reversible condition, which requires high clinical suspicion for diagnosis. It may occur acutely or after chronic use of VPA.

Review how frequent is for valproic acid to cause hyperammonemic encephalopathy, signs to watch out for and how it can be treated.

Presentation of a patient’s case and review of existing literature, in regards to encephalopathy caused by valproic acid as a result of ammonia elevation.

In the case displayed here, the patient is diagnosed of hyperammonemic encephalopathy after being treated with valproic acid as treatment for borderline personality disorder.

Reviewing literature, cases of hyperammonemia are rarely reported as VPA-induced, probably because this increased level of ammonia in blood can vary between asymptomatic, and clinically relevant levels. Symptomatology due to VPA-induced hyperammonemia include: lethargy, impaired consciousness, focal neurological signs and symptoms and increased seizure frequency. More rare described symptoms are: aggression, ataxia, asterixis, vomiting and coma.

There are multiple treatment modalities for patients diagnosed with VHE, the primary treatment being the discontinuation of VPA. Other treatments frequently used are Lactulose and Carnitine.

VHE is a rare occurrence, however can have fatal outcomes if not recognized and managed in time. Physicians should be vigilant while initiating Valproate therapy to patients. Clinicians should consider the possibility of VHE in patients with unexplained altered mental status, regardless of the duration of VPA therapy. A timely diagnosis is essential to prompt effective treatment, thus ensuring the patient’s safety and decreasing the length of hospitalisation and the cost of care in hospitals.

None Declared

Paliperidone Palmitate (PP) is an atypical antipsychotic, approved by the FDA for acute and maintenance treatment of schizophrenia and schizoaffective disorder.

It has a relatively safety profile, and reported cases of paliperidone palmitate-induced angioedema or anaphylaxis are uncommon.

We intend to present a case of paliperidone palmitate-induced anaphylaxis to alert clinicians regarding this rare, but possible complication.

Non-systematic review of the literature and report of a case study.

Long-acting injectable Paliperidone Palmitate (LAIPP) is a safe and effective alternative to oral Paliperidone, with less incidence of disease relapse related to medication non-compliance.

Substance use disorder (SUD) is highly prevalent in first-episode psychosis (FEP), and it is associated to decreased treatment compliance, which impairs the outcomes of these patients. Therefore, several authors have been recommended long-acting injectable antipsychotics (LAI-AP), such the LAIPP, as a first line for treatment of FEP-SUD patients.

The most common side effects associated with LAIPP are injection site reactions, extrapyramidal symptoms, hyperprolactinemia, sedation, hypersalivation, orthostatic hypotension, tachycardia, and weight gain. Hypersensitivity reactions have rarely been reported and may be dose-dependent.

We report a case of a 20-year-old female, without medical history and no history of allergies, who was medicated with once-monthly LAIPP at dose 100 mg for the maintenance treatment of a first psychotic episode associated with cannabis abuse.

Approximately 24 hours after the first monthly injection dose, she was admitted in the emergency room (ER) presenting an increasing angioedema associated with stridor, requiring endotracheal intubation and administration of adrenaline, clemastine and hydrocortisone during the assessment in the ER.

After clinical stabilization, she was transferred to the internal medicine ward, and following a full recovery, she was discharged 6 days later while being medicated with Olanzapine 15 mg/day, Lorazepam 3 mg/day and Sertraline 50 mg/day. LAIPP was suspected as the etiology of the anaphylaxis reaction due to temporal relationship of its onset with therapy administration and by the exclusion of other potential causes. Consequently, LAIPP was discontinued at discharge.

This report shows the possibility of a late and potentially life-threatening anaphylactic reaction to LAIPP. So, all physicians should be aware of this potential complication, which requires timely recognition and management.

None Declared

Tourette syndrome (TS) is a neurodevelopmental disorder characterized by the development of persistent and changing motor and phonic tics over time. The presence of at least two motor tics and one vocal tic that have persisted for at least a period of 1 year is required, and which developed before the age of 18. The most commonly used pharmacological treatment are antipsychotics, with a preference for atypical antipsychotics such as aripiprazole or risperidone. Clonidine and guanfacine have shown effectiveness in suppressing tics, and although generally less effective than antipsychotics, some authors are considering them as first-line treatments. The treatment is also influenced by any comorbidities the patient may present.

To enumerate in a clinical case the pharmacological alternatives for TS, which vary according to the patient’s comorbidities and the intensity of the tic symptoms.

Case study. Anamnesis of the patient and their family.

A 12-year-old boy presenting simple motor and vocal tics for over a year. At the same time that a valuation is requested by child psychiatry, the mother also requests follow-up by neuropediatrics. Other causes are ruled out, an EEG is performed, and a TS diagnosis is made. The initial treatment was low-dose aripiprazole with partial effectiveness. After 3 months, he presents an exacerbation of the tics, interfering with his social and academic life, making it impossible to attend classes. The mother takes him to emergency services, and he is admitted to pediatrics. During the stay in pediatrics, he is diagnosed with Attention Deficit Hyperactivity Disorder, in addition to confirming the TS diagnosis. Extended-release methylphenidate is initiated (neuropediatrics). After starting methylphenidate, the patient’s tics worsen, also presenting insomnia and hyporexia. Due to the diagnosis of ADHD, school failure, and affective symptoms (hypothymia), atomoxetine is initiated. The tics become constant and incapacitating. As the dose of aripiprazole is increased, the child presents extrapyramidal effects. As a therapeutic alternative, guanfacine is initiated, progressively discontinuing aripiprazole. Currently, the child is stable from motor and vocal tics, allowing him to lead a normalized life.

Although guanfacine is not as effective in reducing tics as antipsychotics, since the latter produce more side effects, it is justifiable to use it. This drug is capable of enhancing the therapeutic effect and reducing the adverse effects that antipsychotics could produce. Guanfacine may be a good alternative as a first line in the treatment of Tourette Syndrome with or without attention deficit disorder and hyperactivity .

None Declared

Antipsychotics are psyschotropic medications that are indicated for the treatment of physchosis and mood disorders. Due to minimal side effects and their efficacy (affecting many receptors) compared to standard antipsychotics, today atypical antipsychotics are being used more and more as first-line treatment.

The aim of this study is to show the efficacy of asenapine and its tolerability as opposed to other atypical antipsychotics.

1. 1. What are the side effects identified?

2. 2. Side effects and efficacy of asenapine vs other atypical antipsychotics?

It is a comparative, regular, clinical study, an examination case of a 53-year old female diagnosed with Schizoaffective Disorder 27 years ago and treated outside of hospital with atypical antipsychotics, such as: risperidone, olanzapine, quetiapine, aripiprazole, amisulpride. The study covers the timespan of 2010-2022.

The results showed that asenapine sublingual 15 mg had fewer side effects than other atypical antipsychotics. They were mouth dryness, headache, fatigue.

The other atypical antipsychotics caused: metabolic disorders, like considerable weight gain, cholesterol and glycaemia increase, extrapyramidal side effects, hyperprolactinemia.

Asenapine sublingual 15 mg was not as effective in treating Schyzoaffective Disorder as risperdal 5mg, olanzapine 15 mg, aripiprazole 20 mg, amisulpride 600 mg.

The efficacy of asenapine sublingual 15mg was the same as quetiapine 400 mg.

This study showed that asenapine has minimal side effects but its efficacy in treating Schyzoaffective Disorder as monotherapy is lower than other atypical antipsychotics.

antipsychotics, schyzoaffective disorder, side effects, efficacy

None Declared

The use of long-acting treatments is a common clinical practice in psychiatry. No disease insight and the risk of treatment discontinuation in a significant portion of our patients, increase the demand for psychiatric emergency and hospital admissions. Treatment adherence must be facilitated, taking into account possible side effects and patient´s subjective satisfaction.

-Evaluate the type of long-acting intramuscular treatment in selected patients. -Evaluate the differences in treatment satisfaction between different types of long-acting intramuscular treatments as well as frequency of psychiatric emergency and hospital admissions in the last year.

We select patients with different severe mental disorders who stay in a Medium Stay Unit, Sociosanitary Community Residence, Supervise house and Residence for the elderly in Albacete (Spain); all of them, with intramuscular neuroleptic treatment (zuclopenthixol dihydrochloride, aripiprazole long acting, palmitate paliperidone monthly, 3-monthly and 6-monthly) at least 1 year.

We evaluate their sociodemographic characteristics, the satisfaction questionnaire with the treatment (TSQM-9) and the rate of psychiatric emergencies and admissions after current intramuscular treatment in last year.

We have selected 57 patients with an average age of 45.86. 78.94% with a diagnosis of schizophrenia, 12.28% with schizoaffective disorder, 5.26% bipolar disorder and 3.5% unspecified psychotic disorder.

We can see in the graphics below that the longer duration of the intramuscular treatment, the greater satisfaction in all the items of the TSQM-9 questionnaire.

31% of the patients with zuclopenthixol dihydrochloride treatment, have gone to psychiatric emergencies and 28% of psychiatric admissions in the last year.18% of the patients with aripiprazole long acting, 17% with paliperidone palmitate long acting-monthly and 12% de 3-monthly have gone to psychiatric emergencies and 15%, 12% and 12% needed psychiatric admissions respectively. Patients with palmitate long acting-monthly have not emergencies or psychiatric admissions in the last year.

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• - The longer long acting of the intramuscular treatments, the better patient satisfaction.

• - With the longer duration treatment (Palmitate paliperidone LD 6 month), we have lower psychiatric emergencies and hospital admissions.

None Declared

Aripiprazole is an atypical antipsychotic orally indicated for the treatment of schizophrenia, bipolar I, major depressive disorder. It is also indicated as an injection for agitation associated with schizophrenia or bipolar mania. Aripiprazole exerts its effects through agonism of dopaminergic and 5-HT1A receptors and antagonism of alpha-adrenergic and 5-HT2A receptors (Cosi et al., 2006). Ptosis is known as the drooping of the upper eyelid, and the patient usually presents with the complaint of the defect in vision and cosmesis (Shahzad & Siccardi, 2023). Orofacial dyskinesia and oromandibular dystonia are uncommon neurological disorders with involuntary, mainly choreic (dance-like) movements, or excessive, involuntary and sustained or repetitive muscle contractions that may involve the face, lips, tongue, and/or jaw (Bakke, 2016).

The aim of this study is to present a case of ptosis and orofacial spasm, which are neurological side effects that may be very rare side effects of aripiprazole.

The 22-year-old woman was referred to the psychiatric service via the emergency service, due to thoughts of harming herself and irritability. The patient was planned to be hospitalized due to decreased sleep, increased speech, and persecution delusions for the last days. After the patient stayed in the service for 25 days, the patient was prescribed olanzapine 10 mg for discharge. At the follow-up appointment, it was learned that the patient had gained weight due to olanzapine and was switched to aripiprazole on 4th of July. The patient’s aripiprazole dose was gradually increased to 10 mg/day. The patient’s relatives gradually noticed drooping eyelids, involuntary oral movements, and impaired speech due to aripiprazole. Cranial MRI and cranial MRI angiography performed to rule out organic pathologies resulted normal. Accordingly, the aripiprazole dose was reduced to 5 mg/day by his mother, and at the last follow-up appointment on August 4, aripiprazole was stopped and paliperidone was started, and the neurological symptoms completely resolved 4 days later.

Since aripiprazole is frequently used in the field of psychiatry, its side effects are often wondered about. Extrapyramidal system side effects of antipsychotics are more common than ptosis. And In terms of the incidence of various extrapyramidal side effects, overall, no significant effects of age, sex, mean dose, study duration, or measuring method could be demonstrated. It is very important to distinguish between organic pathology and drug side effects, especially since ptosis accompanies neuromuscular diseases, ischemic, demyelinating brain lesions and intracranial aneurysms.

As a result, patients who are started on antipsychotics should be closely watched for side effects to increase patient comfort and drug compliance. Also organic pathologies must be excluded before making a final decision that it is a drug side effect.

None Declared

DRESS (Drug Reaction with Eoshinophilia and Systemic Symptoms) syndrome, also called DIHS (Drug-Induced Hypersensitivity Syndrome) is a rare drug-induced systemic hypersensitivity reaction that can be potentially life-threatening (Choudhary et al. J Clin Aesthet Dermatol 2013; 6 -7). Risperidone is an antipsychotic drug with significant antagonist activity at the 5-HT2 and the D2 receptors. It has been reported that risperidone may be effective in controlling agitation, delusion, hallucination, and withdrawal behavior in geriatric patients (Yunusa & El Helou. Front Pharmacol 2020;11:596).

The aim of this study is to demonstrate the case of developed DRESS syndrome following the use of risperidone.

The 81-year-old female patient was admitted to the Dermatology Clinic due to skin rash, high fever and leukocytosis following the use of risperidone. The patient was consulted to Psychiatry.

In her history it was determined that risperidone 0.5 mg/d was started to the patient with depression due to agitative symptom. On the 4th day of treatment, targeoid lesions, starting from the back and spreading first to the trunk and then to the extremities, were observed. Further laboratory examinations revealed that the fever was measured at 39.5 C°, liver enzymes were elevated (ALT= 119 IU/ lt, AST= 124 IU /lt), and significant leukocytosis (WBC =12.000) was present along with the lesions. The patient was planned to be hospitalized to Dermatology Clinic on the 5th day and risperidone was stopped. The patient’s agitation increased and following the risperidone discontinuation thereupon the lesions tended to fade and desquamation began. After the treatment of the DRESS syndrome, aripiprazole was given to the patient for agitative symptom. The level of agitation symptoms decreased, and the patient tolerated aripiprazole well without any observed side effects.

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When initiating medication for the elderly population to address agitation, considering such rare side effects can prevent the patient from being hospitalized due to DRESS syndrome. To the best of our knowledge, this is the first case report associated with DRESS syndrome and risperidone treatment thus, it is necessary to be very careful when starting psychotropic medication for elderly patients.

None Declared

Antipsychotics are the primary class of drugs used to manage schizophrenia. These medications help control and reduce the severity of these symptoms, allowing individuals with schizophrenia to better function. On the other hand, rifampicin, used as treatment for tuberculosis, is a powerful inducer of several drug-metabolizing enzymes which have the potential to decrease the plasma levels of antipsychotics. Therefore, the presence of multiple pharmacokinetic interactions can alter how antipsychotics are metabolized, leading to a notable clinical impact when these medications are administered concurrently.

The objective is to share valuable clinical experiences and insights to aid healthcare providers in making informed decisions when faced with the challenge of co-administering antipsychotics with rifampicin, ultimately ensuring the safety and efficacy of treatment for their patients.

It will be discussed a case of a 41-year-old woman with the diagnosis of schizophrenia under treatment with paliperidone palmitate and clozapine who had a sudden relapse after starting treatment for latent tuberculosis with rifampicin as a framework for a literature review based off Pubmed.

The antituberculosis drug rifampicin induces drug-metabolizing enzymes in the liver, having the greatest effects on the expression of cytochrome P450 (CYP3A4) and therefore can lead to a decrease in the plasma levels of antipsychotic medications that also rely on these pathways for clearance. In this particular case, although specific data on clozapine and paliperidone concentrations were not reported, fluctuations in symptomatology following rifampicin introduction were probably explained by an inducing effect of this drug on their metabolism. So, when initiating rifampicin treatment and when discontinuing it, clinicians should carefully assess the dosages of any concomitant medications that may potentially interact with rifampicin. To ensure effective therapy during rifampicin treatment, it is crucial to monitor both the patient’s clinical response and their blood drug concentrations, making dosage adjustments as necessary.

This case report offers valuable guidance to clinicians on safely and effectively managing drug interactions between antipsychotic medications and rifampicin, ensuring the well-being of their patients during treatment. The co-administration of these medications lacks robust clinical evidence, and notably, there is insufficient data regarding its impact on plasma antipsychotic levels, a crucial factor in determining clinical effectiveness.

None Declared

Little research has been conducted on outcomes in mental health care by intensity of level of service.  Mental health care has evolved in the United States to psychiatrists or psychiatric nurse-practitioners overseeing medications in 15-minute appointments while non-physicians provide the psychotherapy.

We wished to compare these two models when one psychiatrist worked in two settings, providing the medication management alone model in one setting and the medication + psychotherapy model in the second setting.

All patients were seen by the same psychiatrist at (1) a community mental health center (CMHC) and (2) a private practice (PP) providing services to the same type of patients over 2 years. Patients were assessed with the My Medical Outcomes Profile (MYMOP2) and the Brief Psychiatric Rating Scale (BPRS). In the CMHC, patients were seen for a 15 – minute visits every 1 to 3 months. Patients were offered psychotherapy, ranging from 1/2 hour monthly to 1 hour every other week. Some patients received weekly psychotherapy due to an interest by the clinician. In the PP, patients were seen every 1 to 4 weeks by the psychiatrist who also provided psychotherapy when that was desired. Visits ranged from 15 to 75 minutes. Other practitioners could have also provided psychotherapy. Analysis was conducted for patients who completed at least four outcome ratings. Multi-level modeling techniques as implemented in SPSS were used to determine if patients improved over time.

There were no differences in age, socioeconomic status, type of insurance, and type of diagnosis among the two groups. Follow-up occurred for two years. On average, no improvement occurred in outcome measurements in the CMHC setting while statistically significant improvement occurred in the PP setting. The cost of care was statistically significantly greater in the CMHC setting, due to the facility fees billed and collected for each patient (and approved by the government) of $176 additional per visit.

Further work can be done on establishing minimal levels of service delivery that can produce improvement for large populations in community settings. Since it is unlikely that we can generate control groups of no treatment, perhaps analyses like this one, comparing treatment models, can establish a benchmark from which we can understand the necessary level of treatment. The PP setting may have afforded more attention for patients than the CMHC setting, though at a lower cost to the government. The psychiatrist believed that he wanted patients to improve equally in both settings, but he could have been more enthusiastic in the setting in which he also did psychotherapy and therefore had better relationships with patients. On the other hand, this may be the point – better relationships with patients may be associated with better outcomes.

None Declared

Psychological vulnerability and problematic psychotropic drug use among medical residents are critical and intricate areas of study in the field of healthcare and mental well-being. This topic looks into the potential links between the psychological vulnerabilities experienced by medical residents, which are frequently associated with the demanding nature of their profession, and their use of psychotropic drugs in a way that poses problems or risks. Exploring this relationship is critical for understanding the mental health challenges that medical residents face and developing effective strategies to support their psychological well-being.

to identify the psychological factors linked to problematic psychotropic drug use in medical residents.

We conducted a cross-sectional descriptive and analytical study among Tunisian medical residents between August and September 2022. We used a self-administered questionnaire with a data collection form, the DAST-10 (Drug Abuse Screening Test) scale, and the DASS-21 (Depression, Anxiety, and Stress Scale) in an online survey. Data was analyzed using the 20th version of the SPSS software.

The sample consisted of 80 medical residents. Among them, 23.8% (n=19) had reported a previous use of psychotropic drugs, and 15% (n=12) a misuse (without a prescription and/or without following the prescription). The DAST-10 revealed that 6 residents (31.6%) had problematic use of psychotropic drugs.

A high level of stress on the DASS-21 scale was associated with a problematic use (p=0.01) and a misuse (p=0.01) of psychotropic drugs. Furthermore, residents with high stress levels were more likely to demonstrate problematic use of psychotropic drugs (p=0.004). Such problematic use was correlated with personal history of anxiety disorders (p=0.01).

Furthermore, residents with problematic psychotropic drug use had higher anxiety and depression scores on the DASS-21 scale (p>0.05).

Our findings revealed a concerning prevalence of psychotropic drug use among medical residents and an association with high stress levels. This result emphasizes the need for targeted interventions to support young doctors’ mental health.

None Declared

The U.S. Food & Drug Administration (FDA) has cleared SNT (Stanford Neuromodulation Therapy) for treatment of major depressive disorder (MDD) in adults who have failed to achieve improvement from at least two prior trials of antidepressants. SNT protocol requires both structural and functional connectivity MRIs which is limited by high cost and lack of availability, its use without neuronavigation is still considered an off label use and need more investigation.

1-To investigate efficacy of SNT like accelerated off-label protocol without Neuronavigation in treating patients with TRD and suicidality.

2-To investigate durabiliy ( up to one month ) of SNT like accelerated off-label protocol without Neuronavigation in treating patients with TRD and suicidality

Two cases diagnosed as treatment resistant unipolar depression with suicidal ideations received accelerated intermittent theta burst stimulation (a iTBS); with figure of eight coil administered to the left dorsolateral prefrontal cortex (DL-PFC) determined using Beam method. Stimulation was at 90% MT for 1800 pulses with an intersession interval of fifty minutes. Patients received ten sessions every day for five consecutive days for a total of fifty sessions (90,000 pulses). The following scales were applied at the baseline and at the end of each day of five treatment days:The Montgomery and Asberg Depression Rating Scale (MADRS) The Beck Depression Inventory, Columbia Suicide Severity Rating Scale (C-SSRS) and Young Mania Rating Scale (YMRS).

The two cases at the end of the fifth day were completely improved regarding both suicidal ideations and depression without emerging of hypomania. Follow up was done weekly for one month with durable results.

SNT protocol without neuronavigation needs to be well investigated in suppressing both suicidality and depression in patients with TRD.

None Declared

Peripartum Depressive Disorder (PPD) is a Peripartum Mental Disorder (PMD) characterized as a Major Depressive Disorder (MDD), wherein the manifestation of depressive symptoms initiates either during pregnancy or within the first 12 months following childbirth.

PPD impacts both maternal well-being and infant health, resulting in unfavorable outcomes during pregnancy and the postpartum period.

Non-Invasive Brain Stimulation (NIBS) is one of the rapidly expanding fields in medicine, using a range of techniques to modulate the brain.

This study aimed to summarize the latest evidence about the impact of NIBS (efficacy, tolerance, and safety) in PPD.

A review was conducted, drawing on reputable (PubMed and Web of Science databases).

Key brain stimulation modalities, such as Transcranial Magnetic Stimulation (TMS), Transcranial Electrical Stimulation (TES), and Electroconvulsive therapy (ECT) were analyzed in the context of PPD.

Preliminary findings indicate promising positive effect of NIBS in reducing symptoms associated with PPD.

In the postpartum, the favorable outlook on the effectiveness of NIBS implies that, when feasible, women diagnosed with mild to moderate PPD, especially those reluctant to initiate pharmacological interventions, should be presented with TMS or TES as an alternative therapeutic approach.

However, some doubts persist about the safety of NIBS regarding fetus and preterm birth.

NIBS constitutes a viable option for pharmacological and psychotherapeutic interventions, and it can also be integrated into comprehensive treatment regimens.

Future research include large-scale clinical trials and longitudinal studies is needed to address the efficacy, security, and long-term effects of NIBS.

None Declared

The journey for the electroconvulsive therapy began in 1938, when convulsive seizures induced by electrical stimulus were used, for the first time, in the therapy of patients diagnosed with Schizophrenia. Over the time, this therapy remains an important one, due to its applicability and necessity in the therapeutic management of patients with psychiatric pathology.

Electroconvulsive therapy has evolved as a technique, nowadays being applied under induced intravenous anesthesia with the administration of oxygen on the mask, and from 2001, the sinus electrical stimulus has been replaced by the one in the form of a short pulse, upon the recommendation of professional organizations, in order to increase its therapeutic effectiveness. However, this form of therapy continues to be stigmatized, largely due to the way it is presented in the mass media. The objective of this work was to analyze how mental health professionals perceive electroconvulsive therapy.

We conducted a study in which we used a questionnaire applied to the Romanian professionals in the field of mental health.

The results were analyzed in accordance with the objective of the study.

Through this analysis we wanted to understand how electroconvulsive therapy is seen through the eyes of mental health professionals and to identify those aspects that can help us in carrying out information programs, with a major impact on mental health, in order to reduce stigma forasmuch the therapeutic benefits of electroconvulsive therapy outweigh the possible risks.

None Declared

Electroconvulsive therapy (ECT) is a psychiatric intervention that has proven effectiveness and safety in various psychiatric conditions, such as major depressive disorder, prolonged or severe manic episodes and catatonia. Despite positive scientific evidence, ECT was always seen as controversial by patients, caregivers, and even some psychiatrists, which lead to a decrease in its use over the years.

To investigate the way young psychiatrists view the place of ECT in modern psychiatry by assessing their knowledge, attitude and access to training opportunities in ECT.

An anonymous survey was disseminated online among early career psychiatrists and psychiatric trainees. The questionnaire consisted of 36 multiple-choice and Likert scale questions.

Most of our respondents consider ECT both an effective and a safe treatment option and would recommend ECT to their patients when indicated. Early career psychiatrists who had access to ECT training are more knowledgeable about the indications, precautions and side effects of this method, but more than half of the participants mentioned ECT training was unavailable during their residency programme. Almost all respondents stated that they are interested in enhancing their theoretical and practical competencies in ECT.

Early career psychiatrists have a positive attitude towards ECT but express the need of targeted education aimed at improving levels of knowledge about ECT.

None Declared

VNS is a long-term adjunctive treatment option in patients with DTD. It has been shown that patients with VNS as add-on to treatment-as-usual (TAU) have higher response and remission rates than TAU alone. Data on the impact of VNS on the other complex concomitant treatments are limited.

In this study we evaluated changes in drug load from baseline to 12 months as well as the impact of previous ECT response status at baseline on changes in mean depression severity after 12 months of VNS.

We included n=20 DTD patients (mean age 52.6 years) in the prospective, observational, naturalistic Restore-Life study, who have been treated with adjunctive VNS as add-on to treatment as usual. The RESTORE-Life study is a multi-center study. In this analysis, we report on exploratory results from a single tertiary center. An index has been calculated for each drug by comparing the actual dose with the standard dose of the drug. The drug load for each patient has been constructed by summing up the indices of all agents prescribed for the patient.

We observed a slight decrease in mean drug load from 4.5 at baseline to 4.4 at 12 months (p=0.594). The drug load was lower in previous ECT-responders than in ECT-non-responders at both timepoints. There was a significant decrease in mean MADRS score from 27.3 at baseline to 15.3 at 12 months (p=0.001). Patients with a history of ECT response at baseline have experienced significantly greater improvement in mean MADRS score at 12 months (p=0.013). Number of maintenance electroconvulsive therapy (ECT) and esketamine sessions decreased from 37 ECT and 58 esketamine sessions in the first six months to 17 ECT (-54%) and 29 esketamine (-50%) sessions between months 6 and 12. VNS-related adverse events were present in 50 % of patients at 12 months (voice alteration/hoarseness 45%, dyspnea and pain during stimulation each 5%). There was no discontinuation of VNS due to adverse events.

Overall, VNS was associated with significant decrease in mean MADRS score at 12 months, whereas we did not detect any significant change in medication load. A more extended observation period might be necessary to observe changes in medication load. There was a reduction in the need of maintenance treatment sessions of ECT and esketamine. History of ECT response may be predictive for greater improvement of depression severity in VNS patients.

E. Kavakbasi Grant / Research support from: The Sponsor of the Restore-Life study is LivaNova. Our institution received fees from LivaNova for study visits of the Restore-Life study. LivaNova had no influence on the content of this work., H. Bauermeister: None Declared, L. Lemcke: None Declared, B. Baune: None Declared

Patients with difficult-to-treat depression (DTD) need multimodal treatment with combination of psychotherapy, pharmacotherapy and neuromodulation. In severe cases, combination of neuromodulatory techniques may be considered to achieve symptom relief.

To describe a novel treatment approach, which combines VNS in synchronization with accelerated intermittent Theta-Burst-Stimulation (aiTBS) over three weeks in two cases with difficult-to-treat depression.

In this presentation we describe two cases of DTD, which have been implanted with VNS and did not respond to aiTBS previously. Patients then were offered a synchronized treatment regimen, where each stimulus train of aiTBS was synchronized with ON-time of VNS. To start each train simultaneously with VNS ON-time, we set treatment cycle of each aiTBS and VNS to 19 sec. Patients received 2400-3000 TBS pulses daily for 3 weeks over left dorsolateral prefrontal cortex (DLPFC) at 100% of resting motor threshold.

In the first patient the MADRS score decreased from 37 to 26 (-30%) and in the other patient there was a decrease of MADRS score from 20 to 9 (-55%), which corresponded to remission after 3 weeks of treatment. The synchronized treatment procedure was well-tolerated in both cases. As both patients experienced significant improvement, we planned maintenance treatment in both cases.

Synchronization of aiTBS with VNS is a novel treatment approach in patients with DTD, which can lead to improvement even if patients previously did not respond to aiTBS without synchronization with VNS.

None Declared

Background:

Somatic symptoms disorders are usually comorbid with depressive disorders despite that there is little evidence for effective treatment for it. Repetitive transcranial magnetic stimulation (rTMS) have been approved by FDA for mildly resistance depression. From this point we hypothesized that rTMS delivered over the prefrontal cortex (PFC) may be useful in somatic symptoms disorder. Therefore, in our case report we want to shed light on the potential effectiveness of rTMS in somatic symptoms disorder.

case report

case report

Case Report:

A 65-year-old Omani female with multiple medical comorbidities on multiple medications. She presented complaining of multiple somatic complains in the last 2 years after visiting multiple clinics and underwent several specialists’ examinations, investigations and procedure for somatic treatments, all of them where normal.

Then patient was seen by different psychiatric clinic multiple anti-depressant and adjuvant anti-psychotic medication were try, patient still not improve.

Patient get admitted to hospital for observation and management. Initially she was preoccupying by her somatic complain kept on Fluoxetine and Olanzapine along with that topiramate was added, but still with minimal improvement. Then rTMS was added to her management plan following Intermittent theta burst (iTBS) rTMS protocol. After complete all sessions of rTMS patient was recovering from her all symptoms, no complain report from her.

Conclusion: our case highlights the important of investigated more thoroughly in rTMS as treatment option for Persistent Somatic symptoms Disorder.

None Declared

Electroconvulsive therapy (ECT) is a therapeutic method that induces artificial seizure by electrical stimulation to resolve various psychiatric symptoms. ECT is particularly effective in resistant schizophrenia and may improve response to medication despite the presence of potential adverse side effects. Post-ECT delirium and Headaches are some of the most frequent side effects presented in literature. Fever is yet another unexplained reaction, however there are a few case reports and retrospective studies that report on it.

We aim to illustrate through a clinical case and a review of literature the prevalence of post ECT fever as well as the possible explanatory mechanisms.

In this study we report the case of a man with ultra-resistant schizophrenia who was treated successfully with ECT despite the development of transient febrile reaction and we present a review of literature on pubmed using the following key words : ECT, fever,resistant psychosis, mechanisms.

Our patient is a 48-year-old man with a psychiatric history of schizophrenia evolving since the age of 34. He has a history of matricide in 2021 resulting in his hospitalisation in a forensic psychiatric ward. He underwent trials of classic and atypical antipsychotics that weren’t efficacious thus he was diagnosed with resistant schizophrenia in 2022. He was treated initially with clozapine 500 mg per day and then with the association (clozapine + amisulpride) yet it wasn’t effective on his persecutory delirium and fratricide ideas. Plus, there was no reduction in his PANSS (Positive and Negative Syndrome Scale) scores. The diagnosis of ultra-resistant schizophrenia was established. The staff indicated the adjunction of ECT to Clozapine. In the inpatient unit, hours after his fourth ECT session he developed a fever (40°C), his blood pressure (120/80 mm Hg), pulse(85 beats per minute),and respiratory rate(20 breaths per minute) were normal. Blood samples, including cultures, were drawn, which showed normal blood cell count and CPK(140U/L) but CRP was elevated (31 U/L), a chest x-ray showed no acute pulmonary disease, and his urinalysis result and Covid test were negative. His fever resolved then spontaneously after two hours. The same transient febrile reaction occurred again 3 times. It was postulated in literature that fever may be due to inadequate muscle reaction. Data also suggested the potential influence of ECT on the hypothalamus that is a key region in regulating body temperature.

Further studies are required in order to establish the real prevalence of this side effect and its possible causes.

None Declared

There is an increasing rate of treatment resistance in severe psychiatric disorders (SPDs), which indicates the necessity for finding new therapeutic interventions, because of the significant negative impact these disorders have on the patient’s quality of life, functionality, and other important parameters. In clinical practice, SPDs are estimated to represent up to 30-60% of all diagnosed cases. Schizophrenia spectrum disorders (SSD), major depressive disorder (MDD), and bipolar disorders (BDs) are associated with lower response to a large variety of therapeutic approaches. In this context, new technologies should be considered for SPDs, and non-invasive neuromodulation techniques can be explored as add-ons to ongoing therapeutic interventions.

A literature review was conducted to detect the available evidence to support recommendations for neuromodulation techniques in SPDs.

Three electronic databases (PubMed, Cochrane, Google Scholar) were searched for papers corresponding to the keywords “treatment-resistant psychiatric disorders” and “neuromodulation” or “electroconvulsive therapy” (ECT) or “transcranial magnetic stimulation” (TMS) or “transcranial direct current stimulation” (tDCS), published from the beginning of the respective databases up to July 2023.

After the initial search, 1258 papers surfaced, but only 72 remained to be included in the analysis, after filtering them according to the inclusion and exclusion criteria. TMS may improve both depressive and manic symptoms, but also reports of polarity changes were found, indicating the need for careful monitoring of treatment-emergent affective switches (TEAS). TMS may also improve cognitive functions, although not sufficient evidence was found to support this observation clearly. The efficacy of temporoparietal TMS in schizophrenia has not been proven with certainty, although this intervention may improve positive symptoms. ECT was an effective and well-tolerated intervention for severe mood episodes, SSD, and BDs. Depressive symptoms responded to tDCS in bipolar/monopolar patients, but reports of TEAS in the BDs population have been reported.

Non-invasive neuromodulation techniques may represent an efficient option in patients with SPD, but more good-quality trials are needed before this recommendation is formulated in clinical guidelines.

None Declared