In spite of the absence of validation by treatment guidelines, the practice of polypharmacy in psychiatry continues to increase. This cross-sectional study tries to describe polypharmacy rates in a psychiatric ward of a general hospital.

Participants (51 patients) were selected from inpatients in the General University Psychiatric Hospital “Papageorgiou”. The study was conducted from July to September 2011. Patients had to be hospitalized for at least 3 weeks in order to be included. The statistical program SPSS was used in the analysis.

Our sample consists of 51 patients, of average age 45.4 years (SD = 16,3), males 39,2%, with average starting age of disease 35.8 years (SD = 16,1), 78,4% voluntary hospitalized, with the diagnosis of schizophrenic disorder in 41.2%, bipolar disorder in 19.6% and depression in 39.2%. 29.4% of patients were working before being hospitalized and 7.8% had history of substance use. Their treatment included more than one antipsychotic in 2% of patients, more than one antidepressant in 4% and a benzodiazepine in 33.3%. At the moment of discharge from hospital, the rates of polypharmacy showed no statistically significant difference compared to the ones at admission. The only exception concerned the use of the long-acting formulations which rose to 7.8%.

Most patients hospitalized in the psychiatric department of the University General Hospital was suffering from mood disorders and had short admission time. These factors led to a decreased need of using multiple kinds of medications. A larger sample of patients is necessary to confirm the presented points.

Psyhiatrists who work in hospitals and treat patients who show aggression present particular challenges. The course and treatment of serious psychiatric disorders can be complicated because of the comorbidity with substance abuse. The objective of the present study is the drug treatment of aggression among in-patients with serious mental disorder.

The participants (423 patients) were randomly screened among the in-patients of the 9 acute departments of PHA (Psyhiatric Hospital of Attica). For the statistical analysis, the program SPSS was used.

The participants (423 patients): average age 45.9 years old (sd = 13.1), 60.8% men, 63.7% involuntary admitted, disorder onset: 28.4 years (sd = 12.1), diagnosis of Schizophrenia 72.1%, Bipolar disorder 16.8%, Depression 11.1% with substance abuse in 18.7%, and reason of admission: auto/hetero- agression 24.3%, relapse of the disease 46.1%, interruption of drug therapy 27%. 67,5% showed aggression at the admission, 25.6% were administered more than one antipsychotic drug at the admission, along with benzodiazepines in 53.7%. During their hospitalization, aggression was reduced to 22.9%, with verbal aggression first in line with 14.4%, and 41.9% of the patients were administered more than one antipsychotic drug. The SGAs dominated and were administered in combination with stabilizers, antidepressants and benzodiazepines.

There are few documented points to guide daily practice, and it seems that case reports, advices from other colleagues and/or personal experience may influence in an important way the therapy of psychiatric patients who show aggressive behavior.

A careful search of Embase, PsychINFO, Medline for studies estimating the prevalence rate of anticholinergic adverse effects identified only three surveys and each was flawed in substantial ways.

To estimate prevalence/incidence rates of anticholinergic effects of antipsychotic medications.

Inclusion criteria: Any systematic reviews involving people with schizophrenia-like illnesses, being treated with any antipsychotic medications and undertaken by the Cochrane Schizophrenia Group.

Outcome measures: Prevalence/incidence rate of any anticholinergic side effect.

Search strategy: Cochrane Library (www.intersience.willey.com) was searched in January 2007; all printed figures were inspected and data extracted. This process was repeated twice.

Analyses: Simple frequencies, proportions and confidence intervals.

46% of trials therein reported data on anticholinergic effects. However, there were also many relevant studies where anticholinergic effects were not reported. Blurred vision, dry mouth and constipation are common adverse effects of all antipsychotic drugs.

This is by far the largest study estimating the proportion of people on specific antipsychotic drugs who experience these problematic adverse effects. The newer generations of drugs do seem to have a spectrum of familiar and common anticholinergic effects. They are not clearly distinguishable from many of the older compounds.

During drug development pharmaceutical manufacturers conduct numerous clinical trials to demonstrate therapeutic efficacy and safety of new antipsychotic drug candidates. However, clinical trials are impacted by the need to comply with scientific standards and regulatory requirements for approval. While supplying information necessary for approval, these trials provide data on a limited sample, obtained under conditions often removed from clinical practice. Drug labeling containing warnings, precautions and adverse events undergo regular revision once the population-based application provides evidence for need to change the information on the safety profiles of drugs.

To provide a systematic review of the safety profiles of 9 selected second-generation antipsychotic agents including aripiprazole, asenapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone upon and following FDA approval.

To gain access to safety profiles of the selected antipsychotic drugs we investigated the FDA's Summary Basis of Approval Documents. Comparison of safety profiles was made possible via the revisions provided in MedWatch Database.

Safety data available upon approval fail to provide a full range of emerging side effects. Our results indicate that the labeling of all investigated antipsychotic drugs has been substantially expanded due to safety reasons both with regard to inclusion of adverse reactions (ARs) newly detected in the postmarketing phase and to providing more precise estimates for the incidence of individual ARs already described at the licensing phase.

Population-based application reveals unforeseeable health risks and additional costs both on manufacturer and patient level, emphasizing the need for novel methods for initial safety evaluation.

To show that a combination of psychopharmacotherapy can result in unwanted side effect.

We are presenting a 31-year-old patient addmitted to the hospital with diagnosis of a Acute stress reaction due to divorce. Before hospitalization, the patient was in occesional psychiatric treatment because of Anorexia Nervosa on Axis I, and with Borderline personality disorder on Axis II. The pre-hospital pharmacological treatment were consisted of olanzapine, diazepam and fluvoxamine.Upon addmitence the patient was restless and in persistent moving and diagnosis of akathisia was established. In the mental status dominated depressive ideas, listless.

After addmission to the hospital, to the pharmacotherapy mentioned earlier were added lamotrigine as a mood stabilizer,and propranolol for akathisia, and the dose of fluvoxamine was reduced. After four days of hospitalization (the patient insists on a discharge from the hospital) was succeeded partially to regulate sleep, but there were still present early-morning awakening, appetite was slightly better, there was no loss of weight. Patient was less intrapsychic tense. Depressive ideas were paler but present. Symptoms of akathisia were reduced.

Considering that the patient was treated with fluvoxamine and olanzapine, we believe that their synergistic effect was responsible for the occurrence of akathisia. Although the antipsychotic alone can have this side effect,in combination with fluvoxamine these side effect may intensify. Specifically fluvoxamine is an inhibitor CY P1A2. This cytochrome is responsible for the metabolic pathway of olanzapine,so when using fluvoxamine may increase serum concentrations of olanzapine, which may result in the appearance of akathisia.

Recent research and guidelines’ recommendations favour clozapine use, probably more than ever, but even though most clinicians remain reluctant prescribing it.

To assess the mismatch between clozapine's treatment indications and prescription rates, discuss the underlying motives for such a discrepancy and possible interventions to reduce the gap.

Promote clozapine use when indicated and raise awareness of the impact in terms of patients’ health and healthcare costs.

A qualitative review of the evidence on clozapine's use.

The response rate to clozapine is approximately 50%, irrespective of non-response to prior treatment and has unique anti-suicidal, anti-aggressive and comorbid substance abuse properties. About one third of schizophrenia patients have treatment-resistant schizophrenia, however only one third are prescribed clozapine and its initiation is 5 years delayed. Doctor's reluctance in prescribing clozapine may be related to its perceptions regarding clozapine's serious side effects and patient's satisfaction. Nevertheless, monitoring serious side effects such as agranulocytosis considerably reduces fatalities and one year after treatment initiation such risk is comparable to other drugs like haloperidol; despite feared side effects with clozapine use, studies showed that clozapine is associated to reduced premature death even compared with those not taking regular medication; most patient's claim to feel better on clozapine, prefer to remain on clozapine and express that the advantages of clozapine outweigh disadvantages.

Clozapine remains the only antipsychotic licensed to treatment-resistant schizophrenia. Despite its clinical superiority, lower costs associated to treatment, patient's preferences and overestimated safety concerns, clozapine remains considerably underused.

Despite a favorable pharmacological rational, the prescription of antipsychotics depot formulation in patients with schizophrenia is low.

The goal of our study was to assess the attitudes of French psychiatrists toward the use of depot antipsychotics in patients with schizophrenia.

113 french psychiatrists were interviewed at a congress of psychiatry, using a questionnaire to identify psychiatrists attitudes influencing the use of long-acting injectable antipsychotics (LAI) in schizophrenia. Multidimensional and cluster analyses were used to detect correlations.

According to data compiled by the german team of S. Heres (2008), two clusters of factors specific to the patient for the prescription of antipsychotic depot, have been identified: the cluster “high level of therapeutic alliance and high level of insight” on the one hand and the cluster “poor compliance to oral therapy and high number of relapses in the past” on the other. The most important factor against the use of LAI antipsychotics is a sufficient estimated compliance with the oral formulation. For first-generation LAI, the main factor is the risk of extra pyramidal symptoms and for second-generation LAI, it is the unavailability of the equivalent of oral formulation.

Among the reasons influencing the prescription of LAI antipsychotic, history of poor adherence to oral therapy is important. In contrast, the highlighting of a profile of patients with a high level of insight and a high level of therapeutic alliance, confirms the value of these forms beyond the traditional profile of non-adherent.

Consists of drugs which their PA counteracts the symptoms of illness e.g. drowsiness as PA of hypnotics when they are used for treatment of insomnia.

1. 1. PA of drug is therapeutic therefore improvement starts quickly.

2. 2. Tolerance develops in long term use.

Consists of drugs which their PA simulates the symptoms of illness e.g. anxiety and palpitation as PA of Citalopram used for Panic disorder.

1. 1. There is possibility of initial paradoxical worsening due to PA of drug. It can be minimized by reducing the initial dose.

2. 2. Unlike above, here the reaction of body (we call it as secondary action) seems to provide the therapeutic effect and therefore improvement starts with delay.

3. 3. They can be used long term without developing tolerance.

Show that 10% of psychotropic drugs work in contrary based and 47% in simulation based mode. Information in BNF has not been conclusive for 43% of drugs, like Benperidol for antisocial behaviour. Confirmation of clinical value requires further studies.

Heptapeptide Selank approved for the treatment of Generalized Anxiety Disorder (GAD). Studies revealed that Selank acts as an anxiolytic with stimulatory and cognitive enhancing properties. Though time to treatment response significantly varied in patients and this issue has not been studied.

Individual treatment response analysis in Selank-treated patients with GAD.

To compare clinical state and EEG changes in patients with different time to treatment response to Selank.

20 patients aged 24–52 y.o. with GAD according to DSM-IV were included. Selank was administered at the dose 2700 μg/day intranasally. Study utilized valid clinical scales and pharmaco-EEG.

40% of patients were rapid responders (RR) and characterized by abrupt reduction of whole set of symptoms in first 1–3 Days. At the Day 3 Hamilton Anxiety Rating Scale (HARS) mean total score [SD] reduced from 20.3[11.9] to 7.0[2.9] (p < 0.01). 60% of patients responded gradually (conventional responders - CR). Clinically significant changes of mean HARS total score from 16.1[7.2] to 6.2[4.7] were achieved at Day 14, p < 0.01. In contrast to CR, RR demonstrated obvious EEG-reaction after single dose (900 μg) with increase of beta-rhythm, decrease of theta- and low frequencies of alpha-rhythm (all p < 0.05). Initially RR and CR significantly differed by the score of asthenic and cognitive symptoms (p < 0.05).

Data that peptide anxiolytic drug Selank in patients with GAD exert significant individual variability of therapeutic effect, including rapid effectiveness, confirmed. RR had more asthenic and cognitive symptoms and characterized by a higher EEG-reactivity than CR.

Neuroleptic-induced movement disorders constitute a worldwide problem in the treatment of schizophrenia because of the limited affordability of atypical antipsychotic drugs. However, the prevalence of Neuroleptic-induced movement disorders and their associated factors have not been studied in psychotic patients in Ethiopia.

To determine the prevalence of conventional antipsychotic induced movement disorders and associated factors among psychotic patients at Amanuel mental specialized Hospital.

Hospital based cross-sectional study was conducted by using established clinical rating scales to identify cases of conventional antipsychotic-induced movement disorders in Amanuel mental specialized Hospital samples of 377 psychotic outpatients. Systematic random sampling method was employed to select subjects. Logistic regression was used for comparison of the subjects with and without Neuroleptic-induced movement disorders.

Neuroleptic-induced movement disorders according to the clinical rating scales were found in: 175(46.4%) had neuroleptic-induced Parkinsonism, 108(28.6%) had neuroleptic-induced Akathisia and 45(11.9%) had neuroleptic-induced tardive dyskinesia. Khat use AOR = 1.93, 95%CI: 1.01–3.66 was factors remained to be associated with the presence of NIA. Alcohol use AOR = 3.25, 95%CI: 1.04–10.16 was associated with TD. Being on chlorpromazine equivalent dose range of > = 400 mg/day AOR = 4.32, 95%CI: 2.25–8.30, AOR = 3.68, 95%CI: 1.81–7.48, AOR = 4.16, 95%CI: 1.17–14.83 were associated with Parkinsonism, Akathisia and TD respectively.

In conclusion, many patients with psychotic disorders suffered from a conventional antipsychotic -induced movement disorder. Khat, alcohol and high dose of drugs were found to be associated with conventional antipsychotic Induced movement disorders.

Mirtazapine is increasingly used in the treatment of depression and other psychiatric conditions. The incidence of seizures associated with Mirtazapine use is low. This is a case of a patient who developed seizures shortly after the initiation of treatment of Mirtazapine.

To highlight the rare occurrence of Mirtazapine associated seizures as well as review the relevant literature.

A middle aged Chinese man who was admitted to the hospital for deterioration in physical function was referred to the consultation liaison psychiatric team for low mood. He was diagnosed to be suffering from a depressive disorder and was started on Mirtazapine 15 mg at night. He developed generalised tonic clonic seizures which aborted spontaneously. All subsequent investigations to look into possible causes were normal.

A search was performed in several biomedical databases and the relevant studies were reviewed.

Mirtazapine was discontinued in the patient with no recurrence of seizures. A review of the literature revealed that seizures associated with Mirtazapine are exceedingly rare. In fact, Mirtazapine is recommended for use in patients with epilepsy due to its low epileptogenic potential.

It is prudent to exercise caution in the prescription of Mirtazapine in patients who may be predisposed to developing seizures.

Paroxetine is a selective serotonin reuptake inhibitor antidepressant. We present a case of a patient who developed herpes zoster 4 weeks after initiating paroxetine.

A 35 year old female was referred to our hospital due to obsessive compulsive disorder. She complained of intrusive thoughts of being contaminated and repetitive behaviors.

After a thorough laboratory and imaging tests she was prescribed paroxetine 40 miligrams daily.

Four weeks later she complained of pain followed by rash along the same dermatomal distribution in the lower abdominal area. The involved area was tender to palpation.

A detailed dermatologic evaluation was performed and the rash was attributed to herpes zoster. Despite the potential association of paroxetine with herpetic rash the patient continued treatment and was prescribed acyclovir and pain killers. One month later herpetic rash had fully remitted.

This is the first report of herpes zoster attributed to paroxetine therapy. The pathophysiological mechanism governing the effects of SSRIs in immune function is controversial. In vitro studies have shown that SSRIs decreased splenic lymphocyte proliferation while other studies have shown that chronic SSRI treatment is associated with a reduction of the number of leucocytes and neutrophils. It has been suggested that the immune effects of SSRIs are mediated by endogenously released serotonine, while T leymphocytes express 5HT receptors. Although a casual association of herpes zoster and paroxetine therapy cannot be attributed with the described case, further studies are needed to clarify under which circumstances, paroxetine could trigger herpetic rash.

To report about treatment of a patient with schizophrenia who had depressive symptoms after establishing diagnosis of breast cancer.

The patient, 35 years old, was diagnosed with schizophrenia in the age of 20. Since then she was in regular psychiatric treatment and was taking different antipsychotics in therapy. She was hospitalized six times in our hospital. About one year ago, the diagnosis of breast cancer was established. Before that, the patient had quetiapine in daily dosage of 300 mg in therapy. When the patient found out about the diagnosis of breast cancer she was afraid and after some time developed depressive symptoms. For that reason, tianeptine was administered in therapy, in daily dosage of 37,5 mg, and treatment with quetiapine in daily dosage of 300 mg was continued. Before initiation of antidepressant the patient refused all suggested treatment for breast cancer. Two weeks after initiation of treatment with tianeptine, and along with supportive psychotherapy, the symptoms of depression were reduced and the patient accepted surgical treatment (mastectomy), and after that chemotherapy and radiotherapy. During such treatment the patient continued taking tianeptine and quetiapine as described, and her mental condition remained stable. Also, for the past six months the patient has been attending meetings of women with diagnosis of breast cancer in the Clinic where she was treated.

Though there are several recommended guidelines for treating schizophrenia, in routine clinical practice, these are not followed.

To conduct an audit of the prescription pattern of antipsychotic drugs in patients with schizophrenia, in a tertiary care centre in India, during a period of 1 year and compare it with Maudsley guidelines and Clinical practice guidelines for Psychiatrists in India (IPS guidelines).

Data were collected from the case records, compiled, and analyzed. The concordance or discordance with Maudsley and IPS guidelines were studied.

The demographic variables of the patients and the prescription pattern of drugs were analyzed. The correlations between supramaximal and sub-threshold dosage of drugs to the gender, age, duration of illness, and combination of drugs were examined.

Polypharmacy of antipsychotics is common. 31% of patients were on combination of typical and atypical antipsychotics. 4% of patients were receiving supramaximal dose of antipsychotics and all of them were on combination (P = < 0.03, ×2). 24% of patients were on sub-threshold doses. 83% were not on anticholinergic drugs.

Various psychomotor dysfunction are observed in opioid-addicted patients. Therefore it is important to determine the effect of psychoactive substance administered therapeutically in substitution therapy.

This study aims to assess the impact of a single therapeutic dose of methadone on hand-eye coordination and motor learning in opioid-addicted patients treated in substitution therapy.

Was examined 72 patients and 60 healthy subjects. The Pursuit Rotor Task (PRT) was used. The PRT was conducted twice: before and about 1 hour after administration of methadone in the opioid-addicted patients and at an about 1 hour interval in the control group. The study was performed for both the dominant and non-dominant hand.

The statistical significantly (p < 0.05) influence of administration of methadone on the growth of motor control and to reduce the tremor of high amplitude and increase low-amplitude tremor was found. The opioid-addicted individuals have obtained more than 50% lower scores on psychomotor performance in hand-eye coordination task compared to the healthy subjects. The dynamics of motor learning in opioid-addicted individuals is similar to the healthy subjects and tends to go up, but without reaching a stable level of learning like was observed in the healthy subjects. In the opioid-addicted patients compared to persons from the control group there are more tremors of high amplitude and low frequency and fewer tremors of low amplitude and high frequency.

Administration of a single therapeutic dose of methadone in opioid-addicted patients may reduce high amplitude tremor and improve hand-eye coordination.

Childhood use of antipsychotics in the U.S. has grown dramatically over the past decade. In North Carolina (NC), roughly 20 thousand children under the age of 18 covered by Medicaid have filled more than $40 million in prescriptions for antipsychotics in the last year.

Traditionally the primary mechanism of controlling drug use has been through prior authorization and determination of appropriate use through medical and pharmacy claims.

Determine if an online safety monitoring system can be successfully deployed without significant prescriber disruption.

Increase monitoring and best practice management of undesirable metabolic effects of current treatment regimens.

North Carolina Medicaid designed an online safety monitoring system that collects prescribing intentions and monitoring activities for children under the age of 18 and is tied to the pharmacy point-of-sale system. A comprehensive educational effort that included promotion of monitoring best practices and assistance with registration in the online system was endorsed by the professional medical societies and deployed using experts from four medical schools in NC. Data regarding call center activity were collected at the time of support and combined with data from the online documentation system. Claims data were examined to determine delays in time to refill medications.

By the end of the first three months, the online system had been used by prescribers 87% of the time for antipsychotics with little evidence of delays in filling the scripts.

Tardive dyskinesia is characterized by involuntary, repetitive, purposeless movements that can affect different parts of the body (1). It is strongly associated with a history of antipsychotic use and usually occurs after several years of treatment.

We report two cases in whom fluvoxamine was beneficial both depressive disorder and tardive dyskinesia.

The pathophysiology of tardive dyskinesia is complex and remains unclear. There is no definitive treatment for tardive dyskinesia, although tetrabenazine ameliorates tardive dyskinesia most effectively. Positron emission tomography showed that fluvoxamine bound to sigma-1 receptors in the living human brain at therapeutic doses, suggesting that sigma-1 receptors play a role in the mechanism of action of fluvoxamine.Currently, fluvoxamine was reported to be effective for both treating hemiballism and depression in a patient and it was suggested that fluvoxamine might act as a reducer of dopamine in striatal area (3). Similarly, the potent sigma-1 agonist fluvoxamine reduced dopaminergic activity in the striatal area in our case.

The potent sigma-1 agonist fluvoxamine might be an alternative treatment option for hyperkinetic movement disorders without significant side effects. More detailed, double-blind studies should clarify the potential use of fluvoxamine in the treatment of hyperkinetic movement disorders.

Neuroleptic Malignant Syndrome (NMS) is life-threatening complication of antipsychotic treatment. The risk of NMS is greater by the classical antipsychotics, however there are reports on induction of NMS with the new antipsychotics NAP.

56 years old male with the schizoaffective disorder currently manic episode, hospitalized and treated with: valproic acid, lithium and olanzapine; developed depression and metabolic syndrome. Twelve days after the olanzapine was changed to amisulpride (400 mg/day) elevation of mood and drive followed by confusion, dysarthria, muscular rigidity and tremor emerged within hours. The lithium intoxication (blood level 1,22 mmol/l) or MNS were suspected. Lithium and amisulpride were discontinued. The occurrence of fever (38 C), insomnia, delirium, rigidity, elevated blood creatine phosphokinase CK (1346j) and myoglobin (144 n/ml) confirmed the NMS. After 20 days treatment with Diazepam and bromocriptine all the symptoms of NMS have disappeared, but the patient started to have depressive symptoms. The quetiapine (100 mg/d) for 3 weeks improved mood and activity, but the treatment was discontinued due to recurrent increase in blood CK and myoglobin (with no clinical symptoms of NMS).

The presented case reveals the risk of NMS connected with NAP. It is to notice that after withdrawal of the clinical NMS symptoms noticeable over-reactivity of receptors to other antispychotics (quetiapine) was persisting. The investigation of the role of other factors (co morbid somatic illness, interaction with lithium etc) in the induction of NMS is needed.