The authors have not supplied their declaration of competing interest.

Cannabis consumption is known to be increased in both schizophrenic and first psychotic episode patients. Contrary to what has been reported in studies with healthy people, all published studies so far have reported no impairments or even beneficial effects on neurocognition associated with cannabis consumption in schizophrenia and first psychotic episode patients. However, these studies did not address the effects of very high cannabis consumption.

Our aim in this study was to assess the effects on neurocognition of regular and heavy cannabis consumption in first psychotic episode patients.

A total of 74 patients were included in the study and assigned to 3 different groups according to their mean cannabis consumption during the last year (non-users, regular users, and heavy users). Participants were administered verbal memory, attention, processing speed, working memory, vocabulary, arithmetic and spatial orientation tasks.

Our results showed the heavy cannabis group of first psychotic episode patients to be significantly impaired in all the verbal memory measures with respect to the non-users group. There were no significant differences between regular users and non-users. Moreover, regular cannabis consumption was associated with an improvement in some attention and processing speed measures.

Our data showed heavy cannabis consumption to impair verbal memory in first psychotic episode patients and suggest a dose-related effect of cannabis consumption, since regular consumption did not impair verbal memory and may be beneficial for other tasks.

The authors have not supplied their declaration of competing interest.

Psychosis with onset in late adulthood already constitutes a challenge on the differential diagnosis and treatment, especially in polypharmacy patients.

We present a case report of a 61-year old woman with a late-onset psychosis and discuss the clinical evolution and the pharmacological treatment.

The patient suffered from obesity, type II diabetes mellitus with poor glycemic control, and hypertension. She had a first psychotic episode at the age of 56, having persecutory delusional ideas and auditory hallucinations with psychomotor agitation and insomnia. She was first medicated with an atypical antipsychotic (olanzapine) with little response and worsening of the glycemic control. A switch was performed to haloperidol with remission of symptomatology with low doses (4 mg/day). Through follow-up the doses of haloperidol was decreased and eventually suspended, but having a relapse a few months later. Haloperidol was again introduced and the symptoms remitted. Stability was maintained, but the patient started to show lower limbs symmetrical rigidity and psychomotor retardation. It was decided to switch haloperidol to risperidone, but the patient reported side effects with its use, and had to stop it. Haloperidol was again introduced, but had to be discontinued after motor symptoms got worse. Again the patient had another recurrence of psychotic symptoms and it was decided to introduce paliperidone (6 mg/day) with good response and tolerability.

The safety and tolerability of antipsychotic medication is variable. When choosing a treatment in a patient with comorbid medical conditions, it can severely influence the desirable outcome.

The authors have not supplied their declaration of competing interest.

Several studies report that Clozapine is more effective in reducing symptoms of schizophrenia, producing clinically meaningful improvements and postponing relapse than other antipsychotic strategies.

To analyze the prescription of Clozapine in a sample of 88 inpatients admitted to a subacute psychiatric hospitalization unit.

This is a transversal study. All patients admitted for a medium-term psychiatric treatment since 01/06/2014 to 30/11/2015 were included. Data about socio-demographical status and clinical situation were obtained and compiled in a database. This study compares patients receiving clozapine treatment with those who receive other psychopharmacologic treatment. Statistics were performed using SPSS Software.

Eighty-eight patients (52% men; mean age: 48.6 years) composed the sample. In 58% of cases, schizophrenia and schizoaffective disorder were the diagnoses motivating the admission. Within the 51 patients with Schizophrenia o Schizoaffective Disorder, 16 of them (31.4%) received Clozapine. Comparing clozapine group vs non-clozapine group, there were no significant differences between the groups in terms of sex, civil state or working state. Instead, Clozapine group patients were older, had a major number of previous hospitalization admissions and had a larger trajectory of their disorder.

Patients requiring treatment with Clozapine had a major number of hospital admissions and had more often committed suicide attempts, suggesting a more severe course of the disorder. They were older than the non-clozapine group. Clozapine is delayed in its use among resistant-treatment patients. It is worth highlighting that only 16 cases of Schizophrenia inpatients received Clozapina. It could mean that Clozapine is underprescribed.

The authors have not supplied their declaration of competing interest.

Adults with autism spectrum disorders (ASD) often have behavioral disorders, like aggression, agitation and self-injury. These problems are frequently severe enough to limit educational and developmental progress. Only risperidone and aripiprazole have so far been approved by the FDA for the treatment of behavioral disturbance associated with autism. These drugs are not very effective in the long term, with little benefits to the social functioning and they are associated with side effects. This case report describes the use of pipamperone, in treating behavioral disorders of a patient with autism spectrum disorder and severe mental retardation.

Here is presented the case of a 32-year-old man with autism spectrum disorder, severe mental retardation (caused by undiagnosed phenylketonuria for the first 3 years of life) treated with antipsychotics since childhood. He showed numerous episodes of psychomotor agitation, hetero-direct physical aggression and self-injury, and movement disorders induced by drugs. Treatment with pipamperone reduced drastically crises of psychomotor agitation, and behavioral disorders, without extrapyramidal side effects, and led to an improvement in social functioning. The control of behavioral symptoms associated with adherence to treatment was maintained for 6-month follow up. These clinical observations are supported by ratings using: ABC, CGI-S and CGI-I, VABS, SAS, AIMS.

This case report provides the first potential evidence that pipamperone may be effective in treating behavioral problems associated with autism spectrum disorders. Moreover, the improvement of social functioning and the lack of extrapyramidal side effects make this drug notable for its effectiveness and tolerability.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

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.