Bariatric surgery is considered an effective treatment against obesity. Psychiatric illness is relatively common in patients who have undergone bariatric surgery. Over one-third of these patients are prescribed psychotropic drugs, particularly antidepressants. Unlike medications for diabetes, hypertension or hyperlipidemia, which are generally reduced and at times discontinued, postsurgery psychotropic use is only slightly reduced. The surgical intervention and the subsequent weight loss can affect several pharmacokinetic parameters, leading to a possible need of dosing adjustment.

To review the influence of bariatric surgery on the use and pharmacokinetics of psychotropic drugs.

Non-systematic review of literature through search on PubMed/MEDLINE for publications from 2011 to 2021, following the terms psychotropic and bariatric surgery. Textbooks were consulted.

It is difficult to predict how psychotropics will be affected by bariatric surgery because of interindividual differences and limited data. Malabsorptive surgical procedures have a relatively greater potential to alter drug exposure. Medication disintegration, dissolution, absorption, metabolism and excretion have been found to be altered in postbariatric patients. Antidepressants are the best studied psychotropics in the bariatric population and their absorption is reduced. The risk of gastric bleeds with bariatric surgery will probably be increased by serotoninergic antidepressants. Antipsychotics and mood stabilisers are not well studied in these patients. Depot antipsychotics avoid the risk of reduced absorption after surgery. Lithium use requires particular close monitoring.

Close treatment monitoring and the ongoing monitoring of symptoms are needed after bariatric surgery. Many patients may not require significant changes to drug treatment after surgery.

No significant relationships.

Lithium has a narrow therapeutic window. Frequent monitoring of both serum levels and clinical signs of toxicity is warranted because toxicity may be present even when concentrations are within the therapeutic range. Persistent neurological signs and symptoms of lithium intoxication gained clinical attention in the 1980s and were named Syndrome of Irreversible Lithium-Effectuated Neurotoxicity (SILENT).

To review the long-term neurological sequelae of lithium intoxication (SILENT) to highlight their clinical presentation, assessment, management and preventive measures.

Non-systematic review of literature through search on PubMed/MEDLINE for publications up to 2021, following the terms syndrome of irreversible lithium-effectuated neurotoxicity.

Neurological manifestations of lithium poisoning may persist, even after effective removal of the drug – SILENT. The most frequent sequelae are cerebellum and brain stem dysfunction, extrapyramidal symptoms and dementia. They may last for weeks, months or years. Infection, dehydration, deteriorating renal function or the addition of other drugs may precipitate acute toxicity. Irreversible damage is difficult to treat. Some cases show spontaneous recovery that may be total, but in others, sequelae persist. Helpful measures include the avoidance of acute intoxications with lithium, long-term and continuous dose adjustment and serum level monitoring, stricter exclusion criteria for starting lithium, and aggressive treatment of acute neurotoxicity. Once the long-term neurologic sequelae have set in, the patient should be managed according to the impediment (physical rehabilitation, speech, cognitive training).

It is important to raise the awareness of SILENT so that clinicians are able to avoid it. There should be a low threshold for suspecting the existence of toxicity.

No significant relationships.

No significant relationships.

Although no drugs are licensed for the treatment of personality disorder, pharmacological treatment in clinical practice remains common.

This study aimed to estimate the prevalence of psychotropic drug use and associations with psychological service use among people with personality disorder.

Using data from a large, anonymised mental healthcare database, we identified all adult patients with a diagnosis of personality disorder and ascertained psychotropic medication use between 1 August 2015 and 1 February 2016. Multivariable logistic regression models were constructed, adjusting for sociodemographic, clinical and service use factors, to examine the association between psychological services use and psychotropic medication prescribing.

Of 3366 identified patients, 2029 (60.3%) were prescribed some form of psychotropic medication. Patients using psychological services were significantly less likely to be prescribed psychotropic medication (adjusted odds ratio 0.48, 95% CI 0.39–0.59, P<0.001) such as antipsychotics, benzodiazepines and antidepressants. This effect was maintained following several sensitivity analyses. We found no difference in the risk for mood stabiliser (adjusted odds ratio 0.79, 95% CI 0.57–1.10, P = 0.169) and multi-class psychotropic use (adjusted odds ratio 0.80, 95% CI 0.60–1.07, P = 0.133) between patients who did and did not use psychological services.

Psychotropic medication prescribing is common in patients with personality disorder, but significantly less likely in those who have used psychological services. This does not appear to be explained by differences in demographic, clinical and service use characteristics. There is a need to develop clear prescribing guidelines and conduct research in clinical settings to examine medication effectiveness for this population.

The hypoactive, hyperactive, and mixed subtypes of delirium differently impact patient management and prognosis, yet the evidence remains sparse. Therefore, we examined the outcome of varying management strategies in the subtypes of delirium.

In this observational cohort study, 602 patients were managed for delirium over 20 days with the following strategies: supportive care alone or in combination with psychotropics, single, dual, or triple+ psychotropic regimens. Cox regression models were calculated for time to remission and benefit rates (BRs) of management strategies.

Generally, the mixed subtype of delirium caused more severe and persistent delirium, and the hypoactive subtype was more persistent than the hyperactive subtype. The subtypes of delirium were similarly predictive for mortality (P = 0.697) and transfer to inpatient psychiatric care (P = 0.320). In the mixed subtype, overall, psychotropic drugs were administered more often (P = 0.016), and particularly triple+ regimens were administered more commonly compared to hypoactive delirium (P = 0.007). Patients on supportive care benefited most, whereas those on triple+ regimens did worst in terms of remission in all groups of hypoactive, hyperactive, and mixed subtypes (BR: 4.59, CI 2.01–10.48; BR: 4.59, CI 1.76–31.66; BR: 3.36, CI 1.73–6.52; all P < 0.05).

The mixed subtype was more persistent to management than the hypoactive and hyperactive subtypes. Delirium management remains controversial and, generally, supportive care benefited patients most. Psychopharmacological management for delirium requires careful choosing of and limiting the number of psychotropics.

To report new prescriptions of psychotropic medications among adolescents presenting with new onset psychotic symptoms during a 5-year period.

The Northern Ireland Early Onset Psychosis Study is a naturalistic longitudinal observational study of patients with an early onset first psychotic episode. All patients aged <18 years presenting to specialist mental health services across Northern Ireland with new onset psychotic symptoms between 2001 and 2006 were recruited (n=113). Clinical case notes were analysed retrospectively for details of subsequent treatment with psychotropic medications.

A total of 100 patients (88.5%) were prescribed some form of psychotropic medication. Over three-quarters of patients received an antipsychotic as their first medication. Risperidone (45.8%), olanzapine (24.0%) and chlorpromazine (12.5%) were the most commonly prescribed first-line antipsychotic medications. Of a total of 160 antipsychotic prescriptions, 81 (50.6%) were off-label. Prescriptions were most likely to have been deemed off-label owing to medications not being licensed in under-18s (71.6% of off-label prescriptions) but other reasons were medications being used outside licensed age ranges (23.5%) and outside licensed indications (4.9%).

This is the first study examining psychotropic prescribing patterns in a complete sample of all children and adolescents presenting with early onset psychotic episodes in a single geographical area. The observation of risperidone as the most commonly prescribed antipsychotic was in keeping with previous studies in child and adolescent populations. Rates of off-label prescribing were lower than previously observed although our study was the first to investigate off-label prescribing solely in children and adolescents presenting with psychotic symptoms.