Background: Fahr's disease is a rare and complex neuropsychiatric disorder resulting from abnormal calcium deposition in the basal ganglia and cerebral cortex. It can have a profound impact on an individual's social functioning as well as causing a wide variety of neurological symptoms, cognitive deficits and motor impairment. A number of specific mutations have recently been identified in phosphate transporter and other genes, but around half of all cases have unidentified mutations. Impulsivity, aggression and violence may pre-date the other manifestations of the illness.

Case Report: Patient X is a 58 year old man currently detained in an independent hospital locked rehabilitation unit following the breakdown of a care home placement. His first admission to hospital was at the age of 18 when he was diagnosed with mania. He had multiple further hospital admissions as well criminal convictions for acquisitive and violent offences. In 2005 he threatened to stab a stranger if he did not give him a cigarette and he was arrested and admitted to a medium secure unit under Section 37 with diagnoses of bipolar affective disorder and emotionally unstable personality disorder. He remained in secure hospital care until 2018 when concerns about Parkinsonian symptoms led to him being referred to a neurologist and a diagnosis of Fahr's disease being made on the basis of his CT findings. He was transferred to a locked rehabilitation service in 2019 but continued to exhibit challenging behaviour on a daily basis. After a reduction in the frequency and severity of his behaviour he was discharged to a care home, but this broke down after a few months as his assaultive and sexually inappropriate behaviour re-emerged.

Discussion: Fahr's disease is traditionally thought of as a late life neurological condition, but as with Huntington's disease neuropsychiatric symptoms of irritability, sexually disinhibited behaviour, impulsivity and aggression can occur early and may pre-date any neurological manifestations. Treatment is often difficult because of sensitivity to antipsychotic medication.

It is important to consider neuropsychiatric conditions in the assessment of adults presenting with antisocial behaviours, especially when these are associated with a change in overall functioning and an absence of adolescent conduct disorder. There is as yet no specific treatment for Fahr's disease, but early identification allows appropriate risk management strategies to be adopted.

Background: Late-onset Tay-Sachs disease (LOTS) is an autosomal recessive lysosomal storage disease due to a variety of mutations in the hexosaminidase-A gene which leads to accumulation of GM2 ganglioside in the brain. It typically presents in late adolescence with a slowly progressive spectrum of neurologic symptoms including lower-extremity weakness with muscle atrophy, dysarthria, incoordination, tremor and mild spasticity and/or dystonia. Psychiatric symptoms including mood disorder, psychosis and neurocognitive symptoms occur in around 50% of cases but are rarely the presenting feature.

Case Report: Patient X is a 35 year old man of Irish descent currently detained in an independent hospital locked rehabilitation unit following the breakdown of a care home placement. He first presented to mental health services at the age of 17 with psychomotor agitation, rapidly changeable moods, manic-like symptoms and sexual disinhibition. He was diagnosed with schizoaffective disorder, attention deficit hyperactivity disorder and Asperger's syndrome and he had several compulsory hospital admissions over the next five years before a prolonged period of rehabilitation and discharge to a residential home for people with autistic spectrum disorders. However, he continued to exhibit disruptive behaviour, often triggered by periods of insomnia and had further hospital admissions. When he was 31 his brother was diagnosed with LOTS and this led to him being tested and found to have the same mutation.

Discussion: There had been no suspicion of a neuropsychiatric disorder prior to the diagnosis of the patient's brother with LOTS and he was treated with conventional psychotropic medication with limited success. However, when the case records were obtained from his first hospital admission there was evidence of dysarthria although the significance of this was not appreciated. With hindsight many of his other symptoms can be seen as indicative of a neuropsychiatric disorder.

It is important to take a family history and consider a neuropsychiatric condition in families with multiple affected individuals. There are as yet no specific treatments for LOTS, and management is aimed at symptom reduction and enhancing quality of life, but a number of disease modifying strategies are being investigated including enzyme replacement therapy, pharmaceutical chaperone therapy, substrate reduction therapy, gene therapy, and hematopoietic stem cell replacement therapy, making it even more important the condition is recognized early.

To understand the prescribing habits and trends of clinicians in a large ADHD clinic and the medication journey of patients from point of diagnosis to the point of agreeing a shared care plan with primary care services.

This was a non-interventional retrospective study collecting information from anonymised electronic patient and prescription records. Following approval by the Clinical Governance body of the practice, in June 2023, all patients with a SCP between the years 2019 and 2021 were identified. Data collected included patient demographics, date that medication was started, discontinued, or switched along with associated reasons. Additionally, to better understand the time taken to gain publication of a SCP, the amount of clinician-patient facing time was recorded, including the number of brief follow-up appointments, number of repeat prescriptions and number of clinician to patient emails. Patient data was fully anonymised and any identifiable data removed.

All but one patient was started on a stimulant medication immediately following diagnosis, in line with national prescribing guidance. Atomoxetine was the medication of choice for a patient with a previous history of stimulant intolerance. 74% (n = 95) of patients were started on lisdexamfetamine, 20% (n = 25) were started on methylphenidate long-acting formulations and five patients on short-acting methylphenidate agent.

Of the 95 patients initiated on lisdexamfetamine, 78 (82.1%) were continued on lisdexamfetamine until the point of publication of their Shared Care Policy (SCP), nine (9.5%) patients switched medication, 10 patients initiated additional fast-acting dexamfetamine tablets and two had a second agent added to their therapy (atomoxetine n = 1, methylphenidate n = 1).

Of 25 patients initiated on methylphenidate long acting, 18 (72%) continued this medication at the point of publication of SCP. Of 25 patients initiated on methylphenidate long acting, seven (28%) patients switched medication and two patients were initiated on an additional fast acting methylphenidate.

To successfully stabilise and publish 134 patients on a SCP, 404 brief follow up appointments of 15-minute duration were utilised, which totals 6060 minutes of patient facing time. Of 134 patients, most n = 41 (30.6%) had 2 brief follow-up appointments; 32 (23.9%) had 3 brief follow up appointments and 22 (16.4%) had 4 appointments. Two patients did not attend a follow up appointment, and one patient had 11 brief follow up appointments.

Stimulant medications were typically used as first line treatment however, of these 74% were started on lisdexamfetamine while only 20% were initiated on long acting methylphenidate. Those started on lisdexamfetamine were more likely to continue on this medication to the point shared care agreement than those started on methylphenidate, 28% of whom switched to an alternative, for a variety of reasons. Mean time to reading a shared care agreement was longer for those initiated on methylphenidate long acting compared to lisdexamfetamine.

The data show that for most patients the journey from initiation of a stimulant medication to a shared care agreement was a straightforward one, with the majority having either two or three follow up appointments.

More research is needed to better understand the apparent differences in pathway for those commenced on lisdexamfetamine and long acting methylphenidate.

Interventions to support people with autism are multidimensional, but primarily psychosocial in nature. These interventions include behavioural, educational and support therapies. Some psychotropic medications are used to manage medical and psychiatric comorbidities associated with autism, which interfere with daily social and occupational functioning or limit the implementation of psychosocial interventions. The aim of this study is to describe the trajectories of psychotropic medications in people newly diagnosed with autism according to sex and age.

This is a retrospective cohort study based on medico-administrative data from the Régie de l'assurance santé du Québec. The cohort included all people living in the province of Quebec (Canada) with a first diagnosis of autism (incident cases) recorded during hospitalisation or during a medical visit between January 2012 and December 2016 (index date: first diagnosis). Only individuals covered by the public prescription drug insurance plan one year before and one year after the index date were included. A patient was considered exposed to a drug from the date a prescription was claimed at a community pharmacy and for the time the drug was provided. However, as no information was available on inpatient drug, the drug trajectory represents the outpatient drug trajectory. The five classes of psychotropic drugs considered were: 1) anticonvulsants and mood stabilisers; 2) antipsychotics; 3) antidepressants; 4) anxiolytics/hypnotics; and 5) psychostimulants. Drug trajectories are represented using state sequence analyses.

The study cohort included 3284 people, of which 867 (26.4%) were females and 2417 (73.6%) were males. Overall, 51.6% of the cohort claimed a psychotropic medication in the year preceding diagnosis and 61.1% in the following year, with higher proportions among females and increasing with age. Psychostimulants were the most prescribed medications among people diagnosed at ages ≤12 years, while antipsychotic use increased considerably with age, becoming the most commonly prescribed medication among those diagnosed in adulthood (≥18 years), with use rates reaching as much as 80% among those diagnosed between 36 and 60 years. State sequence analyses demonstrate slight variations in the use of psychotropic medications over time, but significant variations by age category and sex.

Although psychosocial interventions are recognised by clinical practice guidelines as the cornerstone of interventions for people with autism, the use of psychotropic medications is widespread. This highlights a significant gap between the recommendations of these guidelines and what is observed in the real world.

We aim to examine the prescription patterns of local psychiatrists for adolescent patients with depressive disorder, treated on an outpatient basis, as part of an integrated programme for management of mood disorders in adolescent patients (IPMDA) in Singapore.

An longitudinal cohort observational study was carried out at a psychiatry out-patient department in the National University Hospital of Singapore, as part of a specialised programme for the treatment of adolescents, aged 13 to 18, with depressive disorder. The data which were collected included information about age, gender, education, therapy provision and drug prescription included generic name and dosing.

A total of 129 patients were included in the study. 81.7% (n = 105) were females and 18.3% (n = 24) were males. 72 (76.4% female, 23.6% male) patients were started on medications. All patients were initiated on a monotherapy regime of antidepressants.

The most commonly prescribed antidepressant was Fluoxetine (58.3%), followed by Sertraline (18.1%), Fluvoxamine (12.5%), Escitalopram (6.9%), Mirtazapine (2.8%) and Amitriptyline (1.4%).

Our findings revealed that current psychopharmacology practice for depressive disorder in Singapore generally follows the published Singaporean treatment guidelines, which is generally kept up to date with wider international recommendations.

The factor of pricing may affect the lower prescription of certain medications, such as Escitalopram, as it is more expensive than the other prescribed medications in the list.

The prevalence of delirium among confirmed COVID-19 patients is around 12–33%. Delirium in COVID-19 patients is associated with worse functional outcomes; and associated with length of hospital stay, admission to ICU, and ventilator utilization. COVID-19 patients with delirium have a significantly higher risk for mortality than those who did not develop delirium. This study aimed to describe the risk factors, symptomatology, and predictors of mortality of COVID-19 patients presenting with delirium symptoms admitted between January and October 2021 to the Philippine General Hospital, a public tertiary hospital in the Philippines.

Medical records of adult COVID-19 patients admitted to the Philippine General Hospital were analyzed. Descriptive statistics were used to summarize the demographic and clinical history. Univariate and multivariate logistic regression were done to determine the variables that predict mortality.

One in five (20.01%) COVID-19 patients presented with delirium; of the 1,992 medical records reviewed, 400 patients had either presented with symptoms of delirium or were diagnosed with delirium.

Of the 400 patients, 36.5% were not diagnosed with delirium, only 7% were referred to Psychiatry, and 74% expired during admission. Patients referred to Psychiatry had lower mortality odds than those not referred (aOR = 0.069, p = 0.014). Before the COVID-19 pandemic, patients with psychiatric symptoms from organic causes are already less likely to be referred to psychiatrists. Furthermore, studies have shown that delirium is under-recognized among patients with COVID-19. Early referral to a psychiatrist for assessment and management may possibly be protective against mortality.

Those who received midazolam had higher odds of mortality (aOR = 3.112, p = 0.001). Currently, no literature supports the association between midazolam use and mortality among COVID-19 patients with delirium; however, it is known that midazolam use puts patients at increased risk for delirium and mortality.

Patients with decreased sensorium (aOR = 7.438) and decreased psychomotor activity (aOR = 3.857) had higher odds of mortality (p < 0.001). Decreased sensorium and decreased psychomotor activity are typical in patients with hypoactive delirium; hypoactive delirium is a known prognosticator for patient mortality. The only available studies on specific delirium symptomatology show that decreased sensorium and decreased psychomotor activity are common among COVID-19 patients with delirium.

Timely assessment and appropriate management are critical for COVID-19 patients with delirium symptoms, especially those at an increased risk for mortality. Clinicians dealing with COVID-19 patients presenting with delirium must be reoriented to delirium symptomatology, initial interventions, and indications for referral to psychiatrists.

Psychosis is a common neuropsychiatric symptom associated with Parkinson's disease (PD), with prevalence rates of up to 75%. Parkinson's disease psychosis (PDP) is associated with increased morbidity, caregiver burden, depression, poorer quality of life and progression of dementia. It has also been shown to be a strong predictive factor for long term care placement, and results in up to 71% increase in risk of mortality compared with PD patients free from psychotic symptoms. Use of antipsychotics for PDP is common, with up to 35% of PD patients prescribed at least one antipsychotic within 7 years of PD diagnosis. This systematic literature review aims to search, appraise and synthesise the best available and most up-to-date evidence for the use of antipsychotics in the treatment of PDP, and their effects on PD motor symptoms.

We carried out a comprehensive literature review and meta-analysis following the PRISMA statement for systematic reviews.

Four studies investigated quetiapine, three investigated olanzapine, two investigated clozapine and a further two investigated pimavanserin. Both quetiapine and olanzapine showed no significant improvement for PDP over placebo, however meta-analysis of olanzapine groups showed significant motor worsening, UPDRS +2.89 (95% CI 1.22 to 4.56) compared with placebo. Clozapine showed a significant improvement in psychosis vs placebo in both studies, with a large effect size in their primary outcome measure; -0.82 (95% CI -1.37 to -0.26), -0.89 (95% CI -1.42 to - 0.36). Pimavanserin showed significant improvement in psychosis vs placebo -0.48 (95% CI -0.77 to -0.18). Quetiapine, clozapine and pimavanserin showed no significant worsening in motor scores vs placebo group.

Although Olanzapine and Quetiapine are commonly used to treat psychotic symptoms in Parkinson's Disease, the only medication with robust evidence is Clozapine. This finding may have implications for service delivery.

Differentiation between suicide attempt and suicidal ideation in patients with major depressive disorder using cortical functional network Sehoon Shim, Differentiation between suicide attempt and suicidal ideation in patients with major depressive disorder using cortical functional network Youngjoon Kwon.

Department of Psychiatry, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea, Republic of Korea.

Studies exploring the neurophysiology of suicide are scarce, and the neuropathology of related suicide is poorly understood. This study investigated source-level cortical functional networks using resting-state electroencephalography (EEG) in drug-naive patients with suicide attempt and suicide ideation.

EEG was recorded in 55 patients with suicide attempt and 54 patients with suicide ideation. Graph theory-based source-level weighted functional networks were assessed via strength, clustering coefficient (CC), and path length (PL) in seven frequency bands. This study applied machine learning to differentiate the two groups using source-level network features.

At the global level, patients with suicide attempt showed lower strength and CC, and higher PL in the high alpha band, compared to those with suicide ideation. At the nodal level, compared to suicide ideation, patients with suicide attempt showed lower high alpha band nodal CCs in most of brain regions. The best classification performance for suicide attempt and suicide ideation showed an accuracy of 73.39%, a sensitivity of 76.36%, and a specificity of 70.37% based on high alpha band network features.

Our findings suggest that abnormal high alpha band functional network reflects the pathophysiological characteristics of suicide and might serve clinically as a neuromarker of suicide.

Overactive negative memories are thought to contribute to the core symptoms of psychiatric conditions such as anxiety disorders or post-traumatic stress disorder (PTSD). For talking therapies, such as exposure therapy, there are high rates of relapse demonstrating the necessity for innovative new treatments. It is thought that enhancing the ability to extinguish fear responses to the reactivation of these memories in patients with pharmacological adjunct treatments will enhance the efficacy of interventions.

N-methyl D-aspartate receptors (NMDARs) regulate the process of memory formation and consolidation. It is hypothesised that increasing the function of NMDARs would augment the consolidation of safety learning, during treatment sessions. NMDARs require the co-agonists glycine or d-serine to function. Bitopertin, a GlyT-1 inhibitor, increases the availability of glycine. Bitopertin has been studied in the context of schizophrenia, and therefore has been demonstrated to be safe for use in humans. In this preclinical study, we aim to determine if bitopertin can enhance safety learning, so-called extinction, in rodent models.

24 Lister Hooded rats (male, n = 12) will undergo aversive Pavlovian conditioning to form an associative memory. Rats will then be administered with saline or bitopertin systemically, prior to a session to extinguish fear responses. The strength of the extinction of responses will be measured the following day with a rapid re-acquisition test.

This study is being carried out as part of an intercalated master's degree, so the final results will be available in spring 2024. Given pilot data, it is expected that we will observe that the rats administered with bitopertin exhibit lower levels of fear responses on the rapid reacquisition test than the rats administered with saline. We do not predict any sex difference in responses. This would demonstrate bitopertin has the potential to enhance and safety memory consolidation in rats.

This is an exciting area of research for which results could provide a break-through in improving talking therapies and adjunct treatments offered to patients with anxiety disorders. Negative results would be informative as this allows neurobiologists to refine the search for a pharmacological agent which could be used as a cognitive enhancer in this manner.