A PubMed search revealed 14 cases of ziprasidone associated mania, which carried primary diagnoses of mood disorders, generalized anxiety disorders (GAD), panic disorder, and psychotic disorders. To our knowledge, we report the first case of mania associated with ziprasidone augmentation of a selective serotonin reuptake inhibitor in a 60-year-old man (at time of ziprasidone-induced mania) with obssessive-compulsive disorder (OCD).

In May 2002, after partial response to citalopram 80 mg and low-dose clonazepam 1.5 mg/day in three divided doses, ziprasidone was initiated as an augmenting agent at a dose of 20 mg/day and increased to 20 mg BID. Within 7 days of starting ziprasidone family members noted a decreased need for sleep, impulsivity, grandiosity, and increased energy. He was brought to the emergency room after 17 days with florid manic symptoms. Physical and neurological exams were unremarkable. Routine laboratory work, including a drug screen, was non-contributory. His non-psychiatric medications included fexofenadine, hydroxyzine, and sodium nitroprusside. He was hospitalized and ziprasidone was stopped with reduction in the dose of citalopram to 20 mg. Manic symptoms promptly resolved within 3 days.

Earlier findings suggest that forensic schizophrenia patients are treated with higher doses of antipsychotics. This practice-based specificity is insufficiently studied, and clinicians’ motives regarding this practice remain poorly understood. In this editorial, the authors provide their data on treatment of forensic schizophrenia patients and identify characteristics of psychopathology and previous types of behaviors, including suicidal attempts, as potential reasons for the practice. They also emphasize that “these previous acts” often took place years ago, and suggest that current or recent aggression is unlikely the main reason for dosing, but rather the clinicians’ intention to maintain “must remain unaggressive” condition. Therefore, the authors suggest new ideas that may contribute to a better understanding of the specific prescribing patterns in the forensic population and hope that these ideas would be implemented in further well-designed prospective studies.

Impulsive aggressive (IA, or impulsive aggression) behavior describes an aggregate set of maladaptive, aggressive behaviors occurring across multiple neuropsychiatric disorders. IA is reactive, eruptive, sudden, and unplanned; it provides information about the severity, but not the nature, of its associated primary disorder. IA in children and adolescents is of serious clinical concern for patients, families, and physicians, given the detrimental impact pediatric IA can have on development. Currently, the ability to properly identify, monitor, and treat IA behavior across clinical populations is hindered by two major roadblocks: (1) the lack of an assessment tool designed for and sensitive to the set of behaviors comprising IA, and (2) the absence of a treatment indicated for IA symptomatology. In this review, we discuss the clinical gaps in the approach to monitoring and treating IA behavior, and highlight emerging solutions that may improve clinical outcomes in patients with IA.

Medication nonadherence is a common problem in the treatment of schizophrenia. The consequences of nonadherence are numerous and can be quite serious, including increased risk of rehospitalization and suicide. There are numerous factors that affect a patient's decision and ability to take medication, including medication efficacy and tolerability, treatment regimen, cognitive deficits, and the patient's relationship with the treatment team. Fortunately, there are several strategies that may increase treatment adherence, including individualization of medication selection and dosing strategy to maximize efficacy and minimize adverse side effects, utilization of long-acting injectable depot formulations that eliminate the need for the patient to remember daily oral medication, and psychosocial approaches that emphasize the benefits of staying well.

This review summarizes the evidence for the potential involvement of metabotropic glutamate receptor 5 (mGluR5) in the development of nicotine addiction. Nicotine is consumed worldwide and is highly addictive. Previous research has extensively investigated the role of dopamine in association with reward learning and addiction, which has provided strong evidence for the involvement of dopaminergic neuronal circuitry in nicotine addiction. More recently, researchers focused on glutamatergic transmission after nicotine abuse, and its involvement in the reinforcing and rewarding effects of nicotine addiction. A number of robust preclinical and clinical studies have shown mGluR5 signaling as a facilitating mechanism of nicotine addiction and nicotine withdrawal. Specifically, clinical studies have illustrated lower cortical mGluR5 density in smokers compared to nonsmokers in the human brain. In addition, mGluR5 might selectively regulate craving and withdrawal. This suggests that mGluR5 could be a key receptor in the development of nicotine addiction and therefore clinical trials to examine the therapeutic potential of mGluR5 agents could help to contribute to reduce nicotine addiction in society.

Bipolar disorder (BD) is a potentially chronic mental disorder marked by recurrent depressive and manic episodes, circadian rhythm disruption, and changes in energetic metabolism. “Metabolic jet lag” refers to a state of shift in circadian patterns of energy homeostasis, affecting neuroendocrine, immune, and adipose tissue function, expressed through behavioral changes such as irregularities in sleep and appetite. Risk factors include genetic variation, mitochondrial dysfunction, lifestyle factors, poor gut microbiome health and abnormalities in hunger, satiety, and hedonistic function. Evidence suggests metabolic jet lag is a core component of BD pathophysiology, as individuals with BD frequently exhibit irregular eating rhythms and circadian desynchronization of their energetic metabolism, which is associated with unfavorable clinical outcomes. Although current diagnostic criteria lack any assessment of eating rhythms, technological advancements including mobile phone applications and ecological momentary assessment allow for the reliable tracking of biological rhythms. Overall, methodological refinement of metabolic jet lag assessment will increase knowledge in this field and stimulate the development of interventions targeting metabolic rhythms, such as time-restricted eating.

Suicide is a global public health issue, with behavior differing across genders, age groups, places, and sociopolitical settings. Emile Durkheim characterized anomic suicide as occurring when social standards fail, resulting in purposelessness and directionlessness. Young people who are experiencing social issues are in danger, even if they do not voice suicidal ideas. Prevention interventions should target these people by strengthening resilience, minimizing social dysregulation stress, and fostering the development of life skills, coping resources, and social support. Anomic suicide has important psychological and societal implications, emphasizing the importance of fostering social cohesion and assisting persons experiencing purposelessness or a lack of direction in life.

Psychiatric readmissions contribute to a significant cost and healthcare burden to physicians, hospitals, and the healthcare system as an entity. Furthermore, as part of the Affordable Care Act, the Centers for Medicare and Medicaid Services (CMS) began to reduce financial coverage to hospitals with overwhelming rehospitalization rates. The purpose of this study was to do a systematic analysis on inpatient psychiatric readmission data and identify co-morbidities and risk factors that lead to high readmission rates. The data collection includes 163 patients with a total of 348 readmissions over the span of 90 days at one inner-city hospital in the Chicagoland area. Study findings suggest that higher rates of readmission are linked to cocaine abuse in both male and female populations. Diagnosis of bipolar in females and schizoaffective disorder in male populations were the among the highest for readmission. Key social factors such as homelessness and low socioeconomic status were identified to contribute to a large proportion of psychiatric readmission burden. However, an overwhelming amount of information was missing due to unobtained labs and lack of current patient social history. By using this data as well as data from electronic medical records (EMRs) to further investigate and identify other features of at-risk patients, hospitals can potentially address these markers to lower readmission rates. Ultimately, a higher understanding of the patients’ needs can be understood and can help develop standardized plans of care for prevalent psychiatric illnesses in these populations.

Beginning this month, CNS Spectrums will publish this column, “Trends in Psychopharmacology,” on a bi-monthly basis. Developments in psychopharmacology are proceeding at a fast pace, and this column will cover important and emerging areas from the field in a format that will be brief, and hopefully understandable. Topics will include what is new, “hot,” controversial, or informative in the field, and, of course, suggestions for future columns are always welcome.

Long acting injectable (LAI) antipsychotics are indicated for individuals suffering from schizophrenia, delusional disorder, schizoaffective disorder and bipolar disorder. Even though LAIs have traditionally been used for a subgroup of patients who were not compliant with oral treatments or who were a high risk to others, current trends are changing with increased options and availability of these treatments. A number of factors are implicated in the reversal of this trend including perspectives of patients and perspectives of providers. There is not abundant literature available regarding robust studies to examine these perspectives, but this presentation provides a current summary of available literature.

Some factors that influence perspectives of both patients and providers include knowledge about LAIs, cost of LAIs and the traditional views of these agents as being used under coercive circumstances. Altering perspectives has been a primary barrier to increase the use of these agents. Evidence clearly supports the use of early intervention for individuals with first episode psychosis, and poor medication compliance results in poorer treatment outcomes. With the potential improvement in quality of life and potentially decreasing the cost burden of this illness in society, this avenue for treatment must be a strong consideration for all involved in the treatment of the aforementioned disorders.

Fibromyalgia Syndrome (FM) affects 2-4% of the US adult population. It is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, disrupted sleep, memory and mood issues. Researchers believe that FM amplifies painful sensations by affecting the way the brain processes pain signals. In recent years there is converging data favoring the theory of a dysregulation of pain processing in the central nervous system of FM patients, particularly associated with an increase in cerebral glutamate levels. Traditional medications have not proven to be enough. Since 2017, Keays Medical Group has used neuromodulation with Transcranial Magnetic Stimulation to treat FM patients with comorbid major depressive disorder. Preliminary results have shown improvement in all standardized scoring measures including FIQ-R, GAD-7 and PHQ-9 when treated with our FMS Protocol.