To describe therapeutic features of 120 panic disorder (PD) patients treated with clonazepam, paroxetine, or clonazepam + paroxetine for 3 years and their follow-up for more 6 years.

A prospective open study randomized 120 PD patients to 2 mg/day clonazepam or 40 mg/day paroxetine. Poor responders were switched after 8 weeks to combined treatment with ∼2 mg/day clonazepam + ∼40 mg/day paroxetine. Tapered withdrawal of all treatments was performed after 3 years. Efficacy, safety, and cumulative relapse and remission were studied over the following 6 years, using panic attack (PA) count, clinical global impression-severity (CGI-S), and Hamilton anxiety scale (HAMA).

94 patients completed 3 years treatment. All were free of panic attacks since at least one year before undergoing tapered drug withdrawal. After two months of tapering, 80% of clonazepam patients were drug-free, versus 55% on paroxetine. No serious or severe adverse event were observed but PA/month, CGI-S, and HAMA worsened slightly. In annually studied patients the relapse rates were similar after the 3 treatments with an advantage of clonazepam over the combination (p=0.0035) and paroxetine (p=0.08, exact Fisher) at the first year after drug withdrawal. Cumulative relapses rate were 41%, 77%, and 94% at years 1, 4, and 6, but relapse therapy with either clonazepam or paroxetine was successful in nearly all cases.

PD is a chronic disorder, with many patients relapsing after 3 years treatment. Response to retreatment was excellent. Paroxetine and clonazepam were associated with similar long-term prognoses but clonazepam was better tolerated.

The evolution of various pharmacological therapies for schizophrenia has given rise to several pharmacological models for the neuroreceptor targets of antipsychotics and the influence of various neuroreceptors on specific symptoms and side effects.

Experience in clinical practice affirms clozapine's position as the treatment of choice for patients with treatment-refractory schizophrenia. Unlike clozapine, risperidone has a more targeted profile of neurotransmitter binding, with particular predilection for dopamine and serotonin receptors. Risperidone is, to date, the most extensively documented clozapine augmentation agent.

The aim was to evaluate clinical efficacy, safety and tolerability of augmenting clozapine with risperidone in patients with treatment-resistant schizophrenia.

In a randomized, double-blind, placebo-controlled 8-week trial, 10 patients unresponsive or partially responsive to 300 mg/day of clozapine monotherapy (n = 5) received a steady dose of 450 mg/day clozapine combined with or up to 4 mg/day of risperidone (n = 5). Patient psychopathology was assessed at 2-week intervals with the Brief Psychiatric Rating Scale (BPRS), the Scale for the Assessment of Negative Symptoms (SANS) and Clinical Global Impression (CGI) improvement scale.

From baseline to week 4 and week 8, mean BPRS total and positive symptom subscale scores were reduced significantly in both groups, but the reductions were significantly greater with clozapine/risperidone treatment. Reductions in SANS scores were also significantly greater with clozapine/risperidone treatment than with clozapine monotherapy group. Clozapine/risperidone treatment did not induce additional weight gain or agranulocytosis compared with clozapine monotherapy treatment.

Clozapine augmentation with risperidone appears to be well tolerated, safe and may provide additional clinical benefit for patients who are nonresponsive or only partially responsive to clozapine alone.

The authors have not supplied their declaration of competing interest.

INTRODUCTION TikTok is a social network (SN) that allows users to share short videos about different issues. Since the COVID-19 lockdown, there has been an increase in Pro-Ana and Pro-Mia videos in this specific SN.

OBJECTIVES To know the main characteristics about Pro-Ana and Pro-Mia contents among TikTok users.

METHODS A search was carried out using uncontrolled language with the term “TCA” (ED in English). The study included only Pro-Ana and Pro-Mia resources in Spanish. Resources under the category “recovery” were excluded. A random sample of 16 TikTok was used, since it is enough to estimate, with a confidence of 95% and an accuracy of +/- 20 percentage units, a population percentage that is expected to be around 20%. The studied variables were images, type of resources, “challenges” and misspelled words.

RESULTS In the sample, 68.75% of the profiles were created upon confinement, 56.25% had more than 500 followers and 68.75% had more than 3000 “likes”. 43.75% included more than 30% of ED advocacy content, 18.75% promoted challenges and 37.5% used misspelled words to avoid SN censorship.

CONCLUSIONS There has been a remarkable increase in ED-related content as a result of lockdown. In turn, the increasing number of users who are part of TikTok reveals that this is a SN that can be associated with ED advocacy.

No significant relationships.

Endocannabinoid system has been highlighted as one of the most relevant research topics by neurobiologists, pharmacists, basic scientists and clinicians. The association between endocannabinoids and its congeners and mood disorders is relatively recent. However, evidence from both clinical and preclinical studies is increasing and many researchers point out endocannabinoid system and particularly endocannabinoids and congeners as promising pharmacological targets.

The main objective of this study is to compare the plasma concentrations of endocannabinoids and congeners between a sample of patients with depression and a sample of control subjects, and the influence of variables such as age, body mass index, gender, severity of symptoms, and antidepressant medication.

Plasma concentrations of endocannabinoids and congeners will be analyzed in 69 patients with depression from primary care and 47 controls using mass spectrometry analysis.

Statistically significant differences in 2-arachidonoylglycerol and monoacylglycerols were found between both samples. Somatic symptoms of depression seems to be more related to these compounds that to cognitive-affective symptoms. In addition, differences between mildly and moderately depressed patients were found in concentrations of AEA, LEA, DGLEA and POEA. Patients with antidepressant medication showed higher levels of 2-AG, DGLEA and OEA.

The results of this study provide evidence supporting the hypothesis that in depression there is a dysregulation of the inflammatory signaling and, consequently the immune system. The results of this study could also support the realization of translational research to better understand the mechanisms of this widely distributed system.

The authors have not supplied their declaration of competing interest.

Psychological distress during the SARS-CoV-2 pandemic can manifest itself in interpretations of what is happening.

To analyze response to COVID-19 pandemic in people with high level of esoteric thinking.

Internet survey 23.03.20-29.01.21 (N=621); Constructive Thinking Inventory(CTI); SCL-90R. It was proposed to assess statements: “The authorities are hiding the true scale of the coronavirus pandemic”, “Coronavirus is the result of biological weapons development”, “Coronavirus is a punishment or a sign sent to people from above”, “The emergence of the coronavirus is the Earth’s response to its pollution”. It was offered to express an opinion about pandemic. The answers were coded on the basis of qualitative semantic analysis.

The growth of “esoteric thinking” was revealed (Std.J-T, p=.025). With a high level of esoteric thinking, emotional statements (“fear, anxiety, panic”) are more common (27.8% versus 16.9% for group with high and low level of «esoteric thinking»). Correlations of the level of «esoteric thinking» with level of depression (Spearman’s correlation ,085*), anxiety (,097*), GSI (,130**), «fears for the life» (23.4% versus 14.5%) show high emotional distress. With an increase in the level of «esoteric thinking», belief in various conspiracy theories increases; Spearman’s correlation ,370** with the belief is biological weapons, punishment for sins (,355**), belief in concealing information about the pandemic (,167**).

A high level of esoteric thinking is associated with an increased emotional response to the pandemic and with belief in conspiracy theories, and can increase emotional instability by itself also making constructive decisions difficult in situations related to protecting personal health and safety.

No significant relationships.

Vitamin B12 deficiency may cause neurological and psychiatric symptoms, especially among elderly patients. Two clinical cases are presented of patients admitted to an Acute Inpatient Psychiatry Unit due to psychotic symptoms, being reported a B12 deficiency.

Review clinical information about vitamin B12 deficiency as a factor involved in the development of psychiatric disorders, specifically psychotic symptoms, pointing out the peculiarities regarding clinical presentation, diagnosis, prognosis, and treatment management.

Search in the medical database PUBMED, MEDSCAPE and UPTODATE.

Vitamin B12 deficiency is associated with hematological, neuropsychiatric, and digestive disorders, is estimated that around 5-40% of the elderly population may present it. Neuropsychiatric syndromes may be the first, and sometimes sole, manifestation, related to a different etiological mechanism. Vitamine B12 deficiency implies enzymatic defects that cause an accumulation of methylmalonic acid and homocysteine, which is proportionally related to the severity of the neuropsychiatric symptoms. The range of clinical features includes psychotic and affective episodes, behavioral disorders, cognitive impairment, along with other neurological manifestations such as polyneuropathy and encephalopathy. The diagnosis delay is crucially important, as early detection could lead to reverse the neuropsychiatric symptoms and some of the neuroradiological alterations. Parenteral and oral vitamin B12 supplementation should be initiated, monitoring levels in plasma, together with psychiatric drugs until the symptoms are controlled.

Vitamin B12 deficiency is a factor that may be involved in the etiopathogenesis of psychiatric disorders. Thus, screening must be considered among the vulnerable population when presenting neuropsychiatric disorders as early diagnosis and treatment are key to clinical prognosis.

Haloperidol is one of the first-generation antipsychotics which is used widely around the world and still has its place in psychotic disorders along with his documented antimanic properties.

It acts by blocking essentially dopaminergic receptors but also serotonergic and alpha-adrenergic receptors.

Haloperidol has many side effects, especially extrapyramidal symptoms. Oedema associated with haloperidol is a rare side effect.

The aim of this presentation is to describe the case of a young female who developed a rare side effect of haloperidol.

we conducted a review of literature on different data base about this side effect in order to discuss its potential underlying mechanisms.

Here we report a case of a 24-year-old female with the history of bipolar disorder type 1, and an allergy to chlorpromazine. She was admitted to our psychiatric department for a manic episode with psychotic features and was initially treated with 50 mg of Haloperidol in addition to 30 mg of valium per day. She developed pronounced oedema of the face and upper limbs after two weeks of treatment. All of the paraclinical examinations including blood cell count, liver function tests, renal function tests, serum electrolytes, ECG, urine test didn’t show any abnormalities. We solicited the opinion of both nephrology and pharmacovigilance and concluded to an allergic oedema.

The symptoms disappeared 10 days after the discontinuation of haloperidol which suggested a potential incrimination of this drug

As far as we know, there are very few reports of allergic oedema with haloperidol in the literature. Potential underlying mechanisms will be discussed.

Through this case study, we aimed to focus attention on this very rare but still possible side effect.

None Declared

The COVID-19 pandemic has greatly disrupted the day-to-day life of university students, as it has for the general population. University students have been reported to have high rates of mental health concerns, including suicidal ideation.

Ascertaining the correlation of Covid-19 dissemination and proximity to University students in Vancouver, Canada, with suicidal ideation and suicidal plan.

We analyuzed weekly cross-sectional data from our Canadian World Mental Health International College Student survey by plotting the 30-day suicide ideation as a binary and the ordered 30-day suicide ideation outcomes using logistic and ordered generalized additive model (GAM) respectively, with a cubic spline and adjusting for demographics. We also ran an analysis on the association between binary 30-day ideation and different sample characteristics using logistic regression.

The time trend analysis showed that suicidal ideation did not seem to increase during the COVID-19 pandemic. On the contrary, ideation levels were found to be high in the beginning (February 2020) with a downwards trend through June to September before gradually increasing around November, 2020. We identified sociodemographic risk factors that may be associated with suicidal ideation, and established that those most at risk were students who had been emotionally overwhelmed by Covid-19 and unable to find help.

Our results seem to indicate that, in general, students have remained resilient under the stress factors presented by the pandemic, and that trends in suicidality seem to follow seasonal or school calendar year stressors rather than respond to the pandemic. However, certain subpopulations appear to be more affected than others.

No significant relationships.

Valproic acid is a psychotropic drug used for several years, due to its properties as a mood stabilizer, being considered as first-line treatment for bipolar disorder. In addition to its teratogenic potential, which prevents its recommendation for the treatment of bipolar disorder in women of childbearing age, valproic acid is associated with some side effects, such as gastrointestinal symptoms, alopecia, weight gain, tremor or hepatotoxicity. Hyperammonemia is a side effect that is little described, but relatively frequent, and may progress to variable encephalopathy.

The authors describe a clinical case of a 48-year-old female patient, hospitalized due to a manic episode, who was prescribed valproic acid, in association with lorazepam and olanzapine.

After three days on a dose of 1000mg of valproic acid, the patient began an acute condition of confusion, psychomotor retardation, temporal-spatial disorientation and ataxia. Infection, electrolyte disturbance and acute cerebral event were excluded. Noteworthy only hyperammonemia. Valproic acid was withdrawn and replaced by lithium, with the patient recovering from the confusional state two days later.

Hyperamonemic encephalopathy secondary to valproic acid was concluded. The mechanisms of valproic acid-linked hyperammonemia are not clear, although it appears to be independent of hepatotoxicity. The most studied hypotheses are related to glutamine reabsorption and serum levels carnitine in patients medicated with valproic acid.

It is essential that there is a high level of suspicion in clinicians for this secondary effect of valproic acid, in order to adequately treat the patient who presents with acute confusional conditions, not explained by other complications.

No significant relationships.

There is a notion that emotional expression is universal, yet it is subject to cultural variations. Research in this field has studied cultural extremes in European, American and East Asian cultures. However, very little is known about the differences in emotional expression in the Arab subcultures.

Exploring the differences between the emotional reactions among the nine Arab subcultures.

Aims (1) Examining the cultural differences in emotional reactions; (2) examining the differences between Muslim and non-Muslim individuals; (3) exploring the differences between Arabs and non-Arabs.

Several real life scenarios including 15 different stressful situations and 15 non-stressful situations were presented to 40 individuals from the nine Arab subcultures. The participants were aged between 18 to 40 years of age. The subjects were randomly classified into groups depending on whether they were Arabs or non-Arabs and according to whether they were Muslims or non-Muslims. The subjects’ emotional reactions were measured by means of Likert-like items.

The results showed that there were no significant differences among the nine Arab subcultures in their emotional reactions to the non-stressful situations. However, there were significant differences among the Arab subcultures in the stressful situations. Moreover, both religion and ethics were strong predictors of the differences in the emotional reactions that varied between subjects in their cultural group. The Arab Muslims tended to express more anger but the Arab non-Muslims expressed more sadness.

Emotional expression is impacted by ones’ cultural background and is particularly influenced by religion and ethics. Although Arab countries share the same language, they express emotions differently.

The authors have not supplied their declaration of competing interest.

Obsessive-compulsive disorder (OCD) has high rates of comorbidity with mood disorders, mainly major depressive disorder (MDD). Symptoms of depression are usually secondary to severe and disabling OCD. Electroconvulsive therapy (ECT) has been an effective and well tolerated therapeutic alternative in the management of refractory MDD. Other neuromodulation techniques, such as repetitive transcranial magnetic stimulation (rTMS), have well known efficacy in MDD and also have shown positive results, in clinical trials, treating other psychiatric disorders such as OCD.

To determine the efficacy of combining rTMS, ECT and clomipramine in the treatment of severe OCD with comorbid severe MDD.

The authors report a case of a 54-year-old male patient diagnosed with severe OCD for 23 years. He has been submitted to several drug treatments and intensive cognitive-behavioural therapy (CBT) always with poor response. The patient was admitted in the beginning of 2016 in our inpatient unit. Besides continuing drug treatment (clomipramine IV) and CBT, he was submitted to 12 ECT sessions during one month (3 sessions per week) and to daily sessions of rTMS during the following month.

Outcome measures were obtained using Y-BOCS for OCD and HAM-D for depression.

Our patient responded to ECT with mood improvement after session 4 to full euthymic state at the final session. He also responded well to rTMS with Y-BOCS score reduction.

Combined ECT and rTMS treatment with clomipramine IV and CBT was effective in our patient with a severe form of both disorders (OCD and MDD).

The authors have not supplied their declaration of competing interest.

Mood disorders in the elderly are a relevant clinical problem associated with high prevalence and frequent co-morbidity with chronic somatic diseases.

Study of clinical traits of depression in elder persons with somatic disorders.

The investigation was entered by 582 persons (women = 391 (67,1%), men = 191 (32,9%)), mean age of women has constituted 67,5 ± 5,8 years, men - 62,1 ± 3,8 years.

Age in women 55 years and higher, in men - 60 years and higher, clinical level of depression according to Beck Inventory more than 22 scores.

Affective disorders were represented by symptom complexes that masked depression and complicated diagnosis. Clinical symptoms in the kind of anhedonia and complaints about anergia dominated (73,6%), whereas depression, melancholy have moved behind and have constituted 26,4%. Psychopathologic disturbances presented against the background of lingering chronically flowing neurological and somatic diseases (cerebral atherosclerosis, brain blood circulation impairment, IHD, HI, respiratory organs’ diseases) in 73,6 %. High risk of emergence of depressive disorders was noticed in widows with low level of education, living in rural area and in persons with somatic diseases. In 32% of probands we have revealed depression that correlated with marital status and feeling of loneliness (p > 0,005). In persons with high level of depression and experiencing feeling of loneliness, risk of suicidal behavioral was higher 2,1 as much.

Study of affective disorders in the elderly allows assessing co-morbidity of somatic and mental disorders, developing tactic of psychotherapeutic and psychopharmacological assistance rendering.

Patients with severe mental illness have significantly reduced lifespans. Excepting suicide, cardiovascular risk is the biggest cause. The problem is exacerbated by psychotropic medication and poor primary care engagement. Therefore psychiatrists should maximise every opportunity to promote physical health.

We audited physical examination, investigations, and documentation of past medical history (PMH) & assessments in inpatients. We used the Royal College of Psychiatrist's Physical Health in Mental Health Scoping Group 2009 guidelines as our standard.

We audited notes of all 125 patients admitted to four wards at Ladywell unit over two months (01/07/2011- 31/08/2011). We surveyed trainees to identify training and resource needs and facilitate focussed interventions.

Physical Examination: 102/125(82%) received physical examination, 60/125(48%) on admission. Average delay before examination 12 days.

Blood tests/Investigations: 89/125(71%) received blood tests: 50/125(40%) thyroid function, 67/125(54%) liver function, 28/125(22%) glucose, 1/125(0.8%) HbA1c, 38/125(30%) lipid profile. 48/125(38%) had urine drug screening, 55/125(44%) ECG.

Documentation: The following was documented: 102/125(82%) PMH, 82/125(66%) allergies, 90/125(72%) smoking status. The following was scanned into records: 23/55(42%) ECG, 72/125(58%) physical observation chart.

Survey: The trainee survey highlighted need for training updates on physical health and problems in equipment provision.

Physical assessment is inconsistent, neglecting metabolic screening. Admission is a vital window for screening/modifying physical health.

Focussed assessment guidelines should be formulated. Following the survey, teaching led by consultant physicians has been organised on identified topics including metabolic syndrome. Lack of equipment will be addressed by creation of comprehensive equipment lists, to be distributed to ward administrators.

Suicide is an important public health problem worldwide. The aim of this study was to describe the epidemiology of suicide and attempted suicide in Iran.

A retrospective study from March 2001 to March 2008 examined some characteristics of cases of suicide and attempted suicide in the Islamic Republic of Iran based on the health system database of 41 medical universities.

A total of 53 100 cases of suicide and attempted suicide were analysed. Just over half were among women (55.0%). The most favoured method of attempted suicide among both males and females was drug overdose. Self-burning was more frequent in females (5.8%) while hanging (4.5%), cutting (2.8%) and firearms (0.5%) were more common in males. There were 3883 (7.3%) completed (fatal) suicides. Hanging had the highest case fatality rate (76.5%) and drug overdose the lowest (2.3%). Older people had a higher mortality rate.

Suicide and attempted suicides increased from 8.3 per 100 000 population in 2001 to 19.4 in 2005, then declined to 16.3 in 2008.