Aripiprazole is an antipsychotic that differs from the group in that it is a partial agonist of the D2 receptor, being also a partial agonist of 5HT1A and an antagonist of 5HT2A.Most antipsychotics cause a decrease in libido, affecting both sexual desire and function. According to the literature, D2 partial agonists can cause the appearance of compulsive behaviors as an adverse effect in 6-24% of patients. Among these behaviors you can find hypersexuality. In most cases, it subsides when treatment is stopped. We describe the case of a patient with bipolar disorder who develops hypersexual behaviors following the aripiprazole treatment. This is a 61-year-old bipolar patient receiving valproate and risperidone. It requires hospital admission due to manic symptoms where dysfunctional tremor is observed. Change from risperidone to aripiprazole. Subsequently, hypersexual behaviors appear, increased libido, obsession with sexual activities (compulsive masturbation with TV programs, mobile applications, cartoons) as well as delusional ideas about “receiving sexual gazes” with no other maniac symptomps.

To determine the possibility that hypersexuality was induced by treatment with aripiprazole.

The appearance in the time line of hypersexuality after the change of treatment would be indicative of causality.

After switching back to risperidone, compulsive sexual behaviors disappear but not the delusional idea of being the focus of sexual gazes by everyone.

Although it is not a common adverse effect, hypersexuality is listed in the literature as a rare adverse effect.

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.

Depressive episodes are associated with higher morbidity, mortality (mostly suicidality. Despite the high prevalence and the devastating impact of this condition, there is a long‐standing debate about its treatment, particularly about the use of antidepressants. International guidelines and expert consensus recommend to avoid AD for bipolar depression, or to use AD with caution and as second line treatment only if the depressive episode shows poor response to mood stabilizers (MS) and to some second generation antipsychotics (SGA) (cariprazine, lurasidone, quetiapine and olanzapine combined with fluoxetine) in monotherapy and in combination. Contrary to the advice of guidelines and experts, 50%–80% of acute bipolar depressive episodes are treated with AD in everyday clinical practice.

To evaluate the effectiveness and the safety of AD acute treatment in patients with bipolar depression

Literature review (PubMed)

Short‐term safety, switching and suicidality did not differ significantly, and no suicide attempt was observed. Concerning long‐term safety, patients with bipolar depression had a significant reduction of depressive and total recurrences during the first year.

Acute AD treatment of bipolar depression is effective in the short term and safe in the short‐ and long‐term

No significant relationships.

One of the most frequent side effects seen when prescribing sertraline and clozapine together is the appearance of a seizure crisis. This event is usually related to an increase of plasmatic concentration due to interactions of these drugs with blood components.

To investigate the effects of clozapine when combined with other drugs, especially its effects increasing plasmatic concentration.

A patient was treated sith 300 mg/day of clozapine followed by a treatment with sertraline 50 mg/day, which increases plasmatic concentration. The combination of these treatments produced seizures. Other works published about interactions are reviewed.

It is important to monitor clozapine dosages to avoid increasing plasmatic concentration, especially if other drugs that have this effect are also administered.

It is important to monitor clozapine dosages to avoid increasing plasmatic concentration, especially if other drugs that have this effect are also administered.

No significant relationships.

Over time the prevalence of methamphetamine associated psychosis (MAP) has increased globally including Asia and Europe. Shoptaw et al looked at an RCT and concluded that olanzapine is superior to haloperidol in terms of tolerability and the side effect profile as it causes fewer extrapyramidal symptoms. Another study by Xue et al compared the efficacy of olanzapine and haloperidol and found that they had comparable effects but the onset time in the olanzapine group was significantly earlier than the haloperidol group. Srisurapanont et al analyzed 6 RCTs and concluded that quetiapine and olanzapine are probably superior than aripiprazole and risperidone.

The purpose of this review is to find out if olanzapine is better than other antipsychotics in treating methamphetamine-induced psychosis.

PubMed, SCOPUS, and Web of Science literature databases were screened and filtered by using specific search terms, inclusion/exclusion criteria. Texts of the selected articles and trials were reviewed and the search terms generated a total of 248 results from the databases. After applying the criteria 200 citations were left and 15 papers were reviewed.

The literature review concluded that olanzapine can be used as an effective treatment for methamphetamine-induced psychosis. Olanzapine can help to reduce the psychotic symptoms in MAP with a quicker onset and lesser side effects.

Olanzapine can help in the treatment of methamphetamine-associated psychosis and can be considered as the first-line therapy. Research is further needed with a higher pool of candidates in the future to compare the efficacy and tolerability of different typical and atypical antipsychotics.

No significant relationships.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome refers to a cluster of clinical symptoms/signs related to drug hypersensitivity. The main clinical features include fever, skin rash, eosinophilia, enlarged lymph nodes, atypical lymphocytosis, and involvement of at least one internal organ. Clozapine-related DRESS syndrome has been rarely reported, but this may be due to a different clinical presentation pattern compared to DRESS for other culprit drugs.

We aimed to assess clusters of main clinical features of clozapine-related DRESS.

We ran a network analysis for clinical manifestations in the pooled sample of all previous published cases of clozapine-related DRESS.

We observed a triad of core symptoms (i.e., organ implication, fever, and eosinophilia) among DRESS criteria co-occurring in 59.3% (n=16) of 27 patients. The organs most likely to be involved in clozapine-related DRESS included lungs, liver, heart, and kidneys. Fever was also present in almost all cases (n=25 patients), while eosinophilia was observed in two thirds of the sample (n=18 patients).

Regarding clinical manifestations clozapine-related DRESS may differ from DRESS for other culprit drugs as skin reaction is not very typical; thus, clinicians need to consider DRESS as a potential diagnosis even in absence of a skin reaction. When managing clozapine-treated patients with the core triad of organ implication, fever, and eosinophilia clinicians should consider guidelines for DRESS treatment.

No significant relationships.

Clozapine is commonly associated with hematological side effects. However, little research is available on the impact of adding other psychotropic medication on inducing blood dyscrasias.

The aim of the study was to explore the impact of associating psychotropic medication to clozapine in producing hematological abnormalities.

Our study was a longitudinal, retrospective chart review of adult psychiatric patients receiving clozapine treatment at our clozapine consultation between January 2000 and September 2020.

Our sample consisted of 15 women (23.5%) and 49 men (76.5%), mean age was 41.34 ±9.32 years. Polypharmacy was found in 70.3% of the cases. Association of clozapine to other psychotropic agents was found in 67.2% of the cases. Most prescribed add-on medication was valproic acid in 27 cases, benzodiazepines in 21 cases, promethazine and hydroxyzine in 16 cases, lithium in 8 cases and haloperidol in 6 cases. We found blood dyscrasias in 21 patients (32.8%). Hematological abnormalities were as follow: 2 cases of agranulocytosis, 8 cases of neutropenia, 13 cases of thrombocytopenia, 5 cases of leukocytosis, 5 cases of eosinophilia and 3 cases of anemia. In our sample we did not find a significant association between psychotropic polypharmacy and blood dyscrasias.

Many psychiatric patients on clozapine require polypharmacy to better stabilize their condition. Such co prescriptions may carry the risk of inducing more side effects especially blood dyscrasias. In our study, we did not find a significant association between psychotropic medication added to clozapine and hematological abnormalities. But further research is warranted to better explore this association.

No significant relationships.

Plenty of antidepressants have been reported to induce unpleasant tastes and/or odors as well as altered chemosensations when administered alone or in combination with other medications. Trazodone induced hypogeusia (decreased taste sensation) is a rare side effect. In this report, we would like to present a male patient with with hypogeusia after trazodona use and persisting for 3 months after the drug was discontinued will be discussed.

A 52-year-old male, Trazodone 50 mg/day was started 4 months ago due to difficulty in falling asleep. On the 25th day of her daily treatment, her sense of taste began to decrease and gradually became more severe. So he stopped his treatment and he applied to the internal medicine and neurology polyclinics. Routine blood tests were within normal limits. To rule out the possibility of covid 19, 2 pcr tests were done and it was found negative. No recommendations other than chewing gum. The patient applied to the psychiatry polyclinic with the complaint of decreased taste sensation that in the 3rd month of his complaints.

CASE REPORT

CASE REPORT

Chemosensory side effects due to drugs are frequently seen in the elderly and in polypharmacy. It is usually accompanied by a decrease in salivary secretion. It resolves shortly after the causative drug(s) are stopped. It is important that our patient is middle-aged, does not have additional medical diseases and does not use drugs, and his complaints continue for 3 months after the stopped of Trazodone.

No significant relationships.

We present the case of a 65-year-old woman with multiple and chronic psychosomatic symptoms. Due to motor impairments she was diagnosed in 2009 with Parkinson’s Disease (PD) by the neurology department and empirical treatment with levodopa was prescribed. However, the patient increased her levodopa intake by three times the recommended dose. The patient presented many adverse effects, including psychotic symptoms, that were interrupted after the levodopa intake was ended during a two month internament in a psychiatric unit. Dopamine dysregulation syndrome (DDS) is a condition in which patients with PD increase their levodopa intake without an objective worsening of motor symptoms. Higher-than-prescribed doses are taken by patients who develop tolerance and dependence to dopaminergic agonists.

To analyse the prevalence of DDS, its diagnosis and treatment as well as the identification of risk factors.

A case report is presented alongside a review of the relevant literature regarding DDS.

The available evidence suggests that the main risk factors for DDS are a history of mood disorders and behavioural disorders, but more studies are needed. Given that DDS is considered a rare adverse effect, physicians usually overlook voluntary dose increase by patients.

DDS, even though uncommon, has severe adverse effects such as dependence and acute psychosis. Before prescription of dopamine agonists, individual risk factors (such as psychiatric comorbidities or history of substance abuse) should be assessed. Also, patients and families should be informed and trained in alarm signs detection. Further studies would be justified to determine DDS prevalence, early diagnosis and treatment.

No significant relationships.

Attention-Deficit/Hyperactivity Disorder (ADHD) is characterized by impairing symptoms of inattention and/or hyperactivity/impulsivity. Although Emotional Dysregulation (ED) is not current criteria for ADHD, several clinical, imaging and genetic studies have been suggesting its inclusion. ED seems to impair social and occupational capacities, leading to poor quality life. In this regard, managing this situation is fundamental.

ED in ADHD review and its management, including pharmacological and nonpharmacological approaches.

Non-systematic review through literature using databases as Pubmed and UpToDate. Keywords used: Attention-Deficit/Hyperactivity Disorder, Emotional Dysregulation, management, pharmacotherapy.

Literature refers to ADHD drugs, such as psychostimulants and atomoxetine, as the first line managing ED. However, some studies demonstrated that ADHD drugs have lower efficacy while treating emotional symptoms, when compared to attention or hyperactivity/impulsivity symptom control. Other medications, such as antidepressants or mood stabilizers, are not considered due to low efficacy and side effects (such as irritability or suicidality behaviour worsening). Regarding non pharmacological approaches, there have been results with cognitive behavioral treatment, and management techniques for anger, frustration and communication skills.

Although the majority of studies demonstrate psychostimulants and atomoxetine role, there is an important lack of information regarding management of ADHD emotional dysregulation. It is a multifactorial condition, and, as such, non pharmacological and pharmacological management are needed to address this issue. More research is necessary, in order to improve patients’ quality of life.

No significant relationships.

Cannabis was used as a medicinal plant in Asia before the Christian era. Nowadays, after 40years of a “war on drugs” with an illegal status, there is a big interest on the use of cannabis in some medical conditions. With more and more users revealing having used this substance to cope with certain psychiatric manifestations, researchers have tried to explore this substance in the psychiatric field where the actual pharmacological treatments and psychotherapy remain ineffective in some cases.

To Explore the medical use of cannabis in psychiatric disorders.

A literature review was based on the PubMed interface and adapted for 2 databases: Science Direct and Google Scholar over the last 10 years.

Giving the interactions between cannabinoids and specific neurotransmitters, it has been suggested that cannabis may have medical effect on some psychiatric illnesses. In this direction, a significant overlap has been demonstrated between PTSD and cannabis use. CBD a non-psychotomimetic cannabinoid, seemed to show promising results as an enhancer of fear extinction and therapeutic consolidation of emotional memories. Military veterans are increasingly using it for reducing induced nightmares although this residual symptom remains difficult to treat. No benefit for improving depression was proved. One isolated study indicated a potential efficacy for cannabinoid combined with terpene in ADHD.

Studies exploring the possibility of using cannabis in the treatment of psychiatric illnesses are promising but it is premature to recommend this drug for the moment especially since it requires gradual titration, regular assessment and precaution in certain diseases.

No significant relationships.

Hyperammonemic encephalopathy is an unusual side-effect of the treatment with valproic acid. According to several sources, this side effect could be underdiagnosed and underreported.

We present the case of a 54-year-old patient institutionalized in a psychiatric hospital who was referred to a general hospital after an episode of delirium of unknown etiology. The patient had been diagnosed with Schizoaffective disorder 26 years prior to his admittance and had started treatment with valproic acid the previous month.

A case report is presented alongside a review of the relevant literature regarding valproate-induced hyperammonemic encephalopathy, its differential diagnosis and treatment.

During his hospital stay, the patient underwent a complete panel of tests including CT Scan, EEG, toxic panel and complete blood tests. In them the only altered parameter was hyperammonemia, therefore valproic acid was removed and was treated with lactulose and rifaximin to reduce ammonium levels.

Hyperammonemic encephalopathy in the context of the treatment with valproic acid is a side-effect which is more prevalent than what was thought in the past. Valproate could reduce ammonium elimination therefore increasing the levels of the molecule. It should be administered carefully in cases where the patient may be presenting with other causes of increased ammonium metabolism or decreased elimination. It is important to bear in mind this possible side-effect to increase patient’s safety.

No significant relationships.

Ischemic colitis is a rare condition. It represents 3 to 10% of lower digestive hemorrhages. It preferentially affects the subject over the age of 50 with predisposing factors. Rare cases have been reported in young subjects with the use of cocaine, combined hormones or antipsychotics.

This work aimed to study the potential side effects of antipsychotics

We report a case of ischemic colitis associated with antipsychotics.

A 27-year-old patient, followed for 2 years for schizophrenia treated with antipsychotics (chlorpromazine and haloperidol) and an antiparkinsonian (Biperiden), consulted in the emergency room for rectorragies progressing for 3 days. The examination revealed the installation of diffuse abdominal pain associated with early postprandial vomiting which preceded the 7-day rectal bleeding. The physical examination revealed ascites without edema of the lower extremities. The stools were normal-colored on digital rectal examination. The biological workup revealed anemia and a biological inflammatory syndrome. The abdomino-pelvic scanner showed thickening of the entire colonic wall with signs of recent bleeding. The rectosigmoidoscopy showed an ecchymotic aspect of the sigmoid with less pronounced involvement of the rectum. Pathologic examination of the colonic biopsies concluded with ischemic colitis, showing hemorrhagic suffisions with numerous fibrinous thrombi of the vessels. The course was marked by the onset of multi-organ failure with acute renal failure, a picture of disseminated intravascular coagulation (DIC) and alveolar hemorrhage. Despite the resuscitation, the patient died 2 days after admission.

Ischemic colitis is a rare side effect of antipsychotics. Although rare, this entity should be evoked and diagnosed in time.

No significant relationships.

Valproate is widely used in the treatment of maniac and mixed episodes and is well known to be safe with side effects being mostly related to hepatic disorders and psychomotor retardation.

Raising attention to valproate-induced hypothyroidism that despite the increasing evidence tends to be neglected.

Here, we report a case of a 55-year-old woman, with a previous diagnosis of schizophrenia, treated for many years with 200mg of zuclopenthixol triweekly and 2mg of risperidone daily. Patient developed a maniac episode characterized by elevated mood, sense of grandiosity, increased energy and psychomotor activity, disinhibition and insomnia. No laboratory abnormalities were detected and inpatient treatment was initiated with paliperidone up to 12mg/day and valproate 1000mg/day.

Patient showed progressive clinical recovery attaining full remission within 2 weeks. Despite the absence of clinical side effects and the valproate serum levels of 74.9μg/mL (range 50–100μg/mL), laboratory testing found progressive reduction F-T4 down to 0.45ng/dL (range 0.8–1.5 ng/dL) and a concomitant upregulation of TSH to 73.99mUI/L (range 0.55–4.8mUI/L). Thyroid autoantibodies and thyroid echography were negative. Considering that patient was previously medicated with risperidone, it was suspected that her hypothyroidism was caused by valproate. Normalization of thyroid function was observed after 21 days valproate withdrawal. Patient is currently being treated with 150 mg paliperidone (monthly) with no recurrence of mood or psychotic episodes and maintain normal thyroid function.

Our case emphasizes the need for extended laboratory testing upon prescription of new pharmacological medications as severe analytic alterations can take place in the absence of immediate clinical manifestation.

No significant relationships.

Antidepressants and antipsychotics have a wide range of cardiac side effects. Although the absolute risk is considered low, some are potentially life-threatening.

We aim to review the main cardiological complications of antidepressants and antipsychotics and their management. We will consider 1) QTc prolongation and arrhythmia 2) heart rate 3) blood pressure 4) myocarditis.

Review of cardiological complications of antidepressants and antipsychotics.

Qtc prolongation is correlated with arrhythmia risk. QTc is obtained with Bazett’s formula, which has limitations. All inpatients and some outpatients starting antipsychotic should undergo ECG. Increased QTc can result in different approaches, depending on severity. Most antidepressants do not significantly affect QTc, except for escitalopram and tricyclics, mostly in overdose. Sinus tachycardia can occur with most antipsychotics. Tricyclics can also produce this effect. Other causes should be excluded, and management can be achieved with bisoprolol. Other antidepressants most commonly produce a slight decrease in heart rate or have a minimal to no effect. Antipsychotics can cause hypertension or hypotension depending on the degree of affinity to specific adrenergic receptors. Tricyclics can lead to postural hypotension. Antidepressants interfering with noradrenaline can cause hypertension. Myocarditis is mostly associated with clozapine. Patients should be screened for clinical signs and laboratory findings - especially in the presence of risk factors. Suspicion should prompt echocardiological examination and confirmation leads to cardiology referral.

Weighing the risks and benefits of these medications is a continuous process. Management of cardiological complications is possible and may involve a multidisciplinary approach.

No significant relationships.

Patients with severe mental disease have a considerably shorter lifespan than the general population. The majority of psychiatric drugs are metabolized by the liver. Cytochromes play a central role, interactions between drugs are expected. Neuroleptics are frequently associated with weight gain, steatosis development, elevation of liver enzymes and rare acute cytolytic hepatitis, particularly with clozapine and olanzapine. Mood stabilizers, like Valproate classically gives mitochondrial steatosis with potentially important damages, and also possible acute liver failure.

This case presents a 56-year-old patient, previously diagnosed of schizoaffective disorder, with chronic psychotic symptoms that showed high drug resistance. She had been treated in the past with most common antipsychotic drugs with no clinical response. While being in treatment with valproate and olanzapine, she was started on clozapine while olanzapine removed. Two weeks later she developed Acute Pharmacologic Hepatitis with mild liver failure.

Physical examination was normal. Mental exam revealed presence of delusion. Blood tests showed: hyperbilirubinemia and mil coagulopathy. Clozapine dose was reduced and valproate was suspended.

The patient showed a substantial improvement of hepatic damage. Delusions are active after 12 weeks of treatment with clozapine.

Psychiatric disorders and liver illnesses are entangled in multiple ways. Screening for liver diseases is essential in order to prevent liver complications in patients receiving psychotropic medications. Further investigation of combinations of agents such as mood stabilizers and atypical antipsychotics may yield valuable insights into the potential of combination therapies to enhance clinical outcomes in patients with Severe Mental Disease.

No significant relationships.

A growing number of published cases has showed that hypersexual behavior may arise with treatment with second-generation antipsychotics, including aripiprazole and olanzapine. Aripiprazole is a second-generation antipsychotic commonly used to treat schizophrenia and bipolar disorder. It has a unique pharmacologic profile acting as a partial agonist of the dopamine D2 receptor, as a partial agonist at the 5-HT1A receptor, and as an antagonist at the 5-HT2A receptor. Literature shows that medication with partial dopaminergic agonistic activity can cause compulsive behaviors, such as pathological gambling, compulsive eating, compulsive shopping, and hypersexuality. Although it is difficult to predict who would develop these behaviors, the literature suggests that patients at a higher risk of developing impulsive behaviors include those with a personal or family history of obsessive-compulsive disorder, impulse control disorder, bipolar disorder, impulsive personality, alcoholism, drug abuse, or other addictive behaviors.

Here, we present a case of a 32-year-old male who developed hypersexuality symptoms after receiving aripiprazole as treatment for bipolar disorder.

We have done a literature review using the MeSH terms Aripiprazole and hypersexuality in the “PubMed”.

After switching Aripiprazole to Risperidone the hypersexuality symptoms started to decrease and got almost complete relief after 2 weeks.

This case highlights the rare hypersexuality side effect that can arise in patients receiving aripiprazole for bipolar disorder treatment. Clinicians should be aware of the increased risk of hypersexuality and other impulsive behaviors as they can significantly impair a patient’s daily functioning.

No significant relationships.

Aripiprazole long-acting treatments can significantly control symptom, improve adherence and reduce the risk of relapse compared to oral drugs. An alternative start-up guideline has recently been approved in several countries that simplifies its administration.

To present a case report of a patient with schizophrenia treated with alternative starting regimen of aripiprazole long-acting treatment.

Presentation of a clinical case supported by a non-systematic review of literature.

We present the case of a 22-year-old patient diagnosed with schizophrenia, whose symptoms started after the birth of her son, 2 years ago. She has presented a poor clinical evolution, requiring several admissions to our inpatient service after discontinuation of her medication. The patient has taken different antipsychotics, including olanzapine and paliperidone long-acting treatment, which were suspended due to side effects (weight gain and increased prolactin levels). A switch to oral aripiprazole 20mg was made, which showed good response and tolerance. Given the persistence of irregular intake, it was decided to switch to aripiprazole long-acting treatment, applying an alternative initial regime consisting of two doses of aripiprazole long-acting treatments 400mg and one oral aripiprazole 20mg. The patient has since had no delusions or hallucinations and is living independently at home.

The administration of a simplified initial regime with aripiprazole long-acting treatments could improve therapeutic adherence while maintaining the same effectiveness and similar side effects.

No significant relationships.

Polyfarmacy and unjustified use of high dosages of medicaments represent an unmet need in modern psychiatry. Therefore, tidal medication review of hospitalized geriatric patients is an essential step of the disease management as it can be often of vital importance and, as illustrated by current case, can exhibit a tremendeus impact on their quality of life.

A case rapport on geriatric patient with iatrogenic damage due to ultra high dosage of ropinirole as a treatment for restless legs syndrome

Authors of current paper address pharmacodynamic particularities of psychopharmaca and their reasonable choice in context to RLS

A clinical case of a 72 y.o. patient, known with chronic minor depressive symptomes over the past decades. Since few years he did not take any medicaion, except ropinirol for RLS. Because of the worsening of RLS symptomes, he decided on his own to increase the dose of ropinirol up to 12 mg/day. Two moths later he has been admitted to the psychiatric ward with major depression symptomes, suicidal plans, insomnia and profound edema of his both lower legs.

Current case demonstrates that high dose of ropinirole led to tremendous decrease of quality of life of the patient, and pushed him towards concrete suicidal plans. We advocate for careful assessing of the dose of every drug used; avoiding of polypharmacy by any means and for keeping in consideration that the majority of psychopharmaca leads to deterioration of RLS symptoms through modulation of dopamine pathways.

No significant relationships.

Serotonin syndrome is a mild to potentially life-threatening syndrome associated with excessive serotonergic activity within the central nervous system. Serotonin syndrome is associated with medication use, drug interactions and overdose. All drugs that increase central serotonin neurotransmission at postsynaptic 5-HT1A and 5-HT 2A receptors can produce SS.

Clinical case and literature review.

A 74-year-old female, married, diagnosed of major depressive disorder. Treated with: lithium 600 mg, quetiapine 50 mg, venlafaxine 300 mg. The doses had been maintained for the last months. Lithium levels in the normal range.

In an emergency room, she received a tramadol injection because of strong backpain. After a few hours, she felt an overall worsening, sleepiness and lack of response to external stimuli. Given the persistence of the symptoms and decreased appetite along with decreased water intake, she attended to Hospital. She had a high fever, rigidity and myoclonus. Her language was incoherent. Blood tests showed high CK, and high AST and ALT.

SS is a potentially fatal iatrogenic complication of serotonergic polypharmacy. Considered idiopathic in presentation, it appears tipically after initiation or dose escalation of the offending agent to a regimen including other serotonergic agents. While serotonin syndrome is often associated with the use of selective serotonin inhibitors (SSRI), an increasing number of reports are being presented involving the use of tramadol. It is vital that clinicians are aware of the potential for SS when psychotropic and non-psychotropic agents are co-administered to certain patients, such as those with both depression and pain.

No significant relationships.