Anatomical Therapeutic Chemical (ATC) indication-based classification system is the World Health Organization (WHO) drug classification system and it is widely used in clinical and researh practice, however there has been questions around the scientific base of this (1, 2). Neuroscience-based Nomenclature (NbN) has been developed by representatives from 5 international organizations, with specific expertise in psychopharmacology, to address the issues around neuropsychopharmacological drug classification and improve the focus on pharmacological domains and mode of action:

ECNP – European College of Neuropsychopharmacology

ACNP – American College of Neuropsychopharmacology

AsCNP – Asian College of Neuropsychopharmacology

CINP – International College of Neuropsychopharmacology

IUPHAR – International Union of Basic and Clinical Pharmacology

References:

1. Nutt DJ. Beyond psychoanaleptics - can we improve antidepressant drug nomenclature? [published correction appears in J Psychopharmacol. 2009 Sept;23(7):861]. J Psychopharmacol. 2009;23(4):343-345. doi:10.1177/0269881109105498

2. Zohar J, Stahl S, Moller HJ, et al. A review of the current nomenclature for psychotropic agents and an introduction to the Neuroscience-based Nomenclature. Eur Neuropsychopharmacol. 2015;25(12):2318-2325. doi:10.1016/j.euroneuro.2015.08.019

As NbN is a novel classification system that can be used as a teaching tool as well as for other purposes, we aimed to understand the experience, views and needs of the psychiatric trainees and early career psychiatrists who will shape the future of psychiatry, around drug classification systems.

The ethical clearance of the study was obtained from King’s College London. We prepared an online survey (https://forms.gle/FCSdVTFH4U5QNn5t8) with a multinational group of early career pscyhiatrists who met through the CINP and EFPT, and test-run the survey with a small group of psychiatric trainees. The online survey was then disseminated via emailing lists and groups of early careers psychiatrists as well as through social media.

At the time of this abstract submission, the data collection is ongoing. Results will include analyses of the experience with different drug classifcations systems, awareness, views and attainment of NbN, stratified according to the demographic data (country, careers status, main work setting).

The findings from this study will shed light on the views and needs of early career psychiatrists on the topic from clinical and academic aspects, a previously unexplored perspective on drug classification systems. The findings can inform the planning of various strategies to address areas to improve the use and teaching of these tools.

None Declared

Haematological alterations, especially in the red blood cell series, are a rare adverse effect of olanzapine treatment. A 64-year-old female patient with a diagnosis of long-standing schizophrenia was admitted to the psychiatric room for psychotic decompensation and leukopenia in control laboratory tests. She had a history of mild psoriasis, allergy to sulphonamides and infectious bursitis nine years earlier secondary to neutropenia due to clozapine. On previous admission, episodes of anaemia and neutropenia related to increased doses of olanzapine were observed. On current admission, a new episode of anaemia and neutropenia occurred with doses of up to 20 mg/day of olanzapine, hemoglobin levels of 63g/L ann neutrophil count of 0,8*10^9 neutrophils/l were detected.

Report a very rare but serious adverse effect in patients treated with olanzapine.

Haematological analysis were periodically carried out from 2009 to 2023.

A complete study was carried out with parameters of haemolysis, autoimmunity, a pharmacogenetic study and a myelogram.

The autoimmunity and haemolysis study excluded an autoimmune or haematological illness that could justify the haematological alterations.

The myelogram showed normal cellularity.

The pharmacogenetic study showed no relevant alterations.

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The case was classified as a non-immune haemolytic anaemia secondary to olanzapine and improved with withdrawal of the drug.

None Declared

Intranasal esketamine has been approved as a treatment for patients with treatment-resistant depression. We analyzed the results of its efficacy in 15 patients.

To evaluate the efficacy of intranasal Esketamine as a treatment in patients with treatment-resistant depression

Case series

For the last 8 months, since the treatment with intranasal esketamine was approved for resistant depression, we have treated 14 patients with this drug. Through this process, we followed a standardized method consisting in the following steps:

On the first esketamine session (DAY 1) the patient has to fill a CGI and a MADRS scale.

On the second esketamine session (DAY 7) the patient has to fill a CGI, a MADRS scale, a form about the level of satisfaction with the drug and a last form in which they can include the secondary effects.

On week 6 since the start of the treatment, the patient has to fill again a CGI, a MADRS scale, a form about the level of satisfaction with the drug and a last form in which they can include the secondary effects.

In the 6th month since the start of the treatment, the patient has to fill again a CGI, a MADRS scale, a form about the level of satisfaction with the drug and a last form in which they can include the secondary effects they have perceived.

We analyzed and compared all of the previous data and obtained the following results:

At day 7: 64% of the patients had a response in the form of improvement, of which 66% were feeling “slightly better” and 33% were feeling “better”.

At week 6: 71% of the patients had a response in the form of improvement, of which 50% were feeling “slightly better” and the other 50% were feeling “better”.

At month 6: only 28% of the patients completed the treatment; of which 100% had a response in the form of improvement: 50% were feeling “slightly better”, 25% were feeling “better” and 25% were feeling “far better”.

Although our data suggests that intranasal esketamine has been effective in short term depressive symptoms, we have yet no information about its medium and long-term efficacy or secondary effects. Nevertheless, other potential factors should be evaluated as they could affect the results in the long-term such as the difficulty in maintaining the treatment for more than 6 weeks.

In addition, the patients who experienced the most improvement according to our data were patients with a TAB diagnosis, so this could be an interesting research focus.

None Declared

Sodium oxybate, an effective treatment for narcolepsy-associated daytime sleepiness and cataplexy, has been extensively. Despite its therapeutic benefits, sodium oxybate is not without its risks, and adverse psychiatric effects have been documented. This case report highlights a rare manifestation of sodium oxybate-related secondary mania with psychotic symptoms in a patient with narcolepsy, emphasizing the importance of recognizing and managing such adverse events. Additionally, we provide a brief review of similar cases reported in the literature.

This report aims to describe the presentation, evaluation, and management of sodium oxybate-induced secondary mania with psychotic symptoms in a patient with narcolepsy. We also discuss the potential mechanisms underlying this adverse reaction and its clinical implications. Furthermore, we summarize findings from previous studies that have reported cases of secondary mania associated with sodium oxybate use.

We present the case of Mr. X, a 48-year-old male diagnosed with “Narcolepsy with cataplexy,” who had been receiving sodium oxybate treatment for 11 years. He was admitted to the hospital following a mild head injury and the emergence of a manic episode with psychotic features. Comprehensive clinical evaluation, including medical history, toxicology screening, and neuroimaging, was conducted.

Upon evaluation, Mr. X exhibited hyperactivity, restlessnes, grandiose delusions, paranoid delusions related to hospital staff, and decreased need for sleep. Notably, he had been consuming sodium oxybate excessively. Sodium oxybate was discontinued, and low-dose olanzapine was initiated. Within 24 hours, his manic and psychotic symptoms resolved. He admitted to overusing his medication, and his family reported a recent increase in his activity level. A review of the literature revealed similar cases of sodium oxybate-induced secondary mania with psychotic symptoms.

This case underscores the importance of vigilance for psychiatric side effects of sodium oxybate, particularly in patients with a history of substance abuse or potential overuse. Secondary mania associated with medications is a rare but significant clinical entity. Prompt recognition and intervention are crucial for patient safety and well-being. Further research is needed to elucidate the mechanisms underlying such reactions and to establish guidelines for their prevention and management.

None Declared

The patient is a 50-year-old female, with multiple admissions in the PICU. At her first admission, at the age of 30 she presented the following main symptoms :mutism, negativism, crying and loss of bladder and bowel control. After collecting her complete family history, it was determined that her mother and one of her brothers were diagnosed with mild intellectual disability. Concerning her childhood history, she presented with late milestones as an infant and toddler and difficulties throughout primary education. Little information concerning her adult life was given, since the patient remained mute during the entirety of her first hospitalization.

Determination of the efficacy of olanzapine in a patient with Phelan-McDermit syndrome with mild intellectual disability and psychotic symptoms such as auditory hallucinations, delusional ideas and disrupted behavior.

PANSS Test, intellectual capacity test, genetic testing.

PANSS Scale Score at the 1st day of admission:100

PANSS Scale Score at the last day: 79

Intellectual capacity test: mild intellectual disability

Genetic testing results: Phelan-McDermit syndrome

After 20 days, symptoms showed mild recession in responce to 20mg of olanzapine. In a period of 12 months, the patient showed no signs of relapse and she was not readmitted in the PICU.

None Declared

Neurological bladder is considered a functional disability that has a significant impact on the quality of life and psychological state of patients. Psychotropic drugs, in turn, can worsen the urinary dysfunction caused by this disease.

Our objective is to illustrate, through the case of a patient suffering from a neurological bladder decompensated by the treatment of a characterized depressive episode, the link between these two pathologies.

We report the case of Ms. M.W., aged 51, with a history of high blood pressure stabilized under nebivolol and a neurological bladder diagnosed 10 years ago with episodic pollakiuria, admitted to the psychiatric department for repeated suicide attempts. She had never used psychoactive substances and had no family psychiatric history. The patient presented depressive symptoms evolving for 5 months. The diagnosis of a characterized depressive episode with melancholic features was made and the patient was treated with sertraline. From the first intake of the drug, the patient presented acute urinary retention (UR) requiring the placement of a permanent bladder catheter. The urinary symptoms improved upon stopping the treatment. Sertraline was changed to olanzapine and escitalopram. The patient stopped the treatment after one month because of the worsening of urinary symptoms requiring the installation of a suprapubic catheter. The urinary problem, together with the cessation of treatment, were responsible for a worsening of psychiatric symptoms leading to multiple suicide attempts. Given the advanced stage of the neurological bladder demonstrated by the urodynamic tests, our patient was treated with paroxetine, quetiapine and oxazepam along with psychotherapeutic education. The evolution was characterized by improvement in psychiatric symptoms and the urinary symptoms were stable.

The lack of improvement after treatment discontinuation could be explained by an underlying neurological bladder manifesting with pollakiuria. The current literature on UR induced by psychotropic treatments is quite rare limited in case reports. This effect occurs especially when selective serotonin reuptake inhibitors (SSRIs) are prescribed in combination with other antipsychotics. Unlike first generation antipsychotics, atypical antipsychotics have muscarinic receptor antagonist properties which can induce UR. Among atypical antipsychotics, olanzapine has been shown to have the greatest antimuscarinic effects. Regarding SSRIs, they are associated with a lower risk of UR than other antidepressants and sertraline had the highest risk of UR.

SSRIs can induce UR particularly in combination with atypical antipsychotics. Coordination of care across multiple specialties and understanding the side effects of psychotropic medications can enable faster diagnoses and adequate management.

None Declared

Urine drug tests are commonly used in psychiatry settings, mainly for the purpose of screening for substance abuse and excluding drug-induced psychiatric disorders. When carefully interpreted, these tests offer critical information for clinical judgement. However, certain psychotropic medications can trigger false-positive results in common urine drug screenings. For example, aripiprazole has been reported to cause false-positive urine amphetamine test results, and haloperidol has been associated with false-positive urine drug tests for lysergic acid diethylamide (LSD). It is clinically significant to recognize some false-positive urine drug results and interpret certain results cautiously in clinical settings.

We present a case of false-positive urine drug screening for tricyclic antidepressant (TCA) in a patient on quetiapine and aim to highlight the importance of accurate result interpretation in urine drug tests.

Details of the case were described. Information was gathered based on medical records.

Mr. A, a 25-year-old construction worker, first presented at our hospital’s emergency room on a Saturday in January 2023. He was brought by the police because he was aggressive and mentioned his colleagues were monitoring him. Being a foreigner, he did not have any prior medical records in our hospital. Urgent blood tests were performed, and organic causes were ruled out. He was started on quetiapine and lorazepam in the emergency room and was then admitted to our hospital.

A urine drug test was ordered on the following Monday, the third day of his admission. Surprisingly his urine drug screening revealed positive results for TCA and benzodiazepines. Initially as the patient was psychotic and could not give reliable history, we considered a few differential diagnoses, such as schizoaffective disorder and major depressive disorder with psychotic features, based on the presumption that TCA had been prescribed by the psychiatrist in Mr. A’s home country. After further treatment, Mr. A became less psychotic and was able to share that he had a past psychiatric history of schizophrenia, but he had stopped antipsychotic medications four months ago.

This case report described a false-positive urine drug test for TCA while the patient was taking quetiapine. In this case, initially other diagnoses, such as schizoaffective disorder, were considered based on the incorrect assumption that patient was taking TCA.

False positive urine drug results can be confusing and misleading for clinicians. This report underscores the possibility of such false positives arising from quetiapine and emphasizes the critical importance of careful result interpretation.

None Declared

Lithium is one of the main drugs used in Bipolar Affective Disorder. However, it has a narrow therapeutic window, which requires close monitoring and progressive dose adjustment, according to serum levels, clinical response and the appearance of side effects. The term ‘SILENT’ explains descriptively persistent neurological sequelae related to lithium salt intoxication when symptoms persist for more than 2 months after stopping treatment. SILENT Syndrome is more common in females, at ages ranging from 21 to 77 years and is characterized mainly by avermian-type cerebellar disorder, persistent extrapyramidal syndrome, brainstem dysfunction and dementia of varying severity. It can also result in apraxia of the body, changes in the coordination and balance, dysarthria, as well as intentional and kinetic cerebellar tremor, involuntary movements of orofacial dyskinesias or resting tremor.

The authors intend to review the relevant and current literature in order to extend the knowledge about this condition and find the best conducts for clinical practice.

Non-systematic literature review.

Complications from the use of lithium known in the medical literature include mainly nephrotoxicity, endocrine alterations and neurotoxicity. The neurotoxic effects of lithium usually occur at high serum concentrations. However, they can also occur with lithium in the therapeutic range, and memory, attention and ataxia impairment may be some of the permanent sequelae. The etiopathogenesis is unclear, but demyelination has been detected in multiple brain regions, mainly in the cerebellum. The mechanism of lithium-induced cerebellar injury is believed to be mediated by the entry of calcium into the cells of this organ. The main factors that predispose to greater side effects and risk of toxicity are patients with decreased renal function, advanced age, use of diuretics, dementia, pregnancy, low sodium intake and physical illness with vomiting and/or diarrhea.

Lithium is a drug used mostly in affective disorders and given the narrow therapeutic window, it requires close monitoring in order to avoid side effects that can be permanent. In this way, it is important to review the factors that increase the lithium toxicity and make recommendations about it.

None Declared

The single-injection start regimen for aripiprazole once-monthly 400 mg (AOM 400) in patients with schizofrenia requires a single intramuscular injection in the gluteal or deltoid site and 14 days of concurrent oral therapy. Based on a population-pharmacokinetic model, the European Medicines Agency and Canada has recently approved a simplified starting strayegy of aripiprazole once a month with single-day regimen of two injections at separate gluteal and deltoid injection sites, together with a single 20 mg dose of oral aripiprazole on the 1st day.

The aim of the study is to evaluate the two injection start (TIS) regimen in inpatients in the Psichiatric Unit (SPDC) of the Hospital of Rimini.

We retrospectively reviewed medical records of patients, from February 2021 to April 2023, that have more than 18 years, who received the newly approved 2-injection start regimen as part of their standard care, evaluating if exist changes in clinical indicators, safety and tolerability of this regimen.

We valuated retrospectively the days of hospitalization after the aripiprazole 400 mg TIS and the number of emergency room access, analyzing the “repository of AUSL della Romagna” and discharge letters and the “CURE” program of the Psychiatric Service of Rimini.

We evaluated 24 patients from February 2021 to April 2023, 11 male (45,8%), 13 female (54,2%); average age 37,95, average lenght of stay in hospital was 11,75 days. 10 patients with diagnosis of psychosis/schizophrenia (41,7%), 6 patients with bipolar disorder (25%), 4 patients with personality disorder (16,6%), 2 patients with substance induced psychosi (8,3%), 1 patients with delusional disorder (4,2%), 1 patient with schizoaffective disorder (4,2%). 6 patients had the two-injection start regimen in 2021 (25%), 13 patients in 2022 (54,2), 5 patients in 2023 (20,8%); 20 patients did not have admission in hospital after the TIS (83,3%), 4 patients had 1 or more admission after the injection (16,7%). 3 patients (12,5%) had accesses in emergency-room after Abilify Maintena. 15 patients (62,5%) continue therapy; 9 patients (37,5%) had suspended the injection for drop-out or because of change of therapy not correlated at adverse effects (1 female patient had suspended treatment after the two-injections due to pregnancy). Just 1 patient that continue Abilify Maintena 400 mg had 2 accesses in the emergency-room.

The coadministration of 2 injections of 400 mg aripiprazole was not associated with safety concerns beyond those expected with a single-injection start regimen. From the study it appears that the long-acting therapy with Alibify Maintena 400 mg once-monthly helps to stabilize the patient to prevent hospitalization and accesses in emergency-room.

None Declared

Achieving successful stabilization in patients with mental disorders often requires the administration of multiple antipsychotic medications, with the increasing prevalence of clozapine in cases resistant to other treatments. Constipation emerges as a particularly troublesome side effect, gradually progressing into a chronic state of gastrointestinal dysfunction, often accompanied by recurrent episodes of paralytic ileus of varying severity. Prucalopride, a 5-HT4 agonist, selectively targets receptors within the intestinal system.This interaction induces muscular contractions and promotes chloride secretion. Literature suggest its potential efficacy in managing constipation induced by clozapine. In light of these observations, we designed and will conduct a randomized controlled trial to evaluate the effectiveness of prucalopride in alleviating constipation in patients who had shown limited responsiveness to conventional laxatives or other conservative treatments

The primary objective of this article is to present the methodology of a randomized control trial assessing the efficacy of prucalopride in the treatment of constipation among patients with mental disorders

The study will enroll 60 adult patients with mental disorders who will require more than two antipsychotic medications, including clozapine, for stabilization, and who will be experiencing constipation as a side effect

To ensure the validity of the study, the following additional inclusion criteria will be applied:

• - Patients will have no severe acute medical conditions

• - Patients will have no history of malignancy

• - Patients will have no severe respiratory or cardiac diseases

• - Patients will have negative results from an endoscopic evaluation of the large bowel, ruling out conditions such as irritable bowel syndrome, ischemic colitis, inflammatory bowel disease, or malignant neoplastic disease

Following the screening process, the patients will be randomly assigned to one of two treatment groups:

Prucalopride Group: Patients in this group will receive prucalopride for the treatment of refractory constipation

Conservative Treatment Group: Patients in this group will continue with conservative treatments.The treatment’s success will be determined based on specific endpoints:

• - Normalization of bowel movements, characterized by having more than five bowel movements per week

• - Resolution of symptoms related to gastrointestinal dysfunction, including pain, bloating, defecation difficulties, and paralytic ileus

Following the conclusion of the study, data from both groups will be meticulously collected and subjected to rigorous statistical analysis to identify differences in treatment outcomes between these two therapeutic approachs

The detailed findings will be presented in a forthcoming article

None Declared

Pregabalin is a gamma-aminobutyric acid analogue used for the treatment of neuropathic pain, partial-onset-seizures, fibromyalgia, and anxiety disorders. Mirtazapine is an atypical antidepressant used in major depression and often prescribed off-label for insomnia. Delirium, an acute confusional state, is a very rare adverse reaction of both medications.

We report a case of an elderly patient treated with low dose pregabalin and mirtazapine who developed drug-induced delirium which resolved rapidly upon withdrawal of both drugs

A 75-year-old woman was admitted for symptoms of anxiety, various bodily complaints (dysphagia, headache, tinnitus, weakness) and sleep-onset insomnia over the preceding 2 months. On admission, examination revealed an apparently anxious, uneasy and emotional looking patient. Mini mental state examination, as well as clock drawing and copying were normal, suggesting absence of cognitive impairment. Physical examination was unrevealing except for high blood pressure recordings (150/90 mmHg). Laboratory testing indicated creatinine at 1.19 mg/dl, with a creatinine clearance moderately decreased at 38 ml/min. Upon admission, she was placed on pregabalin 25 mg bid and mirtazapine 30 mg ¼ tablet qd.

Three days after admission, pregabalin was increased to 25 mg tid. On the same day and about 2 hours after the night dose, the patient acutely developed delirium: she presented confusion, disorientation, incoherence, restlessness and deterioration of her anxiety. On physical examination she was afebrile with no hypertonia or ataxia. An urgent brain magnetic resonance imaging was grossly unrevealing. Pregabalin and mirtazapine were discontinued, as a drug-induced delirium was suspected. She received as a symptomatic treatment lorazepam progressively up to 4 mg qd. Symptoms of delirium resolved rapidly, and she was discharged days later with full functional recovery

Cases of delirium have been described following treatment with pregabalin, but in significantly higher doses. Pregabalin relies heavily on renal clearance for its excretion and the dose should be adjusted in patients with creatine clearance below 60 ml/min. As our patient had a moderate decrease in renal clearance, we prescribed a dose within suggested limits, but in combination with mirtazapine led to the appearance of a drug-induced delirium. In conclusion, combined therapy with low-dose pregabalin and mirtazapine seems to account for the development of delirium in our patient as based on its temporal association with the initiation of this drug combination and its prompt resolution upon withdrawal of these two agents

None Declared

Valproic acid (VPA) has been used in clinical practice since the 60’s, with a relatively favourable safety and efficacy profile. Pancreatitis, hepatotoxicity and teratogenicity are the most significant adverse drug reactions. VPA is also known for causing hyperammonemia, which may be asymptomatic or can present with encephalopathy. VPA-induced hyperammonemic encephalopathy (VHE) is a serious but reversible condition, which requires high clinical suspicion for diagnosis. It may occur acutely or after chronic use of VPA.

Review how frequent is for valproic acid to cause hyperammonemic encephalopathy, signs to watch out for and how it can be treated.

Presentation of a patient’s case and review of existing literature, in regards to encephalopathy caused by valproic acid as a result of ammonia elevation.

In the case displayed here, the patient is diagnosed of hyperammonemic encephalopathy after being treated with valproic acid as treatment for borderline personality disorder.

Reviewing literature, cases of hyperammonemia are rarely reported as VPA-induced, probably because this increased level of ammonia in blood can vary between asymptomatic, and clinically relevant levels. Symptomatology due to VPA-induced hyperammonemia include: lethargy, impaired consciousness, focal neurological signs and symptoms and increased seizure frequency. More rare described symptoms are: aggression, ataxia, asterixis, vomiting and coma.

There are multiple treatment modalities for patients diagnosed with VHE, the primary treatment being the discontinuation of VPA. Other treatments frequently used are Lactulose and Carnitine.

VHE is a rare occurrence, however can have fatal outcomes if not recognized and managed in time. Physicians should be vigilant while initiating Valproate therapy to patients. Clinicians should consider the possibility of VHE in patients with unexplained altered mental status, regardless of the duration of VPA therapy. A timely diagnosis is essential to prompt effective treatment, thus ensuring the patient’s safety and decreasing the length of hospitalisation and the cost of care in hospitals.

None Declared

Paliperidone Palmitate (PP) is an atypical antipsychotic, approved by the FDA for acute and maintenance treatment of schizophrenia and schizoaffective disorder.

It has a relatively safety profile, and reported cases of paliperidone palmitate-induced angioedema or anaphylaxis are uncommon.

We intend to present a case of paliperidone palmitate-induced anaphylaxis to alert clinicians regarding this rare, but possible complication.

Non-systematic review of the literature and report of a case study.

Long-acting injectable Paliperidone Palmitate (LAIPP) is a safe and effective alternative to oral Paliperidone, with less incidence of disease relapse related to medication non-compliance.

Substance use disorder (SUD) is highly prevalent in first-episode psychosis (FEP), and it is associated to decreased treatment compliance, which impairs the outcomes of these patients. Therefore, several authors have been recommended long-acting injectable antipsychotics (LAI-AP), such the LAIPP, as a first line for treatment of FEP-SUD patients.

The most common side effects associated with LAIPP are injection site reactions, extrapyramidal symptoms, hyperprolactinemia, sedation, hypersalivation, orthostatic hypotension, tachycardia, and weight gain. Hypersensitivity reactions have rarely been reported and may be dose-dependent.

We report a case of a 20-year-old female, without medical history and no history of allergies, who was medicated with once-monthly LAIPP at dose 100 mg for the maintenance treatment of a first psychotic episode associated with cannabis abuse.

Approximately 24 hours after the first monthly injection dose, she was admitted in the emergency room (ER) presenting an increasing angioedema associated with stridor, requiring endotracheal intubation and administration of adrenaline, clemastine and hydrocortisone during the assessment in the ER.

After clinical stabilization, she was transferred to the internal medicine ward, and following a full recovery, she was discharged 6 days later while being medicated with Olanzapine 15 mg/day, Lorazepam 3 mg/day and Sertraline 50 mg/day. LAIPP was suspected as the etiology of the anaphylaxis reaction due to temporal relationship of its onset with therapy administration and by the exclusion of other potential causes. Consequently, LAIPP was discontinued at discharge.

This report shows the possibility of a late and potentially life-threatening anaphylactic reaction to LAIPP. So, all physicians should be aware of this potential complication, which requires timely recognition and management.

None Declared

Tourette syndrome (TS) is a neurodevelopmental disorder characterized by the development of persistent and changing motor and phonic tics over time. The presence of at least two motor tics and one vocal tic that have persisted for at least a period of 1 year is required, and which developed before the age of 18. The most commonly used pharmacological treatment are antipsychotics, with a preference for atypical antipsychotics such as aripiprazole or risperidone. Clonidine and guanfacine have shown effectiveness in suppressing tics, and although generally less effective than antipsychotics, some authors are considering them as first-line treatments. The treatment is also influenced by any comorbidities the patient may present.

To enumerate in a clinical case the pharmacological alternatives for TS, which vary according to the patient’s comorbidities and the intensity of the tic symptoms.

Case study. Anamnesis of the patient and their family.

A 12-year-old boy presenting simple motor and vocal tics for over a year. At the same time that a valuation is requested by child psychiatry, the mother also requests follow-up by neuropediatrics. Other causes are ruled out, an EEG is performed, and a TS diagnosis is made. The initial treatment was low-dose aripiprazole with partial effectiveness. After 3 months, he presents an exacerbation of the tics, interfering with his social and academic life, making it impossible to attend classes. The mother takes him to emergency services, and he is admitted to pediatrics. During the stay in pediatrics, he is diagnosed with Attention Deficit Hyperactivity Disorder, in addition to confirming the TS diagnosis. Extended-release methylphenidate is initiated (neuropediatrics). After starting methylphenidate, the patient’s tics worsen, also presenting insomnia and hyporexia. Due to the diagnosis of ADHD, school failure, and affective symptoms (hypothymia), atomoxetine is initiated. The tics become constant and incapacitating. As the dose of aripiprazole is increased, the child presents extrapyramidal effects. As a therapeutic alternative, guanfacine is initiated, progressively discontinuing aripiprazole. Currently, the child is stable from motor and vocal tics, allowing him to lead a normalized life.

Although guanfacine is not as effective in reducing tics as antipsychotics, since the latter produce more side effects, it is justifiable to use it. This drug is capable of enhancing the therapeutic effect and reducing the adverse effects that antipsychotics could produce. Guanfacine may be a good alternative as a first line in the treatment of Tourette Syndrome with or without attention deficit disorder and hyperactivity .

None Declared

Antipsychotics are psyschotropic medications that are indicated for the treatment of physchosis and mood disorders. Due to minimal side effects and their efficacy (affecting many receptors) compared to standard antipsychotics, today atypical antipsychotics are being used more and more as first-line treatment.

The aim of this study is to show the efficacy of asenapine and its tolerability as opposed to other atypical antipsychotics.

1. 1. What are the side effects identified?

2. 2. Side effects and efficacy of asenapine vs other atypical antipsychotics?

It is a comparative, regular, clinical study, an examination case of a 53-year old female diagnosed with Schizoaffective Disorder 27 years ago and treated outside of hospital with atypical antipsychotics, such as: risperidone, olanzapine, quetiapine, aripiprazole, amisulpride. The study covers the timespan of 2010-2022.

The results showed that asenapine sublingual 15 mg had fewer side effects than other atypical antipsychotics. They were mouth dryness, headache, fatigue.

The other atypical antipsychotics caused: metabolic disorders, like considerable weight gain, cholesterol and glycaemia increase, extrapyramidal side effects, hyperprolactinemia.

Asenapine sublingual 15 mg was not as effective in treating Schyzoaffective Disorder as risperdal 5mg, olanzapine 15 mg, aripiprazole 20 mg, amisulpride 600 mg.

The efficacy of asenapine sublingual 15mg was the same as quetiapine 400 mg.

This study showed that asenapine has minimal side effects but its efficacy in treating Schyzoaffective Disorder as monotherapy is lower than other atypical antipsychotics.

antipsychotics, schyzoaffective disorder, side effects, efficacy

None Declared

The use of long-acting treatments is a common clinical practice in psychiatry. No disease insight and the risk of treatment discontinuation in a significant portion of our patients, increase the demand for psychiatric emergency and hospital admissions. Treatment adherence must be facilitated, taking into account possible side effects and patient´s subjective satisfaction.

-Evaluate the type of long-acting intramuscular treatment in selected patients. -Evaluate the differences in treatment satisfaction between different types of long-acting intramuscular treatments as well as frequency of psychiatric emergency and hospital admissions in the last year.

We select patients with different severe mental disorders who stay in a Medium Stay Unit, Sociosanitary Community Residence, Supervise house and Residence for the elderly in Albacete (Spain); all of them, with intramuscular neuroleptic treatment (zuclopenthixol dihydrochloride, aripiprazole long acting, palmitate paliperidone monthly, 3-monthly and 6-monthly) at least 1 year.

We evaluate their sociodemographic characteristics, the satisfaction questionnaire with the treatment (TSQM-9) and the rate of psychiatric emergencies and admissions after current intramuscular treatment in last year.

We have selected 57 patients with an average age of 45.86. 78.94% with a diagnosis of schizophrenia, 12.28% with schizoaffective disorder, 5.26% bipolar disorder and 3.5% unspecified psychotic disorder.

We can see in the graphics below that the longer duration of the intramuscular treatment, the greater satisfaction in all the items of the TSQM-9 questionnaire.

31% of the patients with zuclopenthixol dihydrochloride treatment, have gone to psychiatric emergencies and 28% of psychiatric admissions in the last year.18% of the patients with aripiprazole long acting, 17% with paliperidone palmitate long acting-monthly and 12% de 3-monthly have gone to psychiatric emergencies and 15%, 12% and 12% needed psychiatric admissions respectively. Patients with palmitate long acting-monthly have not emergencies or psychiatric admissions in the last year.

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• - The longer long acting of the intramuscular treatments, the better patient satisfaction.

• - With the longer duration treatment (Palmitate paliperidone LD 6 month), we have lower psychiatric emergencies and hospital admissions.

None Declared

Aripiprazole is an atypical antipsychotic orally indicated for the treatment of schizophrenia, bipolar I, major depressive disorder. It is also indicated as an injection for agitation associated with schizophrenia or bipolar mania. Aripiprazole exerts its effects through agonism of dopaminergic and 5-HT1A receptors and antagonism of alpha-adrenergic and 5-HT2A receptors (Cosi et al., 2006). Ptosis is known as the drooping of the upper eyelid, and the patient usually presents with the complaint of the defect in vision and cosmesis (Shahzad & Siccardi, 2023). Orofacial dyskinesia and oromandibular dystonia are uncommon neurological disorders with involuntary, mainly choreic (dance-like) movements, or excessive, involuntary and sustained or repetitive muscle contractions that may involve the face, lips, tongue, and/or jaw (Bakke, 2016).

The aim of this study is to present a case of ptosis and orofacial spasm, which are neurological side effects that may be very rare side effects of aripiprazole.

The 22-year-old woman was referred to the psychiatric service via the emergency service, due to thoughts of harming herself and irritability. The patient was planned to be hospitalized due to decreased sleep, increased speech, and persecution delusions for the last days. After the patient stayed in the service for 25 days, the patient was prescribed olanzapine 10 mg for discharge. At the follow-up appointment, it was learned that the patient had gained weight due to olanzapine and was switched to aripiprazole on 4th of July. The patient’s aripiprazole dose was gradually increased to 10 mg/day. The patient’s relatives gradually noticed drooping eyelids, involuntary oral movements, and impaired speech due to aripiprazole. Cranial MRI and cranial MRI angiography performed to rule out organic pathologies resulted normal. Accordingly, the aripiprazole dose was reduced to 5 mg/day by his mother, and at the last follow-up appointment on August 4, aripiprazole was stopped and paliperidone was started, and the neurological symptoms completely resolved 4 days later.

Since aripiprazole is frequently used in the field of psychiatry, its side effects are often wondered about. Extrapyramidal system side effects of antipsychotics are more common than ptosis. And In terms of the incidence of various extrapyramidal side effects, overall, no significant effects of age, sex, mean dose, study duration, or measuring method could be demonstrated. It is very important to distinguish between organic pathology and drug side effects, especially since ptosis accompanies neuromuscular diseases, ischemic, demyelinating brain lesions and intracranial aneurysms.

As a result, patients who are started on antipsychotics should be closely watched for side effects to increase patient comfort and drug compliance. Also organic pathologies must be excluded before making a final decision that it is a drug side effect.

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DRESS (Drug Reaction with Eoshinophilia and Systemic Symptoms) syndrome, also called DIHS (Drug-Induced Hypersensitivity Syndrome) is a rare drug-induced systemic hypersensitivity reaction that can be potentially life-threatening (Choudhary et al. J Clin Aesthet Dermatol 2013; 6 -7). Risperidone is an antipsychotic drug with significant antagonist activity at the 5-HT2 and the D2 receptors. It has been reported that risperidone may be effective in controlling agitation, delusion, hallucination, and withdrawal behavior in geriatric patients (Yunusa & El Helou. Front Pharmacol 2020;11:596).

The aim of this study is to demonstrate the case of developed DRESS syndrome following the use of risperidone.

The 81-year-old female patient was admitted to the Dermatology Clinic due to skin rash, high fever and leukocytosis following the use of risperidone. The patient was consulted to Psychiatry.

In her history it was determined that risperidone 0.5 mg/d was started to the patient with depression due to agitative symptom. On the 4th day of treatment, targeoid lesions, starting from the back and spreading first to the trunk and then to the extremities, were observed. Further laboratory examinations revealed that the fever was measured at 39.5 C°, liver enzymes were elevated (ALT= 119 IU/ lt, AST= 124 IU /lt), and significant leukocytosis (WBC =12.000) was present along with the lesions. The patient was planned to be hospitalized to Dermatology Clinic on the 5th day and risperidone was stopped. The patient’s agitation increased and following the risperidone discontinuation thereupon the lesions tended to fade and desquamation began. After the treatment of the DRESS syndrome, aripiprazole was given to the patient for agitative symptom. The level of agitation symptoms decreased, and the patient tolerated aripiprazole well without any observed side effects.

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When initiating medication for the elderly population to address agitation, considering such rare side effects can prevent the patient from being hospitalized due to DRESS syndrome. To the best of our knowledge, this is the first case report associated with DRESS syndrome and risperidone treatment thus, it is necessary to be very careful when starting psychotropic medication for elderly patients.

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Antipsychotics are the primary class of drugs used to manage schizophrenia. These medications help control and reduce the severity of these symptoms, allowing individuals with schizophrenia to better function. On the other hand, rifampicin, used as treatment for tuberculosis, is a powerful inducer of several drug-metabolizing enzymes which have the potential to decrease the plasma levels of antipsychotics. Therefore, the presence of multiple pharmacokinetic interactions can alter how antipsychotics are metabolized, leading to a notable clinical impact when these medications are administered concurrently.

The objective is to share valuable clinical experiences and insights to aid healthcare providers in making informed decisions when faced with the challenge of co-administering antipsychotics with rifampicin, ultimately ensuring the safety and efficacy of treatment for their patients.

It will be discussed a case of a 41-year-old woman with the diagnosis of schizophrenia under treatment with paliperidone palmitate and clozapine who had a sudden relapse after starting treatment for latent tuberculosis with rifampicin as a framework for a literature review based off Pubmed.

The antituberculosis drug rifampicin induces drug-metabolizing enzymes in the liver, having the greatest effects on the expression of cytochrome P450 (CYP3A4) and therefore can lead to a decrease in the plasma levels of antipsychotic medications that also rely on these pathways for clearance. In this particular case, although specific data on clozapine and paliperidone concentrations were not reported, fluctuations in symptomatology following rifampicin introduction were probably explained by an inducing effect of this drug on their metabolism. So, when initiating rifampicin treatment and when discontinuing it, clinicians should carefully assess the dosages of any concomitant medications that may potentially interact with rifampicin. To ensure effective therapy during rifampicin treatment, it is crucial to monitor both the patient’s clinical response and their blood drug concentrations, making dosage adjustments as necessary.

This case report offers valuable guidance to clinicians on safely and effectively managing drug interactions between antipsychotic medications and rifampicin, ensuring the well-being of their patients during treatment. The co-administration of these medications lacks robust clinical evidence, and notably, there is insufficient data regarding its impact on plasma antipsychotic levels, a crucial factor in determining clinical effectiveness.

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Little research has been conducted on outcomes in mental health care by intensity of level of service.  Mental health care has evolved in the United States to psychiatrists or psychiatric nurse-practitioners overseeing medications in 15-minute appointments while non-physicians provide the psychotherapy.

We wished to compare these two models when one psychiatrist worked in two settings, providing the medication management alone model in one setting and the medication + psychotherapy model in the second setting.

All patients were seen by the same psychiatrist at (1) a community mental health center (CMHC) and (2) a private practice (PP) providing services to the same type of patients over 2 years. Patients were assessed with the My Medical Outcomes Profile (MYMOP2) and the Brief Psychiatric Rating Scale (BPRS). In the CMHC, patients were seen for a 15 – minute visits every 1 to 3 months. Patients were offered psychotherapy, ranging from 1/2 hour monthly to 1 hour every other week. Some patients received weekly psychotherapy due to an interest by the clinician. In the PP, patients were seen every 1 to 4 weeks by the psychiatrist who also provided psychotherapy when that was desired. Visits ranged from 15 to 75 minutes. Other practitioners could have also provided psychotherapy. Analysis was conducted for patients who completed at least four outcome ratings. Multi-level modeling techniques as implemented in SPSS were used to determine if patients improved over time.

There were no differences in age, socioeconomic status, type of insurance, and type of diagnosis among the two groups. Follow-up occurred for two years. On average, no improvement occurred in outcome measurements in the CMHC setting while statistically significant improvement occurred in the PP setting. The cost of care was statistically significantly greater in the CMHC setting, due to the facility fees billed and collected for each patient (and approved by the government) of $176 additional per visit.

Further work can be done on establishing minimal levels of service delivery that can produce improvement for large populations in community settings. Since it is unlikely that we can generate control groups of no treatment, perhaps analyses like this one, comparing treatment models, can establish a benchmark from which we can understand the necessary level of treatment. The PP setting may have afforded more attention for patients than the CMHC setting, though at a lower cost to the government. The psychiatrist believed that he wanted patients to improve equally in both settings, but he could have been more enthusiastic in the setting in which he also did psychotherapy and therefore had better relationships with patients. On the other hand, this may be the point – better relationships with patients may be associated with better outcomes.

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