Schizoaffective disorder (SAD) is the second most frequent psychotic disorder after schizophrenia. There is a relative scarcity of specific studies looking into SAD treatment and evidence on drug treatment of SAD is patchy. We aimed to study naturalistically, interviewing psychiatrists systematically, what do they think is most useful in SAD treatment.

To know the actual management of SAD in real clinical practice and provided data for effective clinical studies.

We administered an online poll to 65 psychiatrists (52% male, 48% female), 75% of which described themselves as having a holistic background. The poll was completed using a Google doc's questionnaire. The three main questions made were:

– what is your first treatment choice for SAD;

– do you tend to use mono- vs. poly-therapy;

– provide a level of utility for each drug between 1 (little use) to 4 (maximum use).

Atypical antipsychotics were considered the most common first choice in the treatment of SAD according to 66.2% of psychiatrists. The second most selected first choice answer was combining drugs and psychotherapy, which was answered by 20% of the sample. Monotherapy was preferred (60%) to polytherapy (40%). Finally, the most useful drug for SAD according to the sample was aripiprazole followed by mood stabilizers, olanzapine and paliperidone.

Real practice in SAD treatment may differ grossly to what is advocated for in clinical guidelines and seem to also deviate from officially approved indications of some drugs.

The authors have not supplied their declaration of competing interest.

Erotomania (“Clérambault's syndrome”) is a rare syndrome characterized by a delusional belief of being loved by another person, usually of higher social status.

This case report aims to describe and discuss a case of erotomania, providing an updated review on this disorder.

Regular clinical interviews were performed during admission period to collect information about the clinical case and to promote an intervention approach to the patient. A literature review in Science Direct database, with the keyword “erotomania”, was also conducted.

A 51-year-old woman was admitted in Beatriz Ângelo Hospital psychiatric ward with delusional beliefs of being loved by the ex-boss. Positive misperceptions and persecutory delusions regarding her husband as the obstacle for the love were manifested. The lack of insight for the situation and the necessity of treatment created some difficulties. A clinical report and a bibliographic review were made to allow a better understanding about the case and to orient the case evidence based.

Despite the evidence about the good response of atypical antipsychotics (e.g. risperidone) in erotomania, in our case study, the partial remission was only achieved with high dose of the old typical antipsychotic, pimozide.

The authors have not supplied their declaration of competing interest.

Emotional dysregulation is one of the core problems of borderline personality disorder (BPD). Forty-one year-old married female diagnosed with BPD at the age of 21, was admitted to the partial hospitalization unit due to a depressive symptoms and emotional dysregulation and poor overall functioning.

Patient was previously treated with numerous psychotropic agents: antipsychotics (AP) – fluphenazine, levomepromazine, risperidone, clozapine; antidepressants (AD) sertraline, mirtazapine, maprotiline, amitriptyline; psychostabilizers – carbamazepine/valproate) without achieving the full therapeutic response. After switching to combination of clomipramine and aripiprazole, we have reached partial clinical response.

The aim of this treatment was to improve clinical response and achieve emotional stability by augmentation with neuromodulator pregabalin.

Augmentation strategy was realized by gradual titration and tapering of pregabalin (300 mg/d) over a two-week period. We started with pregabalin dose of 75 mg/d, followed by gradual increase to the dose of 300 mg/d. The Beck Depression Scale (BDS) and the Emotional Dysregulation Scale-short form (EDS) have been used for efficacy monitoring.

Mental state before augmentation therapy: the BDS (score 30-moderate depression) and the EDS-short form (score 127). Parameter status after augmentation with pregabalin: BDS score 16-mild mood disturbance, EDS score 87.

Augmentation strategy with pregabalin have improved emotional control, maintained affective and behavioral stability, with significant reduction of feelings of emptiness, as well as the achievement and maintaining of emotional attachment.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

We discuss the different explanations for the results we got.

The authors have not supplied their declaration of competing interest.

Previous studies of prescribing in psychiatric services have identified the relatively frequent use of combined antipsychotics in schizophrenia.

– To analyze the proportion of patients treated with more than one antipsychotic;

– to study clinical as sociodemographic variables associated with types of prescription.

Retrospective descriptive study of treatment prescribed to psychiatric inpatients treated in an acute care unit of Psychiatry Service in a large teaching hospital during a period of 3 years. Consecutively admitted inpatients receiving concurrent antipsychotics were compared with those treated with a single antipsychotic. Prescription drug records at discharging were revised, n = 263.

From the total sample, 61% received more than one antipsychotic. The most common types of combinations were atypical plus a typical antipsychotic followed by two atypical antipsychotics, being less frequent combination of three or more antipsychotics. There were 19 different drug combinations. Concurrent antipsychotics were most frequently prescribed in schizophrenia and schizoaffective disorder. Patients with more previous episodes of illness received more frequently concurrent antipsychotics than patients with low number of previous episodes of illness (P < 0.03). Patients with longer time of hospitalization, and age between 30 and 50 years were treated more frequently with several antipsychotics. Analysis with other variables is presented in the study.

There is a significant difference in the strategies of treatment with antipsychotics depending on diagnosis and number of previous episodes of illness. The concurrent use of multiple antipsychotics in psychiatric inpatients appears to be a response to treatment resistance and is frequent in schizophrenic patients.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

Clozapine is a neuroleptic commonly used in treatments resistant to schizophrenia. However, despite the benefits, clozapine might cause some serious side effects. Hence, it is of the utmost necessity to keep an exacting control of the patients.

To study some of the therapeutical approaches to the treatment of clozapine induced neutropenia and agranulocytosis.

Review of some articles in Mental Health Journals.

The treatment with clozapine, substratum of aminergic and muscarinic receptors, entails a 0.9% risk of causing agranulocytosis, and approximately a 2.7% risk of causing neutropenia. Both occur, over 80% of them, during the first 18 weeks of treatment. Thus, before starting it, it is necessary to draw some blood and analyze the complete blood count (CBC). Also, we must analyze CBCs weekly during the first 18 weeks. Other dyscrasias like leukopenia, leukocytosis, anaemia, eoshinophilia, thrombocythaemia or thrombocytopenia can also be observed. When agranulocytosis appears, it can be treated by discontinuing the clozapine treatment, but also using granulocyte-colony stimulating factor or lithium, both separated or combined with clozapine. Lithium produces reversible leukocytosis onceplasma levels of > 0.4 mmol/L are reached. Despite the simultaneous treatment with lithium, clozapine can trigger some neurological side effects, it seems that seizure risk remains invariable.

Some of the clozapine's side effects, like neutropenia or agranulocytosis, are potentially lethal. Their treatment consists of discontinuing clozapine or initiating granulocyte-colony stimulating factor or lithium. These are good options that can give rise to a later continued treatment with clozapine.

The authors have not supplied their declaration of competing interest.

Trihexyphenidyl (THP) is an anti-Parkison and anticholinergic drug. It is essentially prescribed by psychiatrists in order to treat abnormal movements and Parkinsonism induced by antipsychotics. However, in unusual practice, the THP is widely used by patients.

To assess different factors associated to the prescription of trihexyphenidyl in patients treated with neuroleptics.

A cross-sectional, descriptive, comparative and analytical study among 153 patients followed in outpatients clinics and treated by antipsychotics.

During a six-month period, 153 patients were interested by the study. In total, 79.73% of them were receiving a treatment by THP. Mean age was 47.79 years old. Almost patients were married (44.1%), having a primary level education (46.7%) and jobless (66.7%). Mean factors associated to THP prescription were: hospitalization in a psychiatry unit (P = 0.025), good evolution of mental disorder during hospitalization (P = 0.008), regular follow-up (P = 0.005), episodic evolution and existence of residual symptoms (P = 0.001), personality disorder (P = 0.025) and somatic comorbidities (P = 0.001). Prescription was crucial in order to indicate necessity of THP. Doses of neuroleptics were a determinant factor (P = 0.0001). Forty-one percent of patients were receiving more than one treatment (P = 0.0001). In most cases, prescription consists of classic antipsychotics (67.60%).

Prescription of THP should be argued, considering different factors associated to the prescription, in order to prevent misuse of the drug.

The authors have not supplied their declaration of competing interest.

The indoor light environment of hospital wards may affect functions and symptoms that are central to the process of inpatient recovery, including sleep, anxiety, well-being, and mood.

To assess whether interventions in light improves recovery in hospitalized patients across all medical specialties.

We systematically searched and reviewed the literature for RCT's on adult inpatients where any light intervention were compared to standard care or placebo. We reviewed effects of light on various outcomes, and compared differences in administration, timing, color, and intensity of the light.

We identified 2330 titles, of which 32 met our predefined selection criteria. Choice of administration, timing, wavelengths, and intensity varied. However, most studies investigated bright light therapy with high intensity and short exposure time, others low-intensity light at night filtered of wavelengths in the blue spectrum, and yet others the use of dawn simulation. Comparators were either placebo lamps with low intensity or regular indoor light. Most studies were performed on psychiatric inpatients, showing that bright light therapy is an effective aid in recovery of major depression. Across medical specialties, several studies reported improved sleep quality during the light intervention. Other studies found a lower rate of delirium. In elderly patients with dementia, studies found light interventions to relieve agitation and confusion.

Light may ease a broad range of symptoms and behaviors across inpatient categories. The intervention is inexpensive, well tolerated, and non-invasive. This study underlines intelligent lighting design as an interesting, yet under-explored, non-pharmaceutical treatment.

The authors have not supplied their declaration of competing interest.

The use of long-acting injectable antipsychotics is useful in patients with low therapeutic compliance.

To present the demographic and clinical data of a case series in which long-acting injectable aripiprazole has been prescribed in an ambulatory Mental Health Center.

Systematic review of the related literature and clinical history of patients in which long-acting injectable aripiprazole had been prescribed from January to March 2015 in a Mental Health Center.

We found 10 patients, whose diagnosis were schizophrenia (4), non-specified psychosis (2), personality disorder (1), bipolar disorder (1), schizoaffective disorder (2), of whom 7 were men and 3 women, with a mean age of 43.8 years old. The mean of years since diagnosis was 15.1 years. In 7 patients, we found concomitant treatment with another antipsychotic agent (low dose quetiapine in all of them); antidepressants in 1 patient, benzodiazepines in 6; mood stabiliser in 5 and biperidene in 1. In relation to previous antipsychotic drugs, we found: aripiprazole 15 mg/day oral (4); long-acting injectable paliperdidone 150 mg/28 days (2) paliperdone 6 mg/day oral (1); combination of paliperidone 6 mg/day oral plus olanzapine 5 mg/day oral (1). Only 4 patients had used long-acting injectable drugs previously in their lifetime. The reason of having initiated treatment with long-acting injectable aripiprazole was sexual disturbance (3); lack of compliance (4); clinical inestability (2) and motor side effects (1).

In our series, we can observe a chronic patient profile, predominantly men with diagnosis of psychotic spectrum.

The authors have not supplied their declaration of competing interest.

Clozapine is the first option for treatment-resistant schizophrenia, affecting about 20–30% of all patients. Weight gain, sedation, hypotension and hypersalivation are common and well-known adverse effects associated with clozapine. However, it is also important to be aware of uncommon adverse effects, like parotitis.

We report a case of clozapine-induced parotitis.

Literature was accessed through Pudmed, using the search terms parotitis and clozapine.

A 36-year-old male with paranoid schizophrenia, whose psychotic symptoms have responded only slightly to two antipsychotic trial, with both haloperidol and olanzapine. Therefore, he began treatment with clozapine with the dose titrated to 400 mg/day. At first, the only registered adverse effect was hypersalivation. Eventually, after 3 months of treatment, he developed a unilateral swelling of the left parotid gland. Bacterial and viral parotitis were ruled out and the diagnosis of clozapine-induced parotitis was evoked. Patient scored 5 in the Parotitis-Specific Criteria Modified Naranjo Probability Scale. Symptomatic medication was initiated with paracetamol and a non-steroidal anti-inflammatory with a favorable outcome.

There are few reports of clozapine-induced parotitis, a very rare and poorly known adverse effect with an unknown pathophysiology. Early recognition and proper management are essential to reduce morbidity associated with the treatment. There is no consensus how to manage these adverse effect, however, generally it is not necessary to discontinue the treatment.

The authors have not supplied their declaration of competing interest.

Knee OA is a chronic and multifactorial disease; self-management needs are complex, which requires a multidimensional management plan. There is a need for healthcare providers to provide patients with knowledge of knee OA and how to effectively manage the disease.

Self-management-needs scales are one means of determining the management requirements of an individual patient. There is no suitable instrument available for assessing self-management needs of adult patients with knee OA in Taiwan. This study developed an instrument that could assess the self-management needs of knee OA patients using Orem's self-care theory as a theoretical framework.

This study developed and psychometrically tested a new instrument for measuring adult patients’ self-management needs of knee OA (SMNKOA).

Development of the instrument involved three phases: item generation and scale development; content and face validity of the initial instrument; and evaluation of validity and reliability of the new instrument. Participants (n = 372) were purposively sampled from orthopaedic clinics at medical centres in Taiwan.

The self-care theory guided the development of the 35-item SMNKOA scale. The content validity index was 0.83. Principal components analysis identified a 3-factor solution, accounting for 53.19% of the variance. The divergent validity was –0.67; convergent validity was –0.51. Cronbach's α was 0.95, Pearson correlation coefficient was 0.88, and the intraclass correlation coefficient was 0.95.

The SMNKOA scale can measure and identify the individual self-management needs of knee OA patients. It will help healthcare providers better evaluate strategies that can help these patients cope with this chronic disease.

The authors have not supplied their declaration of competing interest.

Pharmacological treatments for chronic diseases cause side effects. It is important to identify which of these effects could be avoided because it is a cause to drop the treatment. In the chronic psychiatric illness, one of the problems is the induction of changes in prolactin (PRL) serum.

Review of the literature that has been published to assess the association between different types of antipsychotic drugs and prolactin levels.

Literature search on PubMed, NCBI literature in the last three years using MeSH terms: “prolactin” and “antipsychotics”.

The increase of prolactin is a common effect poorly studied in the past. After several studies have been able to achieve treatments, called “atypical”, which cause less effect on this substance. For example, asenapine, olanzapine and zyprasidone have a slight effect on PRL levels. Aripripazole could even result in lower levels probably by partial agonism on dopamine receptors. Therefore, we have to make a good clinical practice taking into account the effectiveness and tolerance and interpersonal variation.

The authors have not supplied their declaration of competing interest.

The author has not supplied his/her declaration of competing interest.

Patients with mental health disorders usually suffer from high stress levels. Trigger points therapy has been shown to be very effective in providing prompt relief from stress in these patients.

To investigate the effect of the combined use of relaxation techniques and trigger points therapy on stress levels of patients with mental health disorders.

Thirty-one patients participated in this study, 14 (45.2%) males and 17 (54.8%) females, with a mean age of 39. Out of them, 10 (32.3%) suffered from anxiety disorders, 6 (19.4%) from obsessive compulsive disorder, 10 (32.3%) from depression and 5 (16.1%) from chronic condition stress. Data analysis was conducted with t-test analysis and ANOVA, using the SPSS software.

The findings revealed significant differences on stress levels before and after the use of relaxation techniques and trigger points therapy as t(30) = 18.316, P < 0.0001. Before the use of relaxation techniques and trigger points therapy, individuals reported higher stress levels (M = 6.129, SD = 1.087) compared to after the therapy (M = 1.741, SD = .889). Moreover, significant differences were found in stress reduction with regard to psychiatric illnesses (F(3,27) = 5.027, P = 0.007). More specifically, individuals with depression reported lower reductions in their stress levels after the therapy compared to both those with chronic condition stress (M = –2.1, SD = 0.61, P = 0.013) and anxiety disorders (M = –1.4, SD = 0.503, P = 0.05).

The findings of this study highlight the importance of using trigger points therapy, combined with relaxation techniques, to reduce stress levels of patients with mental health disorders.

The authors have not supplied their declaration of competing interest.

Treatment strategies in bipolar disorder (BPD) has changed in the last decades and polypharmacy including antipsychotics has become extremely common compared to monotherapy with mood stabilisers. Clinicians tend to use 2 or more atypical antipsychotics despite the lack of evidence to support safety, tolerability and efficacy of this practice.

To determine most frequently used treatment strategies in a sample of bipolar disorder patients and review of the literature.

Analysis of a sample of 35 patients with BPD from Madrid and review of recent literature for evidence arising from international guidelines recommendations and meta-analyses.

Most frequently used treatment approach in our sample was polytherapy, including at least 1 atypical antipsychotic (31%) and polytherapy, including at least 2 antipsychotics (47%) together with mood stabilisers. Only 11% were in monotherapy with mood stabilisers and another 11%were in monotherapy with one atypical antipsychotic but without mood stabilisers. Aripiprazol and olanzapine were among the most preferred atypical antipsychotics. Efficacy and safety of such combinations have not been systematically compared with monotherapy in the literature. Previous data indicate that polytherapy in BPD may incur in important disadvantages [1].

Treatment of BPD remains challenging. Polytherapy seem to have replaced monotherapy due to less relapses and better results in treatment of affective symptoms. However, compliance and secondary long-term effects should be taken into account. Superiority in terms of efficacy in polytherapy needs to be balanced with tolerability issues. More studies on combination therapy, long-term efficacy and safety are needed.

The authors have not supplied their declaration of competing interest.

Lamotrigine is widely used to prevent bipolar depression. Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a rare, potentially life-threatening adverse effect. The long latency between drug exposure and disease onset, added to the high variability of its clinical presentation, can increase the risk of misdiagnosis lamotrigine withdrawal delay.

To highlight potential risk factors that can be related to a worse clinical onset and evolution of lamotrigine-induced DRESS syndrome.

We report the case of a 25-year-old-man, with a type I bipolar disorder, treated with lithium and lamotrigine 50 mg per day during the first 13 days of treatment, progressively increase up to 200 mg. Thirty-five days after the treatment initiation, a pruritic rash appeared in his upper arms, and scabies infestation was diagnosed. After 72 hours, the patient required urgent hospitalization due to hemodynamic instability.

On admission, facial edema and erythrodermia were involving 70 to 80% of the body surface. DRESS diagnosis due to lamotrigine was made following RegiSCAR criteria (Table 1). Psychiatric medication was stopped and DRESS treatment established. Complete recovery without recurrence was achieved after 2 months.

The lamotrigine up titration faster than recommended may have facilitated the DRESS syndrome reaction. Moreover, the latency between lamotrigine introduction and the rash onset could have increased the possibilities of misdiagnosis. In light of this, physicians need to consider at least the last 3 months treatment history when assessing a rash, as the delay of DRESS syndrome diagnosis can fastly lead to a fatal event.

Table not available.

The authors have not supplied their declaration of competing interest.

Long-acting injectable antipsychotics (LAIs) were developed in the sixties with the purpose of improving schizophrenia maintenance treatment. The main advantages are: the ability to ensure compliance, maintaining stable plasma concentrations and allowing better clinical management of drug therapy. Long-acting atypical injectable antipsychotics start to develop in the late nineties. Currently, they are the most widely used depot treatment for severe mental illness.

Checking patient profile and diagnosis where we use LAIs.

Review of 217 patients treated with LAIs in CSM El Coto–Gijón.

In our sample, the average age of the patients was 48.94 years old. Most of them were men (135 vs. 82). More than half of treated patients were diagnosed with schizophrenia (112), the paranoid subtype was the most repeated (93). Other severe mental illnesses were also treated with LAIs: emotionally unstable personality disorder (31), delusional disorder (19), bipolar disorder (15), schizoaffective disorder (12) and other less frequently. For all groups, paliperidone palmitate was the most used injectable antipsychotic. The new aripiprazole long-acting injectable starts being used in psychotic patients with a significant affective component.

The schizophrenic patient remains being the prime candidate for this therapy although other severe mental disorders may also benefit of LAIs treatment. Most classical long-acting injectable antipsychotics have been replaced by new atypical injectable antipsychotics with a more tolerable side effects profile.

The authors have not supplied their declaration of competing interest.

Maintaining antipsychotic therapy in mental disorder is important in preventing relapse, rehospitalization, and suicide. Lack of awareness of illness may be a leading cause for non-adherence. Long-acting depot can prevent non- adherence and thus potentially contribute to better patient outcomes.

The aim of this prospective, observational, non interventional 2-year-long study is to assess severity and post-intervention changes and attitudes toward medication of a group of patients treated paliperidone palmitate (PP).

Thirty-three outpatients stabilised with PP during the last 24 months. Inclusion criteria were: patients’ age (> 18 years), a diagnosis of schizophrenia, bipolar disorder, schizoaffective disorder stabilised during the last 12 months with PP, without a diagnostics from axis I or II (except for nicotine of caffeine) and able to sign the inform consent. Data collected: general sociodemographic and clinical data (age, sex, level of education, socioeconomic situation, family support, psychiatric diagnosis, years of evolution, use/abuse of substances, treatment, previous and later number of hospitalisations. Evaluations included disease severity (Clinical Global Impression-Severity (CGI-S) and Drug Attitude Inventory, (DAI)).

Thirty-threeoutpatients were followed during 24 months [mean dose 132,58 (44,4) mg], 75,8% were men, age 45,05 years old, 87,8% with a diagnoses of paranoid schizophrenia. Antipsychotic monotherapy increased over the time with PP. Significant improvements were observed on both Clinical Global Impression and Drug Attitude Inventory. The number of rehospitalizations and mean stays decreased from the beginning until the end of these 24 months.

Our results suggest an improvement in the patient's clinical vision and attitude towards medication with long-acting depot.

The authors have not supplied their declaration of competing interest.