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.

Shared decision-making denotes a structured process that encourages full participation by patient and provider in making complex medical decisions. There has been extensive and growing interest in its application to long-term illnesses but surprisingly not in severe psychiatric disorders, such as schizophrenia. However, the great majority of schizophrenics are capable of understanding treatment choices and making rational decisions. Although the main justification for shared decision-making is ethical, several randomized controlled trials support its effectiveness in improving the quality of decisions, but robust evidence in objective health outcomes is needed.

Of the study: to demonstrate the effectiveness, measured as treatment adherence and readmissions at 3, 6 and 12 months, of shared decision making in the choice of antipsychotic treatment at discharge.

Of the oral presentation: to present the study design; to make an interim report of the data obtained at the moment of the congress.

Randomized controlled trial, prospective, two parallel groups, not masked, comparing two interventions (shared decision making and treatment as usual). Study population: Inpatients diagnosed of schizophrenia and schizoaffective disorders (ICD-10/DSM-IV-R: F20 y F25) at Adult Acute Hospitalization Unit at Jerez General Hospital.

Currently in the recruiting phase with 55 patients included in the study. An interim analysis of at least half of the target sample size.

We will show the study design and decision tools employed. Conclusions in relation to the effectiveness (adherence and readmissions) and subjective perception.

The authors have not supplied their declaration of competing interest.

Shared decision-making denotes a structured process that encourages full participation by patient and provider in making complex medical decisions. Although the main justification for shared decision-making is ethical, several randomized controlled trials support its effectiveness in improving the quality of decisions, but robust evidence in objective health outcomes is needed.

Analyze the degree of antipsychotic politherapy or monotherapy in patients discharged after their inclusion in the study and randomized to Share Decision-Making or Treat as Usual. Present preliminary conclusions after 20 months of follow-up.

Randomized controlled trial, prospective, two parallel groups, not masked, comparing two interventions (shared decision making and treatment as usual). Previous antipsychotic treatment is collected by interviewing patient and family and as included in digital history and health card, discharge and reviews conducted at 3, 6 and 12 months.

Interim analysis shows there are no differences between groups (SDM and TaU) before intervention, we note the following results:

• – the degree of antipsychotic politherapy prior to admission for the entire sample decreased at discharge;

• – at discharge, there is a difference between SDM and TaU. Antipsychotic polytherapy in SDM decreases in a higher level.

The authors have not supplied their declaration of competing interest.

Recent studies have reported therapeutic benefit from the use of omega-3 fatty acids (EPA and DHA) as adjunctive treatment of depression.

The goal of this work is to assess the effectiveness and tolerability of dietary supplementation with omega-3 in the treatment of depressed patients.

Prospective, descriptive, observational study in a general psychiatry outpatient clinic. Consecutive inclusion of depressed patients started on dietary supplementation with omega-3 because of partial response to antidepressants and/or intolerance to high doses or combination of antidepressant drugs between January and May 2015. Sociodemographic variables, clinical data and information about tolerability were recorded. Clinical response to treatment over time was assessed at 4–6 months follow up using the 5-item CGI (Clinical Global Impression) scale.

We included 30 depressed patients started on omega-3. None of them reported side effects. Seventy-three percent of patients reported clinical improvement (40% much improvement, 33% some improvement). None of them got worse. We did not find association between clinical response and age, sex, type of depression nor duration of illness.

Despite the limitations of this study, our work support previous positive results on the use of omega-3 fatty acids (EPA and DHA) as adjunctive treatment of depression. Giving the safety of its use, clinicians might recommend omega-3 as adjunctive treatment of depression in cases with a partial response to antidepressants.

The authors have not supplied their declaration of competing interest.

To demonstrate the therapeutic efficacy of aripiprazole LP by a case of difficult clinical management and that we often find in our daily practice.

Description of a clinical case of a 21-year-old man, recently diagnosed with paranoid schizophrenia with no awareness of disease neither treatment adherence and harmful use of THC and cocaine that are identified as precipitating factors for multiple hospital admissions.

Injectable medication with objective clinical improvement is significant, cessation of readmissions, achieving improvement in all parameters measured functionality and proper adherence to treatment as well as outpatient mental health of both devices as of drug dependence.

Psychiatry is facing the great challenge of modifying the natural history to the deterioration of schizophrenia, a disease considered one of the leading causes of years lived with disability. The objectives medium and long-term treatment of this disease are centered on the delay-avoidance disability and improving the functioning and quality of life of people with this disease.

The authors have not supplied their declaration of competing interest.

The extended release injectable offers a good alternative for those patients with no or poor adherence to treatment. Numerous studies indicate that decrease the number of relapses in such individuals. Our aim is to check whether a group of our patients diagnosed with dual pathology coincide with these data.

We followed a group of 5 patients diagnosed with paranoid schizophrenia or delusional disorder with drug consumption in the last year. We measured the number of relapses, understood as the number of visits to emergency and outpatient devices Mental Health Hospitals and hospitalizations six months before the start of treatment with aripiprazole injectable extended release and six months after.

The preliminary results point to a significant reduction in the number of emergency room visits and hospitalizations after starting sustained release injectable treatment.

Our preliminary results are consistent with the literature, we found also reduced consumption of toxic and better adherence to drug addiction devices. The new antipsychotics extended release is a good alternative for patients with dual diagnosis.

The authors have not supplied their declaration of competing interest.

Electroconvulsive therapy (ECT) is an effective depression treatment, but it has potential cognitive side effects. Bitemporal ECT has been traditionally used, but in recent decades, right unilateral (RUL) electrode placement has been proposed to decrease the cognitive side effects of ECT. Ultrabrief pulse (UBP) right unilateral (RUL) ECT is an increasingly used treatment option that can potentially combine efficacy with lesser cognitive side effects.

To evaluate whether ultrabrief pulse (UBP) right unilateral (RUL) electroconvulsive therapy (ECT) is as effective as brief pulse (BP) RUL ECT in addition to cause lesser cognitive side effects.

A search is performed in the available scientific literature on systematic review and meta-analysis of the subject under study, through the database PubMed.

• – Current evidence supports the efficacy of right unilateral (RUL) electroconvulsive therapy (ECT) given with an ultrabrief pulse width in the treatment of depression;

• – ultrabrief pulse RUL ECT leads to lesser cognitive side effects than traditional forms of ECT;

• – ultrabrief pulse RUL ECT may be slightly less effective than traditional forms of ECT.

BP compared with UBP RUL ECT was slightly more efficacious in treating depression and required fewer treatment sessions, but led to greater cognitive side effects. The decision of whether to use BP or UBP RUL ECT should be made on an individual patient basis and should be based on a careful weighing of the relative priorities of efficacy versus minimization of cognitive impairment.

The authors have not supplied their declaration of competing interest.

People experiencing severe mental illness (SMI) face a shortened life expectancy of up to 20 years, primarily due to preventable cardiovascular (CV) diseases. Lifestyle interventions are effective in reducing CV risk, yet examples of service-wide interventions are lacking. Staff culture remains a barrier to the successful implementation of lifestyle interventions. The Keeping the Body in Mind (KBIM) program, established by SESLHD (Australia), aims to close the gap in life expectancy through multidisciplinary teams, including clinical nurse consultants, dieticians, exercise physiologists, and peer support workers. Prior to the KBIM rollout, an individualized lifestyle intervention called Keeping Our Staff In Mind (KoSiM) was offered to all district mental health staff.

KoSiM examined the effectiveness of a staff intervention to improve physical health, confidence, knowledge and attitudes of mental health staff.

Mental health staffs were invited to participate in an online survey and a 4-week individualized intervention including personalised health screening and lifestyle advice, with a 16-week follow-up. Outcomes assessed included: attitudes, confidence and knowledge regarding metabolic health, weight, waist circumference (WC), blood pressure, sleep, diet, physical activity and exercise capacity.

Of a total of 702 staff, 204 completed the survey (29%). Among those completing the survey, 154 staff (75%) participated in the intervention. A mean decrease in waist circumference of 2 ± 2.7 cm, (P < 0.001) was achieved. Among staffs that were overweight or obese at baseline, 75% achieved a decrease in WC.

Improving staff culture regarding physical health interventions is an important step in integrating lifestyle interventions into routine care.

The authors have not supplied their declaration of competing interest.