The filliation delusion was first described in 1950 by Ey as a false belief about belonging to a family group other than one’s own. Since then, 70 years have passed and litterature is still scarce on this type of presentation.

Using a case report as a starting point, the aim of this article is to review data on the various frameworks of delusional development, while discussing in what capacity social cognition impairment, theory of mind and overall lack of insight, typical in schizophrenic patients, could be related to this type of delusion.

The authors present a case report of an episode of a filliation delusion in a patient with chronic schizophrenia. A search on PubMed and ClinicalKey was performed, from which the relevant publications were selected and reviewed.

The case referes to a 64 year old woman previously diagnosed with schizophrenia who developed, over the period of two years, a filliation delusion. The patient believed having been born in Russia and being subsequently adopted by different families. There was history of irregular attendance to consultations and non-compliance to treatment.

There is still lack of proper investigation regarding the development of delusions in schizophrenic patients. Social cognition and insight are important predictors of functioning, and might behave as a marker of liability to psychosis. This should have strong implications in these patients’ treatment approaches. The lack of consensual measurement instruments make it difficult to draw solid conclusions, and this should be the main focus moving forward.

Hepatitis C virus (HCV) infection produces a chronic systemic disease that induces chronic hepatitis, cirrhosis and hepatocellular carcinoma. Patients with chronic HCV infection may present with a range of extrahepatic symptoms including neuropsychiatric disorders.

The aims of this review are to summarize recent literature looking at the associations between psychosocial and neurocognitive factors and HCV, identify the most common neuropsychological disorders and consider the probable mechanisms of mental and cognitive impairment in patients with HCV.

PubMed/Medline was systematically searched for psychosocial and neurocognitive factors associated with hepatitis C and patient wellbeing. In this review 83 valid articles were analyzed from 1994 to 2018.

According to the literature review in the group of HCV-positive patients were found a significant decrease in higher cognitive functions: memory impairment, concentration and listening. These manifestations of cognitive dysfunction are supposed to be similar to the early symptoms of Alzheimer’s disease. An increased risk of developing dementia has also been noted. The most frequently diagnosed symptoms were fatigue and sleep disturbances, associated with mood disorders diagnosed in 19,2% of cases. Several mechanisms have been considered to explain the pathogenesis of neuropsychiatric disorders observed in chronic HCV infection: 1) the concept of the direct neuroinvasion of HCV; 2) derangement of metabolic pathways; 3) cerebral or systemic inflammation.

To date, the mechanisms of various mental and neurological disorders in patients with chronic HCV infection have been partially identified, but the long-term effect of these changes requires further study.

According to previous studies, about 8,8-14,5% cases of schizophrenia is comorbid to type 2 diabetes. The focus of the study was the evaluation and dynamics of positive and negative symptoms in case of combination of the diseases.

100 patients were divided in two groups: 48 patients was assigned to receive a monotherapy treatment with antipsychotic; 52 patients received the combination of antipsychotics, nootropics and antioxidants. The efficiency criterion was the dynamics of the questionnaire The quality of life of patients SF- 36, Hamilton’s scale of Depression and anxiety, overall score on a scale for evaluation positive and negative symptoms (PANSS).

After treatment the physical component of health is 41,38% in the first group and 56,34% in the second group (p≤ 0,05). The psychical component of health is 39,79% in the first group and 50,8% in the second group (p≤ 0,05). Also statistically confirmed (p≤ 0,05) in the patients of the second group the improvement on the Hamilton’s scale of Depression and anxiety questionnaire and PANSS.

After treatment the physical component of health is 41,38% in the first group and 56,34% in the second group (p≤ 0,05). The psychical component of health is 39,79% in the first group and 50,8% in the second group (p≤ 0,05). Also statistically confirmed (p≤ 0,05) in the patients of the second group the improvement on the Hamilton’s scale of Depression and anxiety questionnaire and PANSS.

According to Quality of Life questionnaire combination of antipsychotic, nootropic, antioxidant is significant more effective than treatment only with antipsychotic.

The topic of research was phenomenon of impaired age self-consciousness in non-psychotic latent schizophrenia patients defined.

To explore features of impaired age self-identity and to determine syndromic affiliation of the syndrome in comparison with premorbid personality disorders traits.

The study sample comprised 141 patients with latent schizophrenia (pseudo neurotic (F21.3 - 64.5%, 91 patients), coenesthopathic (F20.8 - 25.5%, 36 patients) and pseudo psychopathic (F21.4, - 9.9%, 14 patients)) aged 16-31 (average 22.1 years old) in 2007-2019. A follow-up, experimental psychological and clinical study was conducted.

The onset of impaired age self-identity was dominated by a radical drop of the subjective age in self-conscious mind of the patients accompanied by a tormented feeling of loss of self-dependence, role autonomy, helplessness, inability of decision making and to be answerable. Patients described this sudden condition as a loss of ‘maturity feeling’ and return to the juvenile perception of self. In a delusive and unclear manner, phrases such as ‘I feel inferior to others as if a helpless child among adults’, ‘I feel as if my childhood is back’ were uttered. Excessive worrying and enlivening of childhood memories were also included. This correlates to occurrence of humble and sometimes dependent/avoidant behavior, feeling of helplessness and fear with respect to caring for one self, rising subordination and suggestibility.

This phenomenon of regress to earlier ontogenetic level of personal development reported as impaired age self-consciousness can thus be regarded as an obligate form of depersonalization in patients with latent schizophrenia.

Major depressive disorder (MDD) is a highly prevalent clinical condition with a leading cause of disability worldwide. Unfortunately, about 1/3 of patients with MDD fail to achieve remission despite treatment with multiple antidepressants and are considered to have treatment-resistant depression (TRD). Research showed abnormalities in glutamatergic transmission in neural circuits and antidepressant efficacy with the N-methyl-D-aspartate (NMDA) receptor antagonist, ketamine.

The authors elaborate a narrative literature review on the intranasal esketamine as a new-class antidepressant.

PubMed database searched using the terms “treatment-resistant depression” and “esketamine”.

Ketamine, synthetized from PCP, acts as an antagonist of NMDA receptor, reducing Central Nervous System excitability. One limitation of ketamine for treating depression is that requires intravenous administration, reducing its applicability in outpatient settings. Esketamine, the S-enantiomer of ketamine, developed as an intranasal formulation has a higher affinity for the NMDA receptor. The evidence of the rapid antidepressant effect of intranasal esketamine was first made by Lapidus et al, that demonstrated intranasal esketamine ability to reduce depressive symptomatology. However, some recent studies reported significant acute cardiovascular, psychotomimetic and neurological side-effects. Thus, drug formulation, delivery device, insufflation technique, and individual factors seem to contribute importantly to the tolerability and efficacy of the intranasal administration rote.

There is the need to develop novel treatments providing effective, more rapid-acting, and sustained relief of depressive symptoms, especially in patients with TRD. Intranasal esketamine has shown antidepressant effects in patients with TRD but further investigation is required to strongly reinforce this potential and safety.

Benzodiazepines (BZD) are psychotropic drugs prescribed in psychiatry for their anxiolytic, hypnotic and sedative properties. Several guidelines aimed to limit the chronic use of BZDs. However, BZDs prescribing that does not comply with international recommendations remains widespread, estimated in France at 20% for hypnotic BZDs.

The aims of our study were to evaluate BZDs prescribing practices in the treatment of insomnia and to assess their compliance with international recommendations.

This is a cross-sectional study conducted through a Google-forms self-administered questionnaire,intended for psychiatrists and psychiatric residents, over a period of two months, from April 1 to May 31, 2019.

One hundred physicians practicing in psychiatry answered our questionnaire. The response rate was 28%. Four BZDs are recommended for the treatment of insomnia, none of which is available in Tunisia. Almost the third of the participants did not systematically look for signs of sleep apnea syndrome before treating an insomnia (30.5%). For treating insomnia, the majority of the participants began by indicating hygieno-dietetic rules (64%), 4% prescribed directly a BZD. Cognitive behavioral therapy was not indicated at all by the particiants. The maximum duration of prescribing BZDs in insomnia was 4 weeks in 20% of cases, and more than 4 weeks in 38% of cases. Among the participants, 41% prescribed BZDs for the treatment of chronic insomnia.

Insomnia appear to be badly managed and early drug prescribing is frequent. These practices do not comply with the recommendations of good practice and increase the risk of dependance and other side effects.

Clozapine is a second-generation antipsychotic agent approved for treatment-resistant schizophrenia and risk reduction of recurrent suicidal behavior in schizophrenia and schizoaffective disorder. Given the known negative consequences of relapse of severe mental disorders for both mother and infant, the maintenance of clozapine during pregnancy is recommended.1 Studies of pregnancy regarding to clozapine have demonstrated a heterogenous range of neonatal and infant complications.2

To evaluate neonatal and infants outcomes of clozapine exposure in pregnancy.

We report three cases of infants exposed to clozapine politherapy throughout pregnancy. The dose range for all women on clozapine was 200-600 mg/day. Infants were evaluated between 4-6 months of chronological age with the Bayley-III infant development scale (BSID-III)3 and with the Alarme Détresse Bébé Scale (ADBB)4 for the detection of early-signs of withdrawal.

Women remained stable during pregnancy but presented obesity and gestational diabetes. Clozapine Newborn were born to term by caesarean section due to breech presentation (N=2) or instrumental delivery due to loss of fetal well-being (N=1). They presented normal weight (3500-3800 gr). Two presented Apgarmin1-5 9/10 and one Apgarmin1-5 6/8 which showed lethargy and low alertness during the first weeks of life. All showed normal capacity for sociability, reciprocity and development of language and communication. However, one baby had scores in the low normal zone for cognition and another for motor skills.

The infant’s risks of clozapine exposure during pregnancy should be discussed with women and weighed against those associated with other treatments and/or with untreated severe mental illness.

Placebo research investigated the underlying mechanisms of placebo effects, but they are rarely used to optimize treatments. Ethical and legal concerns have been raised, but research demonstrated that placebo mechanisms can be used without patients’ deception: Experimental studies showed that half of drugs in treatment of attention-deficit/hyperactivity disorder (ADHD) combined with open-label placebos could be as effective as standard medication to reduce ADHD symptoms.

To estimate the health economic advantages of harnessing the combination of open-label placebos with standard medication in ADHD.

For preliminary estimation of the mean treatment costs, the 12-months prevalence of ADHD in children and adolescents aged 5 to 14 years as well as the percentage of medication treatments were extracted from the literature. Mean treatment costs per patient and year were calculated for four treatment plans (different drugs and dosages) with both treatment with standard medication and half of drugs in combination with placebos.

A 12-months prevalence of 4.3% equals around 260,000 children and adolescents with a compulsory health insurance in Germany. Of those, around 40-50% are equally treated with two standard drugs and two different dosages. Full standard drug treatments cost around 119 million EUR, and treatment with half of drugs in combination with placebos cost around 66 million EUR.

The combination of open-label placebos with half of standard medication could considerably reduce health costs. Reduction of side effects still must be considered. However, current studies are of experimental nature and lasted for no longer than two weeks.

Low white blood cell counts and agranulocytosis are a relatively rare side effect of atypical antipsychotic treatment. Like most atypical antipsychotics, quetiapine only has a 1%-4% risk of low blood cell count. The mechanism by which quetiapine causes these adverse effects is still unclear, some authors have proposed that this drug acts directly as a cytotoxic agent on immune cells and produces cell death, or the products of these drug could induce apoptosis by oxidative stress. Other authors have suggested a bone marrow depression, which could be produced by an inhibitory effect on leukopoiesis.

Presentation of a case of a bycitopenia after initiation of Quetiapine Prolong treatment to bipolar disorder and a literature review.

We carried out a literature review in Pubmed electing those articles focused on cases of patients being treated with quetiapine and cytopenia as a side effect.

A 43-year-old woman with type I bipolar disorder is being treated with quetiapine prolong (50mg). After 6 years bicytopenia (anemia + leukopenia) was discovered in a routine analysis. In the Haematology Unit, long-term treatment with Quetiapine Prolong was found to be the cause of bicytopenia, having ruled out other ethological causes. This drug was suspended and switched to Aripiprazol. Eventually, the remission of symptoms and normalization of analytical parameters were achieved.

In this case highlights the importance of understanding antipsychotic medications and their effects on the haematological system. Quetiapine Prolong produced bycitpoenia (anemia and thrombocytopenia), especially in long treatments. Therefore, clinical practitioners should be aware of this adverse effect.

For almost three decades, botulinum toxin type A (BT-A) has been used for medical purposes. Evidence of the potential use of BT-A is emerging for psychiatric disorders, like unipolar and bipolar depression, borderline personality disorder (BPD), late dyskinesia, amongst others. This may represent a new role of BT-A treatment and could expand the therapeutic arsenal in psychiatry.

The goal is to review current evidence regarding BT-A and psychiatry disorders.

Literature review of BT-A use in psychiatric conditions using Medline database.

There’s evidence supporting the use of BT-A in resistant unipolar depression, with studies showing an 8 and 4 times higher response and remission rates comparing with placebo. Beneficial effects were also found in bipolar depression. Preliminary data suggest that BT-A therapy may also be effective in the treatment of mental disorders characterized by an excess of negative emotions, such as BPD. The underlying mechanism might be the “facial feedback hypothesis”. Hyperhidrosis is a common comorbidity in social anxiety disorder and may itself give rise to depressive or anxiety symptoms. BT-A has proved to be a safe and effective treatment for hyperhidrosis. BT-A can also be safely used for dystonia secondary to the use of psychiatric medication, when there’s an inadequate response to anticholinergic medication. Also, BT-A injections in the salivary glands have been investigated for treating clozapine-induced sialorrhea and studies reported successful reduction in hypersalivation.

Although more studies are needed to evaluate the potential of BT-A in psychiatry, there is growing evidence of its potential use for some psychiatric conditions.

Haloperidol is a high-potency first generation antipsychotic and one of the most frequently used antipsychotic medications. It is a potent central antagonist of type 2 dopamine receptors, with low alpha 1 adrenergic activity and has no antihistamine or anti-cholinergic activity. It is a widely used drug with proven efficacy. Angioedema is a very rare side effect, occurring in <1% of cases.

Case report and reflection on its etiology

A Pubmed search was performed with the MeSH terms “haloperidol” and “Anaphylactic reactions”. Relevant articles obtained from the respective bibliographic references were also consulted.

The following case describes the development of angioedema in a patient with an acute confusional syndrome on the second haloperidol IM administration for symptomatic control of agitation. Angioedema has been reported as an adverse effect of various antipsychotics such as clozapine, risperidone, ziprazidone and chlorpromazine, however, resulting from haloperidol administration is rare.

In long-term formulations sensitization testing is especially important but a single prior administration is not sufficient, a second controlled administration is essential to avoid this kind of fatal reactions.

There is an increased rate of sudden cardiac death in mental health patients. Studies provide consistent evidence that prolonged QT interval is associated with higher risk of all-cause and cardiovascular mortality.

This study aimed to assess the prevalence of prolonged QTc interval (corrected QT>450 milliseconds) and to determine the possible factors in hospitalized psychiatric patients.

We reviewed records of all mental health inpatient admissions to the psychiatry “C” department at Hedi Chaker university hospital in Sfax, between 1 february and 30 april 2019. Electrocardiogram (ECG) availability was noted and QTc interval was manually measured. Sociodemographic, clinical, biological and therapeutic data were collected.

Of 68 mental health inpatient admissions, 59 (86.6 %) presentations had an ECG. A total of seven (11.8 %) had a prolonged QTc interval. These seven patients were treated with typical antipsychotics. Of the 7 patients with a prolonged QTc, 4 patients (57.1%) suffered from schizophrenia. QTc prolongation was significantly correlated with the presence of a recent physical trauma (p = 0.021), dietary restriction (p = 0.026), and taking at least two antipsychotics (p = 0.008). Moreover, this prolongation of QTc was linked to a longer duration of disease and an older age, without significant associations.

Our study supports an association between a prolonged QTc interval and clinical situations at risk and antipsychotic polypharmacy. However, a larger study with routine ECG screening is required to better assess the significance of this problem.

Oxcarbazepine (OXC) is an antiepileptic drug widely used in the treatment of bipolar disorder (BD), specially when there are side effects with other mood stabilizers. Nevertheless, it isn’t innocuous of adverse effects and its consequences can even endanger the patient’s life.

Brief review of the literature on OXC-induced hyponatremia and exposure of a case report.

Review of the literature through research in the PubMed database, using the following keywords: “oxcarbazepine”, “hyponatremia” and “adverse effects”.

Although most of the patients are asymptomatic, hyponatremia is one of the most important side effects of OXC. About 29.9% of the patients develop hyponatremia, but only 2.5-3% of psychiatric patients develop severe hyponatremia. The risk of hyponatremia is higher during the first three months of treatment. Severe and/or symptomatic hyponatremia has important clinical implications and may be associated with neurological damage, including seizures, brain stem herniation and death. A 44-year-old woman diagnosed with BD started OXC due to drug intoxications with other mood stabilizers. Six days after initiating treatment, she presented persistent vomiting and severe hyponatremia was detected in blood tests. OXC was suspended with symptomatic resolution.

Healthcare professionals should be alert to symptoms that may arise in patients under OXC. Periodic evaluations of serum sodium levels should be carried out. Cases of severe and/or symptomatic hyponatremia should be rapidly identified and treated in order to reduce the risk of developing brain injury and death.

Akathisia is a relatively common adverse effect of antipsychotics although some second-generation antipsychotics are known to have a lower liability for the condition. The core feature of akathisia is mental unease characterized by a sense of agitation, usually accompanied by motor restlessness, which can cause patients to pace up and down and be unable to stay seated for more than a short time. An association between this discomfiting subjective experience and suicidal ideation has been postulated but remains uncertain.

Our aim is to perform a non-systematic review of the literature regarding the current understanding of antipsychotic-induced akathisia and its management.

A semi-structured review was conducted on Pubmed concerning the relationship between akathisia and antipsychotics.

All antipsychotics drugs can cause akathisia. The management of antipsychotic-induced akathisia should include a dose reduction of the antipsychotic treatment or a switch to quetiapine or olanzapine. If ineffective, a trial with propranolol may be useful as well as the addition of a 5-HT2A antagonist like mirtazapine or mianserine. At last the inclusion of a benzodiazepine may be helpful albeit the risk of dependence and anticholinergics mainly when other extrapyramidal symptoms are present.

High‐dose antipsychotic medication, antipsychotic polypharmacy and rapid increase in antipsychotic dosage should be avoided to prevent akathisia. There is limited evidence for any pharmacological treatment for akathisia such as switching to an antipsychotic medication with a lower liability for the condition, or adding a beta‐adrenergic blocker, a 5‐HT2A antagonist or an anticholinergic agent although some patients may benefit from such interventions.

Quincke-edema has been specifically associated with using certain drugs including chlorpromazine as detailed through two clinical cases.

Illustration of two clinical cases about angioedema induced by Chlorpromazine.

We reviewed clinical data from two patients who committed a suicide attempt and then transferred to the psychiatry department after their somatic stabilization: the first was 27-year-old followed in psychiatry since childhood for intellectual deficiency and admitted to the emergency department for the suicide attempt by taking 14 tablets of chlorpromazine 100 mg and the second was a 20-year-old patient, admitted to the emergency department for suicide attempt by Raticid.

The first patient presented a delusional persecution-themed syndrome with auditory hallucinations. Therefore, he was initially put on injectable treatment with Haloperidol 15mg and Diazepam 30mg then oral relay after 48h by Risperidone 4 mg and Chlorpromazine 200 mg. On the fourthday of his hospitalization, he presented a Quincke edema without laryngeal impairment. We stopped chlorpromazine and eliminated the other causes of this edema, resulting in a gradual regression of symptomatology. The second patient was put on chlorpromazine. On the second day, the patient presented a Quincke edema without laryngeal impairment. Somatic examination and biological exploration did not reveal any abnormalities. We stopped chlorpromazine and put the patient on Dexamethasone 3 days in a row resulting in a good outcome.

These two cases identified a Quincke-edema reaction associated with the use of Chlorpromazine, this complication can lead to life-threatening manifestations and warrants greater awareness of the potential for recurrence.

Due to its mood-stabilizing properties, clozapine is known for reducing symptom severity in manic episodes of treatment-resistant bipolar disorder as well as in treatment-resistant schizophrenia. However, its use may be hindered by potential adverse effects, including hematologic ones, such as non-dose-dependent eosinophilia. The mechanism of the underlying process probably involves a type-I hypersensitivity reaction, which can manifest as either transient asymptomatic eosinophilia or as eosinophilia with multiorgan dysfunction.

We present the case of a patient diagnosed with manic episode of schizoaffective disorder who developed eosinophilia, with severe systemic manifestations, in response to clozapine therapy. A review of literature will be conducted in order to provide further insight into the phenomenon.

Case report and literature review.

The incidence of eosinophilia reported in literature ranges between 0.2% and 62%, with its appearance about three weeks after clozapine initiation. Although clozapine is an antipsychotic that normally requires frequent monitoring due to the potential side effect of agranulocytosis, we would like to place emphasis on the possible risk of eosinophilia, in connection with potential fatal complications. As described in this report, eosinophilia could long remain unrecognized due to subsequent multiorgan involvement, including lymphadenopathy, leukocytosis, lymphopenia, anemia, liver enzyme elevations, as well as pleural effusion, all of which were described in our patient.

Clozapine-associated eosinophilia may be used as an early marker of possible clozapine-induced systemic complications and it may warrant prompt discontinuation of the causing drug, as suggested by the literature.

Psychedelics - including LSD (lysergic acid diethylamide), psilocybin, DMT (N, N-dimethyltryptamine), ayahuasca and mescaline - have an ancient history across various civilizations. In 1950, after LSD’s discovery by Hofmann, psychedelics enjoyed a short-lived relationship with psychiatry, before prohibitive legislature emerging in response to the recreational use in the mid-1960s. However, the last decade has witnessed a renewed scientific interest in psychedelics - a phenomenon referred to as the ‘Psychedelic Renaissance’.

Review the pharmacology of psychedelic drugs and the latest evidence of its therapeutic potentials in anxiety, mood and addictive disorders.

Literature review performed on PubMed and Google Scholar databases, using the keywords “psychedelics”, “hallucinogens”, “d-lysergic acid diethylamide (LSD)”, “psilocybin”, “ayahuasca”, “mescaline”, “DMT (N,N-dimethyltryptamine)”.

The psychedelics or “classic hallucinogens” can be subdivided into three sub-classes: the plant-derived tryptamines (psilocybin and ibogaine) and phenethylamines (mescaline), and the semisynthetic ergolines (LSD). The therapeutic potentials are mediated by an agonist action on 5-HT2A receptors expressed in frontal and paralimbic structures involved in mood and emotion regulation, introspection, interoception and self-consciousness. Stimulation of 5-HT2ARincreases the glutamatergic tone and neuroplasticity and is accompanied by reduced amygdala activity, reducing anxiety. Experimental, open-label, and RCTs showed anxiolytic, antidepressive, and antiaddictive effects with psychedelics. As examples, psilocybin and LSD reduced anxiety and depression in cancer patients and symptoms of alcohol and tobacco dependence, and ayahuasca reduced depression in treatment-resistant depression.

Despite the promising effects of psychedelics on anxiety, depression and addiction, the evidence is still preliminary, waiting for long-term studies with bigger samples.

No significant relationships.

Lithium is widely used for the treatment of bipolar disorder. Owing to its narrow therapeutic index and side-effect profile, regular monitoring is recommended by all major guidelines on lithium use.

The aim of this study was to determine whether routine lithium monitoring practice at the local mental hospital in Malta reaches the standard set by the most recent NICE guidelines (NICE, 2014a).

All patients on lithium maintenance treatment for bipolar disorder at the local Mental Hospital were included. Blood tests within the last one year were collected using iSOFT clinical manager (iCM). After the first audit cycle, a lithium monitoring sheet was created in accordance with the NICE guideline and after 6 months of implementation, the second audit cycle was conducuted.

In the first cycle, 28 patients met the NICE criteria for increased risk of toxicity and have a recommended testing frequency for lithium levels of every 3 months. However, only 1 patient was observed to meet this criteria. When assessing the last lithium level only 35.7% were within 0.4-0.8 mmol/L. In the second audit cycle, 28 patients met the NICE criteria for increased risk of toxicity and have a recommended testing frequency for lithium levels of every 3 months. Almost half of the patients (12 patients, 42%) were to observed to meet this criteria. When assessing the last lithium level, 50% were within 0.4-0.8 mmol/L

After the introduction of the lithium monitoring sheet, monitoring improved substantially especially in high risk patients. Moreover, the majority of test results for lithium levels were within the therapeutic range.

Benzodiazepines (BZDs) are psychotropic drugs that are predominantly prescribed in psychiatry and that can have serious side effects. BZDs prescribing is well codified by several guidelines, yet the epidemiological data on their prescribing remains alarming.

Our study aimed to evaluate the general modalities of BZDs prescribing in psychiatry in Tunisia.

This is a descriptive cross-sectional study conducted through a Google-forms self-administered questionnaire, intended for psychiatrists and psychiatric residents, over a period of two months, from April 1 to May 31, 2019.

One hundred physicians practicing in psychiatry answered our questionnaire. The response rate was 28%. The purpose of treatment with BZDs was explained to the patient at its initiation in 98.2% of cases and the risks associated with it in 87.7% of cases. Special precautions were taken in elderly patients (96.5%), at risk of respiratory failure (94.7%), and in cases of personality disorders (80.7%). Only three quarters of physicians took precautions before prescribing BZDs to a pregnant woman (77.9%). In cases of rebellious or refractory symptoms, 14.4% of the participants stated that they combine two BZDs. Before reproducing/repeating a BZD prescription, 18.4% of the participants indicated that they did not systematically and regularly assess its necessity.

The severity of the side effects associated with BZDs, especially those of tolerance and dependence, are at the origin of strict prescribing rules, dictated by several guidelines. According to the results of our study and to the literature data, the prescribing practices of these molecules remain nonetheless in many cases non-compliant with the recommendations.

The use of selectiveserotonin reuptake inhibitors (SSRIs) is an independent risk factor for bleeding events. Antidepressants and oral anticoagulants (OACs) are often prescribed together as depression and anxiety often coexist with cardiovascular diseases, atrial fibrillation and thromboembolic disorders. Serotonin is released from platelets in response to vascular injury, promoting aggregation. Inhibition of serotonin transporter (responsible for the uptake of serotonin into platelets) can lead into a reduced ability to form clots and a subsequent increase in the risk of bleeding. Direct oral aticoagulants (DOACs), rivaroxaban, apixaban and edoxaban are primarily metabolized via CYP3A4. The co-administration of antidepressants with inhibitory effects on CYP3A4 may theoretically interact with them.

Presentation of a case of upper gastrointestinal bleeding after initiation of Apixaban in a patient taking Sertraline and literature review.

We carried out a literature review in Pubmed electing those articles focused on bleeding risk between newer direct oral antigulants and selective serotinin reuptake inhibitors.

A 66-year-old woman sought medical assistance for generalized ecchymosis and melena. She was diagnosed with atrial fibrillation treated with apixaban 7 days ago. Concomitant treatment between apixaban and sertraline was the possible cause of upper gastrointestinal bleeding and ecchymosis. We had to switch sertraline into vortioxetine (with less dregree of serotonin reuptake inhibition) and add proton-pump inhibitor (Omeprazole) in order to decrease the risk of bleeding.

SSRIs increase the risk of gastrointestinal bleeding, much more in case of concomitant use of oral anticoagulants. If SSRI use cannot be avoided, monitor closely and prescribe proton pump inhibitors.