Introduction

Corticosteroids are commonly used for several conditions. Among their various adverse effects, psychiatric conditions have been described. We present a 53-year-old woman on treatment with 60 mg prednisone for eosinophilic pneumonia, who enters to the emergency room. Interviewing the patient and her family, they describe a clinical picture, in the last 4 days, of euphoria, insomnia, irritability, increase of activity, restless and transient verbalization of delusional ideas. The patient has no psychiatric personal history, although a significant family history of depression, mania and psychosis. Olanzapine 7,5 mg was added and the symptoms disappeared gradually in 3 weeks.

Objectives

To review the epidemiology and clinical features of the corticoid induced mania, as well as its clinical management in the emergencies room.

Methods

Review of the literature on manic episodes induced by corticosteroids applying the information to this case.

Results

Among patients receiving doses greater than 40 mg prednisone, 20% will suffer psychiatric disorders severe enough to require medication. Manic symptoms are the most common manifestation of these disorders and account for about 40% of them. The onset of these symptoms is commonly after 10 days of sustained corticosteroid treatment. Reducing doses or cessation, if possible, should be the first line for treatment. Antipsychotic treatment, such as olanzapine or quetiapine is supported by literature.

Conclusions

-Corticosteroid induced mania is the most common severe neuropsychiatric disorder caused by corticosteroids.

-Doses greater than 40mg of prednisone and longer than 10 days increase the risk.

-Cessation of corticosteroids and antipsychotics are effective treatments.

Introduction

Even though that the etiopathogenic hypothesis that associates cerebral changes produced by the Moons gravity and mental disorders has been disproved, when the night shift has been thought it is often heard “It surely was full moon!”.

Objectives

To study de association of full moon and number of Psychiatric Emergency Care visits

Methods

We obtain the daily number of Psychiatric Emergency Care visits from September 2018 to July 2019 and compared the median of full moon days and not-full moon days using the Wilcoxon rank-sum test.

Results

The median of the number of Psychiatric Emergency Care visits of full moon days was 7 (95%CI 2.65- 9.35) and without full moon was 7 (95%CI 6.75-7.25). The difference between both medians was not statistically significant (WRS p 0.51).

Conclusions

There are not more Psychiatric Emergency Care visits in full moon days.

Introduction

Involuntary admissions (IA) affect the patients’ autonomy and take place in order to prevent them to harm themselves or other people. The incidence of compulsory assessment (CA) seems to increase worldwide.

Objectives

To investigate the epidemiological patterns of patients hospitalized involuntary after CA, during the economic crisis in North-West Greece.

Methods

During 2009-2017, CA and IA were retrospectively assessed from the records of patients admitted to the Psychiatry Department at the University Hospital of Ioannina. Socio-demographic characteristics and data regarding legal procedures were collected.

Results

A total of 602 CA were identified, 50% of them (every second year) were evaluated, 284 (85.5%) leaded to IA. The majority were men (67.5%), mean age 49 years, unmarried (70.2%), living with parents or siblings (74.8%), not working (64.8%), without tertiary education (70.2%), with residence in Ioannina (51.5%). First diagnosis was performed by a public hospital psychiatrist (88.6%), average length of stay was 24 days and most of them had been hospitalized in the past (64.2%). In 2009 there were 47 IA, whereas in 2017 there were 83. During 2009, the Female-to-Male ratio for IA was 1 to 2.4, whereas in 2017 we observed 1 to 1.3, respectively. The main reason for IA was schizophrenia (56%) and to a lesser extent mood disorder (19.6%).

Conclusions

The economic crisis seems to affect IA. Between 2009 and 2017 there was an increase in IA and an increase in women IA.

Introduction

According to DSM-V, agitation is defined as “excessive motor activity associated with a feeling of inner tension.The activity is usually non-productive and repetitious and consists of behaviors such as pacing, fidgeting, wringing of the hands, pulling of clothes, and inability to sit still”. It is a frequent phenomenon, both in medical and psychiatric emergency. Up to 10% of all emergency psychiatric interventions are related to psychomotor agitation.Towards the diversity of underlying causes for psychomotor agitation and the different degrees of severity, choosing the best approach is challenging.

Objectives

We aim to present a summary of the best practices for the management of agitation in the emergency department.

Methods

Selective literature review based on articles obtained via PubMed search, using terms as “psychomotor agitation”, “agitation”, “behavioral agitation” and guidelines on the treatment of agitation in various psychiatric disorders.

Results

There is a general agreement in considering verbal de-escalation and environmental modification strategies first and physical restraint as a last resort strategy. Respecting pharmacological treatment, the aim is to calm without over sedate. There is a wide variation between countries, generally including first and second-generation antipsychotics and benzodiazepines. Oral or inhaled formulations should be preferred over IM routes in mildly agitated patients. The management on the acute fase has consequences in the long-term treatment, making it important to have local protocols.

Conclusions

The management of psychomotor agitation involves non-pharmacological and/or pharmacological strategies with wide variability of available drugs. An oriented approach according to the best evidence allows to provide the best care to the agitated patient.

Introduction

It is occasionally assumed that poor individuals in urban areas visiting the ER tend to exaggerate psychiatric symptoms for secondary gains such a warm bed and a meal. This may cause unnecessary hospitalization or, on the contrary, denial of justifiable hospitalization. In the US, economically deprived psychiatric patients receive Supplemental Security Income(SSI). Running out of money could be an incentive to visit the ER.

Objectives

Investigate the hypothesis that patients receiving SSI present to the ER towards the end of the stipend cycle when supposedly are out of funds.

Methods

Medical records of all psychiatric patients seen in the ER of a general hospital in Philadelphia during 2018 were reviewed. The relationship between the number of days between SSI payments and time of presentation to the ER was examined. Homelessness status and the presence of a positive drug screen were also examined.

Results

274/1007 of the psychiatric patients seen in the ER in 2018 received SSI. No relationship between ER visit time and days since last SSI payment was found. Also, the interval between receiving SSI payments and presenting to the ER had no relationship to homelessness status(p=0.9271) or the presence of a positive drug screen(p=0.0752)

Conclusions

There was no pattern of increased visits at the end of the payment cycle to suggest that exhausted SSI funds played a role, either as a psychosocial stressor or as a motivation for secondary gain. Despite the limitations of this study, this data suggest that secondary gains do not influence the timing of visiting the psychiatric ER.

Introduction

Etiological diagnosis of acute hepatic failure in elderly population is a challenge for the medical practitioner, due to the multiple intercurrent factors, especially in multipathological and polymedicated patients. Among the psychiatric drugs used in the elderlies it is not rare to find antipsychotics used off label. For instance, quetiapine is one of the atypical antipsychotics more often employed to manage behavioural disturbance of pacients whith dementia diagnosis. Liver safety linked to atypical antipsychotics has been the focus of study in last decades, because of their hepatic metabolism and high metabolic risk associated. Nevertheless, it is an heterogenous group of drugs that has to be analysed one by one

Objectives

Get to know the risk of liver injury associated to quetiapine

Methods

It is presented a clinical case of a 77-year-old-woman who was prescribed high doses of quetiapine for behavioural managing and suffered an acute hepatic failure. We'll discuss the differential diagnosis and review the literature about liver damage risk linked to quetiapine.

Results

Two diagnosis were mainly suspected: bacterial and toxic origin of acute liver failure. Quetiapine was stopped to observe the evolution after a wash-out period.

Conclusions

Among quetiapine side effects we can found: somnolence, dizziness, headache, postural hypotension and wight gain. Up to 27 % of patients develop an elevation of transaminases during first month of therapy, but mainly asyntomatic. Acute hepatic failure is a rare phenomenon, but reported.

Introduction

Psychiatric patients may experience aggression when patients lose control of their behavior.It is precisely such aggression that is associated with patient non-cooperation in the treatment process and undergoes restraint measures.An emergency psychiatric unit is the place where it is performed triage and first diagnostic assessments and therapeutic decisions.The course of the review and interview should be targeted in the manner to get key information on which to decide further action. The key is to work on the principles of good clinical practices aimed at maintaining patient safety,employee safety and mutual preservation of dignity.

Objectives

The objective is to show the treatment of aggressive and non-cooperative patients in the acute care psychiatrc unit in University hospital Rijeka during 2017and2018.

Methods

Statistically was processed data from records of restraint and separation measures performed on patients admitted to the Acute psychiatric ward.

Results

From January 2017 to January 2018.1963 patients were admitted to the to the psychiatric ward through the emergency unit.640 patients were restrained by Standard operating procedure for separation and restriction of patients(I-V)

Conclusions

Complete ban on restriction and separation of psychiatric patients has never been implemented,despite the fact that some of these measures
sometimes are controversial and sometimes with fatal side effects Steinert et al.(2009).Consider that the complete abolition of these measures is not possible.

Restriction and separation of patients are exceptionally allowed in cases of current dangers for the patient himself or for others in the environment.It is conducted only on non-cooperative patients and when we cannot reach our goal through cooperative communication.

Introduction

Multiple sclerosis is an inflammatory disease that affects the central nervous system. The onset of MS with isolated psychotic symptoms is rare and cases which first develop psychotic signs without neurological deficits and triggering stressors are limited.

Objectives

Describe the onset of MS with isolated psychotic symptoms in pregnant woman.

Methods

Retrospective study of a woman with first-episode psychosis developped 15 days after that she gave born to a child and was finally diagnosed as MS.

Results

We report a case of MS with first-episode psychosis in a 35-year-old women with no history of psychiatric disorder.The patient developed psychiatric symptoms after 15 days that she gave born to a child and was finally diagnosed as a case of MS.Her symptoms started with delusional ideas, behavioral dysfunction, auditory and visual hallucinations associated to visual blur and diplopia.The patient was treated with neuroleptics and no improvements were observeed.Neurological examination was normal.T2-weighted magnetic resonance imaging has demonstrated periventricular and white matter MS plugs with lesions of the spinal cord and activity signs.Isoelectric focusing revealed oligoclonal band in the CSF.The diagnosis ofMS was retained according to the criteria of MacDonald2017.She was treated with methylprednisolone,interferon and antipsychotic which resulted in improvements in the clinical conditions.

Conclusions

Psychiatric diseases are frequent in MS and, among these, depression and anxiety disorders constitute the highest percentages. Psychotic disorders accompanying MS occur less frequently with rates of 2-3%.This case represents a good example of the necessity for a detailed examination of Postpartum psychosis with sudden onset, and performing a cranial MRI has particular importance.

Introduction

Physical restraint is a coercive measure used in many psychiatric emergencies. This measure is used for agitated or aggressive behaviors, since the physical integrity of the patient and other people are endangered. However, the use of coercive measures differs between countries, even between different regions.

Objectives

Describe the prevalence and characteristics of physical restraints in the psychiatric emergencies at the "Hospital 12 de Octubre", Madrid.

Methods

A descriptive study was carried out, gathering sociodemographic and clinical data of the patients who needed a physical restraint in emergencies department between April and August 2019. Patients could be physically restrained before being evaluated by a psychiatrist or could need the measurement during the first evaluation by a mental health professional.

Results

A total of 72 patients required a restraint of the 1301 (5.53%) patients seen by the mental health team of our hospital emergencies in the period of time described. Of these, 56.9% were male.

Figure 1 shows the professionals who indicated the need of physical restraint. Figure 2 shows the diagnoses of the patients who were immobilized.

Figure 1. Professionals who prescribes a physical restraint in patients who have been assessed by psychiatry in the emergency department.

Figure 2. Diagnoses of the patients who needed a physical restraint.

Conclusions

An important percentage of patients treated in the psychiatric emergencies are physically restrainted. The majority are unspecified psicosis (n=23). Therefore an intervention protocol seems to be necessary.

Introduction

The nature of some mental illness is such that persons affected by their conduct endangering life, health and safety, as well as life, health and safety of others from their surroundings. These persons, because of their mental condition, are often unable to properly assess their own interest. Because of the above it is permitted for these persons, under certain circumstances, to be forcibly hospitalized against their will. Therefore, there is a judicial measure of involuntary hospitalization that serves to protect the patient and the environment and is usually applied in the emergency psychiatric departments.

Objectives

Examine the number of involuntary hospitalization on the Emergency psychiatric department in the Clinical hospital Rijeka 2015-2017 and percentage of these hospitalization in the total number of hospitalizations.

Methods

The study statistically processed data of the total number and percentage of involuntary hospitalizations compared to the total number of all hospitalizations in the Emergency psychiatric unit at Clinical hospital Rijeka from 2015-2017.

Results

Januray, 2015 - December, 2017 on the emergency psychiatric department in the Clinical hospital Rijeka, were involuntary hospitalized 112 patients which is 5,3% of all hospitalization on that departmenet in these years. The largest number was in 2017. when 44 patients were forced hospitalized, which was 5.4% involuntary hospitalizations of the total number of hospitalizations

Conclusions

Involuntary hospitalization is a necessary measure in psychiatric treatment that enables adequate treatment of the non-cooperative patient and provides the opportunity to establish the patient's co-operation and criticality about the need for treatment and and acceptance of their illness.

Introduction

Use of cannabis is a growing problem internationally and its relation inducing psychosis is also a growing public health concern. It leads to significant impairment, including emotional distress, difficulty communicating, and other debilitating symptoms

Objectives

In this case report, we discuss a patient with no previous history of psychotic symptoms, presenting with first-episode psychosis in the context of progressive, acutely worsening, psychotic thoughts and behaviors following prolonged use of cannabis.

Methods

26-year-old patient, male with no past psychiatric history or hospitalizations, who was admitted in psychiatric emergencies of local hospital with a first-time psychotic episode in the context of cannabis consume.

This patient presented paranoid ideation, bizarre delusional thoughts, paranoid auditory hallucinations, persecution delusions with his neighbors, insomnia with 0–2 hours of sleep per night, affecting his activities of daily living..

His affect was guarded, suspicious, and perplexed with apparent slowed cognition

The patient had no known drug or environmental allergies, bloods labs were normal except urine toxicology positive for cannabinoids and normal head computerized tomography scan.

Results

During the two-week, the patient was treated with oral olanzapina 5 mg at bedtime and discontinuation of cannabis use, with significant improvement, with resolution of paranoid ideation, abnormal thought processes, and insomnia.The strong response to olanzapine as an initial treatment may indicates the use of an effective antipsychotic for cannabis-induced psychosis.

Conclusions

We should be aware of the possibility of cannabis-induced psychotic delusions, paranoia, and distorted thoughts, in order to identify and treat this condition.

Introduction

The patient is a 28 years old men without psychiatric history who is attended in the emergency room because of disorganised behaviour.

Objectives

The aim of this case is to show the neuropsychiatric effects of steroid drug and its treatment.

Methods

case report and literature review

Results

Highlights the beginning of dexamethasone 12 mg per day (equivalent to 60mg of prednisone) seven days before as pain treatment of discal hernia. He had an increased speech speed, being hard to lead the conversation. He explained that two days after taking the steroids he started with high energy sensation, sleepping less hours, and having the feeling of increase work performance, but his wife clarified that he chaotic in his activities. He realized that his family had been supplanted by actors who were following a script, making him mistrust them with self-referential phenomena thorugh the TV and strangers of the streets.

Olanzapine was started up to 20 mg per day. Initially, insomnia and the organization of discourse and its behaviors were regulated, followed by criticism of delusions, understanding that they were due to steroid medication.

Conclusions

Steroid-induced mania is a dose dependent reaction (5% in 40-80 kg of prednisone, 20% in >80mg/day) that happens at most in the first week of treatment. Mania is the most common presentation. This has a remission close to 90% after withdrawing the drug. Olanzapine has been placed as the gold standard in cases in which symptomatology persists despite withdrawal or when high functional impact is presented.

Introduction

The war in the East of Ukraine, like other emergencies, leads to impairment of mental and physical health, disruption of social adaptation, addictive and suicidal behavior in the persons involved in its orbit. The complex social and medical support to them is crucial.

Objectives

To scientifically justify, develop and test the model of the medical-psychological and neuropsychiatric maintenance system to Anti-Terrorist Operation / Joint Force Operation (ATO/JFO) combatants based on own experience on medico-social consequences of the Chornobyl catastrophe mitigation and providing medical assistance to veterans of armed conflicts.

Methods

A prospective clinical study was conducted in 2014–2019 with comprehensive examination and treatment of 148 ATO/JFO combatants. Neuropsychiatric and somatoneurological, psychodiagnostic, neurophysiological, neuroimaging, laboratory and instrumental methods were used. Treatment and rehabilitation interventions were carried out on the basis of evidence-based medicine and included pharmacological, psycho - and physiotherapy.

Results

PTSD, adaptation disorders, chronic personality changes, anxiety, depressive and somatoform disorders, alcohol and substance abuse, as well as suicidal tendencies dominate in ATO/JFO combatants. Comorbid pathologies include consequences of mine-blasting acoustic-barotraumas, traumatic brain injuries and chronic somatoneurological diseases. The effectiveness of a complex social-psychological-psychiatric and somatoneurological approach, the use of the biopsychosocial paradigm, consistency and continuity of therapeutic and rehabilitation interventions based on evidence-based medicine has been shown. It is advisable to involve NGOs and volunteers.

Conclusions

The complex psychosocial, medical, and neuropsychiatric system of providing the maintenance to ATO/JFO combatants on the base of a multidisciplinary clinic is reasonable and effective.

Introduction

A part of East Ukrainian territory involved in the Anti-Terrorist Operation / Joint Force Operation (ATO/JFO) is potential for radiation emergencies, including terroristic radiological attacks (“dirty bomb”).

Objectives

To determine the personality patterns of ATO/JFO combatants in comparison with clean-up workers of the Chornobyl catastrophe (liquidators).

Methods

The retrospective-prospective psychophysiological study included 101 ATO/JFO combatants, 122 liquidators and 85 non-exposed persons. Schmieschek–Leongard’s and Eysenck’s (EPI) personality questionnaires and quantitative electroencephalography (qEEG) with brain mapping were used.

Results

An accentuation of personality traits (pedantic, cyclothymic, dysthymic and excitable) is typical for the persons with traumatic experience. The liquidators have an increased rate of anxious and emotional accentuations, while the ATO/JFO combatants have stuck (jam) character accentuations, which can be explained by a different type of the traumatic experience. The liquidators, in comparison with the unexposed control, have increased relative and absolute spectral power of delta range of qEEG, decreased beta range mainly in the left frontotemporal region and reduced dominant frequency of qEEG. The liquidators, in comparison with ATO/JFO combatants, have increased spectral power of delta range in the left temporal region, and decreased relative spectral power of theta range. Neurophysiological correlates of personality traits were also found.

Conclusions

There are psychophysiological differences in the personality pattern of ATO/JFO combatants in comparison with clean-up workers of the Chornobyl catastrophe. The specificity of the psychological trauma at different emergencies should be taking into account in preventive and treatment interventions.

Introduction

In October 2017 Portugal was affected by a major wildfire that struck the central region of the country, resulting in 49 deaths, about 70 injured and an impressive number of material losses, with more than 1500 homes completely or partially destroyed. Although the occurrence of wildfires is a relatively frequent situation in Portugal during the warmer months, the lack of intervention strategies is clear and there is little interest, particularly in the field of mental health, in the immediate approach and consequent minimization of long-term risks of such traumatic experiences. Even though a significant number of exposed individuals fully recover without any intervention, others, with greater vulnerability, will develop different posttraumatic psychiatric disorders.

Objectives

To present an emergency disaster assistance program developed in the district of Guarda (Portugal) in the context of the wildfires of October 2017 and that resulted in the creation of a crisis consultation. The authors also discuss the results obtained and the relevance of the replication of the created model in similar catastrophic situations.

Methods

The created program is the result of the cooperation between the Department of Psychiatry and Mental Health of Hospital of Guarda and local structures, allowing an appropriate response to the mental health needs of the population in that specific scenario.

Results

The presented program has provided direct support to 59 victims and an early screening of those who still require psychiatric care.

Conclusions

The nature of traumatic psychological experiences, concomitant disturbances and associated risks should be the target of a multidisciplinary and multifactorial work.

Introduction

A 47-year-old woman requires urgent transfer to the hospital due to a low level of consciousness. When she arrives, flumazenil is given with good response, the toxins are positive for benzodiazepines, however, the patient denies having performed a medication overdose and comments on taking lorazepam to sleep. It was not possible to reduce the infusion of flumazenil due to persistence of symptoms, we found a severe alteration of liver transaminases and an increase in alkaline phosphatase; given the diagnostic suspicion of hepatic encephalopathy, treatment with lactulose is initiated with a good response.

Objectives

The case of a woman with hepatic encephalopathy and response to flumazenil is described.

Methods

We made a literature review.

Results

Exposed in conclusions.

Conclusions

Hepatic encephalopathy is a neuropsychiatric condition that can begin as drowsiness and alteration of the normal sleep pattern, with a progressive alteration of consciousness and generalized motor dysfunction. Ammonium is the main substance involved in the pathophysiology, but there are other theories that refer to GABA produced at the intestinal tract can act as a neuroinhibitor, relating to the identification of endogenous benzodiazepines (Idrovo, 2003), or modulators of the non-benzodiazepine GABA-A complex (Ahboucha, 2005).

Numerous studies have proposed the effectiveness of flumazenil as a treatment of hepatic encephalopathy, however we must be cautious: in a systemic review published in the Cochrane Database (Goh, 2017) there is low quality evidence suggesting a short-term beneficial effect of flumazenil on hepatic encephalopathy in people with cirrhosis, but no evidence of an effect on all-cause mortality, recommending long-term studies.