The present paper aimed to explore the neuropsychiatric characteristics of the antiterrorism (ATO) combatants in the Donets Basin (Donbass) and to propose therapeutic strategies for managing their mental healthcare.

A total of 54 ATO combatants were included in our study and compared with four groups of subjects exposed to other emergencies, including the Chernobyl disaster and the war in Afghanistan. The neuropsychiatric features were assessed through psychopathological assessments, neurological examinations, and quantitative electroencephalography (qEEG).

The ATO combatants were characterized by low health self-estimation, somatic concerns, a high prevalence of posttraumatic stress disorder, anxiety, insomnia, depression, social dysfunction, mild cognitive impairment, and neurological soft signs, similar to individuals involved in the Chernobyl disaster and veterans of the Afghan War. Quantitative EEG showed abnormalities suggestive of irritation of the corticolimbic system and diencephalic structures. Some post-conflict personality changes in ATO combatants were recorded. The treatment of ATO combatants included a comprehensive strategy: from psychotropic drugs to different psychotherapies.

On the basis of 30 years of experience in the management of the consequences of Chernobyl disaster and the available studies on war veterans, the authors proposed a method for assessment and an approach to providing mental healthcare for ATO combatants, refugees, and migrants from the Donbass, which perhaps can be used as guidelines for other conflicts. Taken together, the findings of the study suggest that voluntary participation in war may decrease but does not eliminate the risk of developing the neuropsychiatric consequences caused by such conflicts. A comprehensive strategy—one that would encompass psychopharmacological, psychological, and rehabilitation techniques—seems to be the most successful approach to managing the main symptoms and disorders involved.

Hyperammonemia and carnitine deficiency with concomitant encephalopathy have been reported to result from valproic acid administration (Coulter DL, J Child Neurol 1991Jan; 6(1); 7-14 and Mock, CM, et al, Am J Health Syst Pharm, 2012 Jan; 69(1):35-9). Although there have been numerous publications regarding this adverse event in the neurology literature, there have been very few reports published in the psychiatric literature. The reported incidence of hyperammonemia in children treated with valproate is 19%. It is important that prescribers be aware of the risk of valproic acid induced hyperammonemic encephalopathy, as well as its diagnosis and management.

The current study explores the feasibility of reversing Valproate Induced Hyperammonemic Encephalopathy (VHE) by discontinuing valproic acid and normalizing the carnitine level via L-carnitine supplementation.

Three males (ages 10-16 years), are reported with 12 - 24 month histories of cognitive decline during treatment for “Bipolar Disorder of Childhood” with valproate. All were referred with multi-year histories of explosive/impulsive aggression and multiple unsuccessful psychopharmacological regimes. The one consistent medication throughout treatment was sodium valproate. The subjects received serial neuropsychological testing, complex EEG, MRI, valproic acid, carnitine, and ammonia blood levels. Oxcarbazepine titrated to 30-50 mg/kg/day was substituted for valproate after initial testing was completed. Normative reference laboratory levels were as follows: (1) ammonia (reference interval 15-45 mcg/dl), (2) total carnitine (reference interval 34-77 nmol/ml), and (3) valproic acid (reference interval 50-125 mcg/ml).

Case Study 1: Male, 10 years old, ammonia 78 mcg/dl; carnitine 17 nmol/ml; valproic acid 92 mcg/ml. IQ 79 (compared to 105 one year earlier); MRI cerebral atrophy; EEG - left temporal aberrancies.

Case Study 2: Male, 12 years old, ammonia 76 mcg/dL; carnitine 14 nmol/ml; valproic acid 104 mcg/ml. IQ 89 (compared to 109); MRI normal; EEG - left temporal aberrancies.

Case Study 3: Male, 16 years old, ammonia 72 mcg/dl; carnitine 24 nmol/ml; valproic acid 125 mcg/ml. IQ 45 (compared to 65); MRI normal; EEG - left temporal aberrancies.

In all three subjects, after valproate was removed (oxcarbazepine substituted) and supplemental L-carnitine added, ammonia and total carnitine levels normalized. At one year follow up, IQ’s returned to previous baselines, and MRI atrophy (Case 1) normalized. EEG aberrancies were unchanged. Patients were mood and behaviorally stable on oxcarbazepine.

Evidence of cognitive decline while on valproate warrants ammonia and carnitine level testing. If these levels are abnormal, VHE should be diagnosed and valproate should be removed as rapidly as feasible; L-carnitine supplementation (the lesser of 100 mg/kg/day or 2 grams/day) should be implemented to normalize the carnitine level.

No funding.

Obesity is a rapidly growing epidemic in the United States of America resulting in a multitude of comorbid conditions. Individuals living in rural areas have a higher prevalence of obesity than in urban settings. Effective treatment of obesity is needed to decrease the morbidity and mortality of this chronic disease. Using motivational interviewing (MI) techniques to address unhealthy lifestyle habits has previously proven to be effective in aiding individuals to achieve a healthier lifestyle.

The main objective is to determine the effectiveness of brief MI used during regular office visits and with phone follow-ups on body mass index (BMI) at the initiation of the project, as well as at the 3-month follow-up. Secondary objectives are to determine the effect brief MI has on the amount of weekly physical activity, advancing the individual to the next stage on the Transtheoretical Model of Change (TTM) continuum and determining common barriers to leading a healthy lifestyle in a rural adult population.

Participants (n=15) were recruited using a convenience sampling method from the primary care practice. Using a pretest/posttest design, individuals were asked to complete a survey regarding their amount of weekly exercise, their perceived stage of change and their barriers to healthy lifestyle choices. A pre- and post-intervention BMI was collected. One in-office brief MI session and two monthly phone sessions were conducted, each lasting not longer than ten minutes.

A total of 14 participants, mostly female (67%), aged 36 to 45 years old (33%), Caucasian (73.3%), and had some college education (40%), completed the study. It was hypothesized that brief MI would result in decreased BMI, increased exercise and advancement along the TTM continuum. No significant difference in the pre-and post -intervention BMI ([M=37.88, SD=9.15] vs [M=37.01, SD=9.37]); t (27)=0.25, p=0.801 was found. Many participants (n=10), however, had a decrease in BMI. The difference in weekly activity (M=644.2 min vs M=268.57 min) was not found to be statistically significant; t (27)=1.40, p=0.17. An increase in readiness to change was noted, but, was not significant (p =0.52). Of 34 responses, chronic pain or health conditions (n=10) and scheduling conflicts (n=7) were the two top cited reasons for not practicing a healthylifestyle.

This QI project did not demonstrate statistically significant improvement in BMI, weekly exercise or readiness to change after three months of brief MI. It is important to note, however, that many individuals did experience an overall decrease in BMI. It is also promising to note that more individuals were participating in healthylifestyle activities more frequently post-intervention when analyzed on the TTM continuum. Further studies are needed to analyze the most effective strategies to assist individuals in rural settings to make healthier lifestyle choices.

No funding.

To evaluate the efficacy and safety of lurasidone in the treatment of children and adolescents with bipolar depression presenting with mixed features.

Patients 10 to 17 years of age, inclusive, with a DSM-IV-TR diagnosis of bipolar I depression, were randomized to 6 weeks of double-blind treatment with once-daily, flexible doses of lurasidone 20-80 mg or placebo. The presence of mixed features (subthreshold hypomanic symptoms) was defined as a YMRS score > 5 at study baseline. Efficacy analyses included change from baseline to week 6 in Children Depression Rating Scale, Revised (CDRS-R) score (the primary outcome), and Clinical Global Impressions, Bipolar Severity of Depression Score (CGI-BP-S), using mixed model for repeated measures (MMRM) analysis.

At baseline, mixed features were present in 54.2% of patients (lurasidone, n=97/173; placebo, n=89/170). Treatment with lurasidone (vs placebo) was associated with significantly greater reductions in CDRS-R scores at week 6 in the mixed features group (-21.5 vs -15.9; P<0.01; effect size, 0.45), and in the group without mixed features (-20.4 vs -14.8; P<0.01; effect size, 0.45). Likewise, lurasidone was associated with greater effect size (vs placebo) for reductions inCGI-BP-S scores at week 6 in the mixed features group (-1.6 vs -1.1; P<0.001; effect size 0.57), and in the group without mixed features (-1.3 vs -1.0; P=0.05; effect size 0.30). Rates of protocol-defined treatment-emergent hypomania or mania were similar for lurasidone and placebo in patients with mixed features(lurasidone 8.2% vs. placebo 9.0%) and without mixed features (lurasidone 1.3% vs. placebo 3.7%).

In this post-hoc analysis, lurasidone was found to be efficacious for treating child and adolescent patients with bipolar depression presenting with mixed features(assessed cross-sectionally at study baseline). There was no increased risk of treatment-emergent mania observed in patients with or without mixed features.

Sunovion Pharmaceuticals Inc.

This analysis assessed the relative efficacy and tolerability of lurasidone versus other atypical antipsychotics in the treatment of pediatricschizophrenia.

A systematic literature review identified 13 randomized-controlled trials for the treatment of pediatric schizophrenia. A Bayesian network meta-analysis compared the efficacy and tolerability of the following atypical antipsychotics: aripiprazole, asenapine, clozapine, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, andziprasidone. Patients were 7-17 years old and trial duration ranged from 6-12 weeks. Outcomes included Positive and Negative Syndrome Scale (PANSS), Clinical Global Impressions-Severity (CGI-S), weight gain, all-cause treatment discontinuation, and extrapyramidal symptoms. Results from the fixed effect models were reported as mean differences for continuous outcomes and odds ratios for binary outcomes; each with a 95% credible interval.

Lurasidone had significantly greater improvement compared with placebo for PANSS (-7.95 [-11.76, -4.16]) and CGI-S (-0.44 [-0.67, -0.22]), but did not differ from comparators. The differences in weight gain for lurasidone relative to comparators were as follows: clozapine (-3.81kg [-8.03, 0.42]), olanzapine (-3.62kg [-4.84, -2.41]), quetiapine (-2.13kg [-3.20, -1.08]), risperidone (-1.16kg [-2.14, -0.17]), asenapine (-0.98kg [-1.71, -0.24]), paliperidone (-0.85kg [-1.57, -0.14]), aripiprazole (-0.15kg [-0.88, 0.58]), and ziprasidone (0.38kg [-0.49, 1.24]); all were statistically significant except for clozapine, aripiprazole, and ziprasidone. Rates of all-cause discontinuation andextrapyramidal symptoms were similar for lurasidone and comparators, except aripiprazole and paliperidone, which had higher rates of all-cause discontinuation.

In this network meta-analysis of atypical antipsychotics for the treatment of adolescent schizophrenia, lurasidone was associated with similar efficacy, but less weight gain than active comparators.

This study was funded by Sunovion Pharmaceuticals Inc.

Mal de Debarquement Syndrome (MdDS) is a prolonged rocking or swaying type of imbalance that occurs after lengthy exposure to motion, yet ensuing in the absence of motion. The provoking motion is most commonly following sea travel. MdDS has not heretofore been described in association with increased intracranial pressure. Such a case is presented.

Case Study: A 46-year-old female, with a history of hydrocephalus after infantile meningitis with ventriculoperitoneal shunt placement and multiple revisions, has a constant feeling of ‘rocking side to side’. One year and one-half year prior to presentation, she suffered two epochs of severe bilateral headaches coinciding with, as she describes, “the feeling of rocking, as if on a ship”. Both of these episodes were constant and lasted all day, progressively increasing in intensity for one week. During these events, she admits to nausea, but denied any vomiting, spinning, epigastric rising, or déjà vu or jamais vu. During the epochs there was no tinnitus, orthostatic hypertension, visual obscuration, loss of consciousness, syncope, seizures, weakness or falls. Prior to, or associated with the swaying sensation, she denies lightheadedness, pallor, salivation, blurred vision, tachycardia, visual auras or other neurological auras. There were no alleviating or aggravating factors, and were unrelated to position change, head movement, neck extension or rotation, coughing, or urination. She denies any recent air-travel, diving, sleeping on a waterbed, or alcohol use. In both epochs, shunt malfunction and associated increased intracranial pressure were discovered. Immediate resolution of the headache and dizziness episodes were achieved after shunt revision with correction of increased intracranial pressure.

Abnormalities in Cranial Nerve (CN) Examination: CN I: Alcohol Sniff Test: 14 (hyposmia). CN II: Visual Acuity OS 20/25. CN III, IV, VI: Saccadization of horizontal eye movement. Bilateral ptosis left > right. CN IX, X: Uvula deviated to the right. Motor Examination: Drift Testing: Left upward and outward drift with left Abductor Digiti Minimi sign. Reflexes: 3+ throughout.

Typically seen in middle aged woman, MdDS is a rare, self-limiting condition in which an abnormal sensation of rocking or swaying back and forth is perceived after exposure to air, car, land or sea travel (Nwagwu 2015). The phantom perception of self-motion occurs upon return to ground (Nwagwu 2015). This has been postulated to be due to maladaptation of the vestibulo-ocular reflex (Hain 2016) or disorder of connection between the entorhinal cortex and amygdala (Cha 2012). Increased intracranial pressure can affect the entire neural axis, including brainstem and cortical areas associated with MdDS. In those who present with intractable MdDS, measurement of intracranial pressure and treatment of any elevations may be warranted.

Smell and Taste Treatment and Research Foundation

Repetitive deep transcranial magnetic stimulation (dTMS) is efficacious for treatment resistant major depressive disorder (TRD) with the H1 coil by stimulating the prefrontal cortex, left more than right, at high frequency. Theoretically, the efficacy of dTMS could be optimized by simultaneously stimulating the right and left lateral prefrontal cortices (PFC) with different frequencies. This study tested the efficacy of a novel dual-channel dTMS stimulator with dual dTMS coils, in patients with TRD.

This study recruited forty-seven outpatients diagnosed with TRD, age 18-65, Hamilton Depression Rating Scale (HDRS-21) score ≥25. Each patient received 20 open label treatment sessions, five days a week for 4 consecutive weeks. Treatments were administered with the dual-channel stimulator (Brainsway Multiway dTMS device) using two channels: a. 10 Hz over the left PFC. b. 1 Hz over the right PFC. Primary and secondary efficacy outcome measures were the change in HDRS-21 score and response/remission rates at week 5, respectively.

The HDRS-21 score decreased from an average of 25.94 to 14.69 (P<0.001). Thirty-six patients completed four weeks of treatment. Of them, seventeen (47%) responded (HDRS-21 score decrease of ≥ 50% from their initial score) and eight (22%) remitted (HDRS-21 score of < 10 at the end of the study).

This open study shows promising results for multichannel simultaneous dTMS treatment of TRD using the Brainsway Multiway Device. Further randomized controlled studies are necessary to aid the high number of patients with TRD.

Brainsway Ltd.

Tardive dyskinesia (TD) is an often-irreversible movement disorder that usually results from prolonged use of antipsychotics. Although the burden of TD on patients’ quality of life has been reported, there is limited evidence of its impact on the healthcare system.

To assess healthcare utilization and costs between TD and non-TD patients in a sample of patients from the commercially insured and Medicare Supplemental US populations.

A retrospective cohort analysis was conducted using Truven MarketScan Commercial/Medicare claims data. For each patient included in the analysis, the index date was set as the first TD diagnosis between 1/1/2008 and 9/30/2014. Patients with TD were then matched to similar patients without TD to compare resource utilization andcosts. Descriptive statistics on the incidence of resource utilization and costs of healthcare were reported.

A total of 1020 patients were included in this analysis. TD patients had significantly greater annual all-cause (TD: $54,656; non-TD: $28,777) and mental health-related (TD: $10,199; non-TD: $2,605) healthcare costs compared with non-TD patients (P<0.01). This was primarily because a higher proportion of the TD patientsexperienced hospitalizations (all-cause 56%; mental health 17%) and emergency room visits (all-cause 62%; mental health 27%) compared with non-TD patients(hospitalizations: all-cause 26%, mental health 5%; emergency room visits: all-cause 41%; mental health 13%) (all P<0.001).

Patients identified as being diagnosed with TD demonstrate significantly higher healthcare utilization and costs in the 12 months after diagnosis than do similar patients without TD.

Presented at: Psych Congress; September 16–19, 2017; New Orleans, Louisiana, USA.

This study was funded by Teva Pharmaceutical Industries, Petach Tikva, Israel.

Binge eating disorder (BED) is the most common eating disorder in the US, with a lifetime prevalence of 2.8%. Disturbances in reward circuitry have been implicated in its pathogenesis. Dasotraline is a novel and potent dopamine and norepinephrine reuptake inhibitor with slow absorption and a long half-life resulting in stable plasma concentrations over 24 hours with once-daily dosing. This study evaluated the efficacy and safety of flexibly-dosed dasotraline (4, 6, and 8 mg/day) vs placebo in adults with moderate to severe BED over a 12-week period (NCT02564588).

Key inclusion criteria included moderate to severe BED based on a history of ≥2 binge eating days/week for ≥6 months prior to screening, and ≥3 binge eating days for each of2 weeks prior to randomization, as documented in participant’s binge eating diary. Patients were randomized 1:1 to flexibly-dosed dasotraline (4, 6, 8 mg/day) or placebo. Theprimary endpoint was change from baseline (CFB) in the number of binge eating days per week at Week 12. Key secondary endpoints were: CFB in Clinical Global Impression–Severity (CGI-S) Scale at Week 12; CFB in Yale-Brown Obsessive Compulsive Scale Modified for Binge Eating (YBOCS-BE) at Week 12; and the percentage ofsubjects with a 4-week cessation from binge eating prior to Week 12 or end of treatment (EOT). Except for 4-week cessation, the other three variables were analyzed using amixed model for repeated measures (MMRM).

317 subjects (84% female) received ≥1 dose of study medication (mean age was 38.2 years; mean number of binge eating days per week, 4.25; mean CGI-S score, 4.5; mean BMI, 34.7). The MMRM analysis of CFB at Week 12 in the number of binge days/week yielded a significant mean difference of –0.99 (95% CI: –0.65 to –1.33; p<0.001) infavour of dasotraline (–3.74 in the dasotraline group vs –2.75 in the placebo group). All three key secondary endpoints were met at Week 12 or EOT: 46.5% of subjects in thedasotraline group achieved at least 4 consecutive weeks’ cessation from binge eating vs 20.6% in the placebo group (p<0.001); CFB in CGI-S and YBOCS-BE scores were also statistically significant in favour of dasotraline (p<0.001). The treatment-emergent adverse events (TEAEs) that occurred more frequently with dasotraline vs placebo at >2% incidence included: insomnia (44.6% vs 8.1%), dry mouth (27.4% vs 5.0%), decreased appetite (19.7% vs 6.9%), anxiety (17.8% vs 2.5%), nausea (12.7% vs 6.9%) and decreased body weight (12.1% vs 0%). Discontinuation due to AEs occurred in 11.5% of patients taking dasotraline vs 2.5% taking placebo.

In adults with moderate to severe BED, there were highly significant and clinically meaningful reductions with dasotraline vs placebo in the frequency of binge eating, global severity of illness, and obsessive-compulsive symptoms related to binge eating. These results suggest dasotraline may offer a novel, well-tolerated and efficacious treatmentfor BED.

Study sponsored by Sunovion Pharmaceuticals Inc.

This retrospective analysis hopes to add to the literature about Treatment Resistant Schizophrenia (TRS), augmentation strategies with antipsychotics used in our patient population with the hopes of clarifying what possibilities should be further studied. In addition, we aim to emphasize the need for focusing on individualized treatment and multidisciplinary efforts to ensure compliance and appropriate disposition options.

We reviewed retrospectively 3025 charts of patients between January 2017 to March 2017 in our outpatient department establishing which antipsychotic clozapineaugmentation strategies were being used. We also did a literature review to establish what augmentation strategies are recommended. These patients will then be compared to a random sample of patients in the clinic who were not prescribed clozapine and compared for readmission rate, side effect profile, length of stay while admitted, frequency of clinic attendance and compliance with outpatient appointments.

Out of 3025 patients 35 were prescribed Clozapine as monotherapy and 5 patients had clozapine plus psychopharmacological augmentation. Ages ranged from 21-86. Out of the 39 patients, there were 13 male and 26 female. The predominant diagnosis was mood disorder or MDD with psychotic features followed by schizophrenia. The augmentation antipsychotics used were aripiprazole and risperidone. In the literature, the most frequent augmentation strategy for TRS is adding another antipsychotic with more D2 receptor blockade. Other strategies involve identifying and treating the symptoms not controlled by clozapine.

Currently augmentation of Clozapine in TRS is highly individualized due to lack of supporting evidence to state the contrary. When working with treatmentresistant patients who are not responding to clozapine alone, it is imperative to thoroughly review and consider all treatment options and augmentation strategies. More studies should be done in controlled settings to better evaluate possibilities as well as more evaluations to be done on other ways of augmentation of clozapine. Literature has stated between 20-60% of patients are defined as TRS. Clozapine is considered as one of the most effective treatment available at present time for TRS. Recent literature suggests despite its superior efficacy, as many as 70% of those suffering from TRS on clozapine continue to suffer from positive, negative or cognitive symptoms. The literature has abundant adjunctive treatment strategies such as the addition of antipsychotics, mood stabilizers, antidepressants, or even with the use of electroconvulsive therapy. We emphasize the importance of correctly identifying TRS patients who may benefit from the initiation of clozapine, what would be beneficial for them if they do not respond, how to tailor their treatment to target symptoms not being ameliorated, and recommend treatment in these complex cases be multidisciplinary.

No funding.

Tardive dyskinesia (TD) is associated with prolonged exposure to dopamine receptor blockers including antipsychotics. This registry describes the prevalence and impact of involuntary movements (possible TD) in a real-world population of patients taking antipsychotics.

RE-KINECT (NCT03062033) aims to enroll 1,000 patients from 70 US psychiatric practices. Adults with ≥3 months lifetime exposure to antipsychotic(s) and ≥1 psychiatric disorder are eligible for two-tier screening: informal observation, and then clinician observation of abnormal involuntary movements in general body regions (head/face, neck/trunk, upper/lower limbs) and confirmation of possible TD. Based on clinician assessment, patients are assigned to Cohort 1 or Cohort 2 (without or with abnormal involuntary movements, respectively). In both cohorts, the following baseline assessments are included: clinician’s assessment of clinical psychiatric severity, patient perceived health‐related quality of life (EuroQOL 5-Dimensions), social burden/disability questionnaire (Sheehan Disability Scale), and 12-month retrospective chart review ofmedical and treatment history. Cohort 2 also participate in 12-month longitudinal evaluation. Interim baseline data are available from four sites.

Baseline data are currently available for 116 patients—mean age, 49.6 years; female, 60.3%; schizophrenia/schizoaffective disorder, 32.8%; at least 1 mood disorder, 84.5%, and 10.4 years mean cumulative lifetime exposure to antipsychotic(s). The most concerning health condition for both cohorts is their mental health (69.0%), followed by physical activity and nutrition (33.6%). 32.8% of subjects had clinician confirmation of possible TD.

This novel registry aims to evaluate the real-world potential impact/burden of TD. Preliminary analyses suggest that TD is common in patients with schizophrenia and mood disorders taking antipsychotics. Further analyses will explore the burden of illness in this population.

This study was funded by Neurocrine Biosciences, Inc.