The adverse effects of insomnia on health and quality of life are matters receiving increasing attention. Yet, surveys have consistently shown that most people suffering from insomnia do not seek medical help, perhaps, in part, because of a concern of becoming dependent on hypnotic medication. The treatment of chronic insomnia poses a particular dilemma in that continuous hypnotic treatment is restricted in many countries to a maximum of 4 weeks, and behavioural treatment is not readily available. Non-nightly hypnotic treatment of chronic insomnia offers a promising alternative option for the many patients whose symptoms do not necessitate nightly drug intake, allaying fears of psychological dependence on medication and respecting regulatory constraints on hypnotic use while providing patients with adequate symptom relief. The practical feasibility and efficacy of this approach has been demonstrated with zolpidem using various treatment regimens and study designs. So far, six clinical trials have been completed on over 4000 patients. Published results show effective treatment of insomnia without any evidence of either adverse event associated with a discontinuous regimen or increased hypnotic use over the treatment period.

Following the reintroduction of clozapine, several atypical antipsychotics have become available for the treatment of schizophrenia. These drugs are at least as effective as conventional treatment. Although each has an individual pattern of affinities, new work suggests that the hallmark of atypicality is fast dissociation at the dopamine-2 receptor. Numerous novel drugs are in development, but it is not clear how these conform to this theory of therapeutic effect. Atypical antipsychotics cause less extrapyramidal side effects than conventional treatment, but other effects such as hyperprolactinaemia, weight gain, glucose dysregulation and prolonged QTc interval remain problematic for some. Current antipsychotic prescribing practice is far from ideal: the NICE guidance stresses that atypical treatments should be considered unless symptoms are well controlled and side effects are acceptable, or depot formulation is indicated. There is a welcome emphasis on drug treatment as part of an integrated package of care negotiated with patients and their carers.

This study investigated the nature of factor structure of schizophrenia syndromes using a sample of 151 patients with schizophrenia according to DSM-IV. The patients were assessed on the Scale for the Assessment of Positive Symptoms (SAPS), the Scale for the Assessment of Negative Symptoms (SANS), Hamilton Depression Rating Scale (HDRS) and the Phillips Rating Scale of Premorbid Adjustment in schizophrenia. Three factors—negative syndrome, reality-distortion syndrome and disorganized syndrome were extracted when only SAPS and SANS were analysed. Addition of the Phillips Rating Scale scores to SAPS and SANS ratings in the factorial equation led to splitting of the negative syndrome though reality-distortion and disorganized syndromes remained stable. Factor analysis of the HDRS scores with SAPS and SANS ratings resulted in the HDRS loading highly on reality-distortion syndrome and splitting of negative syndrome. Factor analysis of all the variables taken together resulted in delineation of four factors. The study suggests a link between depression and reality distortion. Apathy and anhedonia seem to be linked to premorbid adjustment.

Alcohol treatment professionals are often reluctant to address tobacco dependence in their patients or to implement smoke-free policies in inpatient treatment programs, fearing, among others, non-adherence to alcohol treatment. The aim of the present study was to evaluate the acceptance of an intended smoking ban in a specialized hospital for alcohol withdrawal. Fifteen of 54 patients reported that they would not begin or quit alcohol treatment if smoking were banned in the clinic, but only five would not begin or quit if nicotine replacement were available. The present study indicates that a non-smoking policy would be feasible in a Swiss alcohol clinic, without jeopardizing alcohol treatment adherence.

Clozapine is the least likely anti-psychotic to induce extrapyramidal symptoms (EPS). We present a surprising case of a woman schizophrenic patient treated with clozapine suffering from EPS. Single photon emission computed tomography (SPECT) revealed a low density of presynaptic dopamine transporters in our patient's brain. A comorbid diagnosis of Parkinson's disease in schizophrenia was confirmed in this way. This helped us to find a proper therapeutic strategy for our patient.

Clozapine is indicated for the treatment of patients intolerant of conventional antipsychotic agents. It is often used to treat those patients who have developed movement disorders while on conventional antipsychotics. We report three cases of dyskinesia associated with clozapine induction. We suggest a mechanism that might explain an underlying dopaminergic hypersensitivity during this transitional period. Further, we identify groups that might be at high risk of developing dyskinesia and suggest strategies to reduce risk especially in these groups.

Tuberculosis (TB) increasingly appears in a multidrug-resistant form (MDR-TB) in Europe, too. Treatment remains difficult due to various side effects of the multi-drug-regimens. Ciprofloxacin is widely used as one of the few TB-second-line drugs. We report on the course of a ciprofloxacin-induced acute psychosis in a patient with MDR(isoniazid, streptomycin)-TB which resolved after cessation of ciprofloxacin treatment and introduction of a novel oxazolidone. Careful treatment considerations particularly in patients with additional predisposing factors to neuropsychiatric symptoms are recommended in the potentially dangerous MDR-TB, thus creating an enormous therapeutic challenge.

This case report describes a patient on tranylcypromine who erroneously received a single dose of imipramine and subsequently developed a fatal serotonin syndrome. Both the clinical features and the pathophysiology of the serotonin syndrome are discussed.