Opioid prescribing practices have come under increased scrutiny due to the ongoing opioid crisis, with efforts focusing on harm reduction strategies such as co-prescription of opioid antagonists. This study analyzes opioid prescribing trends and the frequency of opioid-antagonist co-prescription over the course of 2024. A retrospective analysis was performed using electronic medical record data to identify all opioid prescriptions issued between January 1, 2024, and December 31, 2024. Each opioid prescription was cross-referenced with any concurrent prescription for an opioid antagonist. The analysis did not differentiate opioid type, duration of therapy, or prescribing indication. A total of 68,212 opioid prescriptions were issued in 2024. Quarterly totals were: Q1: 16,574; Q2: 16,882; Q3: 16,922; and Q4: 17,834. Among these, 7,586 (11.1%) were co-prescribed with an opioid antagonist, while 60,626 (88.9%) were not. The distribution across quarters was:Q1: 16,574 prescriptionsQ2: 16,882 prescriptionsQ3: 16,922 prescriptionsQ4: 17,834 prescriptionsOf these, 7,586 (11.1%) were co-prescribed with an opioid antagonist, while 60,626 (88.9%) were prescribed without one. The quarterly breakdown of opioid-antagonist co-prescription was:Q1: 1,874 prescriptions with an antagonist, 14,700 withoutQ2: 1,867 prescriptions with an antagonist, 15,015 withoutQ3: 1,945 prescriptions with an antagonist, 14,977 withoutQ4: 1,900 prescriptions with an antagonist, 15,934 without. Despite ongoing recommendations to increase opioid-antagonist co-prescription, a large majority (88.9%) of opioid prescriptions in 2024 were issued without an antagonist. While there was a modest increase in overall opioid prescriptions over the year, opioid-antagonist co-prescription rates remained relatively stable. These findings highlight the need for further investigation into barriers preventing wider adoption of opioid-antagonist co-prescription and the potential impact on patient safety.

This case report presents a complex psychiatric profile of a 19-year-old female with diagnoses of Fetal Alcohol Syndrome (FAS), Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), mild intellectual disability, and mood dysregulation, complicated by trauma history, psychotic features, and repeated hospitalizations. Her neurodevelopmental and psychiatric disorders have contributed to persistent high-risk behaviors, legal involvement, and challenges with independent living, ultimately necessitating group home placement. This case highlights the unique relationship between FAS and coexisting neurodevelopmental conditions, emphasizing the poor long-term outcomes frequently associated with FAS and ultimately the importance of comprehensive, multidisciplinary care in managing such patients. We review the current literature on co-occurrence of ASD and FAS, prognosis, and clinical management challenges posed by these overlapping conditions.

Clozapine and olanzapine are associated with clinically relevant weight gain and metabolic risk. To compare the risk of obesity (BMI ⩾ 30) between clozapine and olanzapine and to develop a parsimonious prediction model with performance and clinical-utility evaluation. We fit a multivariable logistic regression on complete cases using index drug, daily dose, prolactin (PRL), cortisol, free thyroxine (FT4), and HDL. Discrimination (AUC), probability accuracy (Brier score), calibration (intercept/slope and deciles), and decision-curve analysis (DCA) were reported. In the classification cohort, obesity counts were equal for clozapine (9/19) and olanzapine (9/19). The model achieved strong internal discrimination (AUC 0.869) with good calibration (slope 1.00; intercept -0.00) and Brier 0.123. DCA indicated net benefit at practical thresholds (∼5-15%), supporting low-harm preventive actions. Drug-related risk can be individualized with a lean model using routine variables. External validation and unit harmonization-especially for HDL-are recommended before broad deployment.

To estimate the association between tobacco use and the prevalence of psychotropic medication use and prescribed dosage among inpatients and outpatients with severe mental disorders treated at a neuropsychiatric hospital. Observational, cross-sectional, analytical study conducted on May 3, 2023. Smoking status and prescribed psychotropic medications were recorded for all hospitalized patients and community-based outpatients. Dosages were reported in mg/day, defined daily doses (DDD), and for antipsychotics as chlorpromazine equivalents (CPZeq). Bivariate and multivariate analyses were performed. Tobacco use data were collected from 325 out of 425 total patients (71.7% male, mean age [SD]: 51.4 [14.4] years, 56% inpatients, 70.2% with schizophrenia and related psychosis). The prevalence of smoking was 72.3%, with differences by gender (78.1% in males vs. 57.8% in females, p < 0.001), and decreased with age (18-39 years: 86.1%; 40-59 years: 71.7%; ⩾ 60 years: 63.2%; p = 0.01). Mean dosages of antipsychotics, clozapine, and olanzapine measured in CPZeq were higher in smokers than in non-smokers by 35.4%, 37.1%, and 33.3%, respectively. After adjusting for confounding factors, smoking was associated with a 21.8% higher dosage of antipsychotics (95% CI: 0.4%-43.2%; p = 0.046), equivalent to an additional 132.2 mg/day (24.2-240.1; p = 0.017) of clozapine and 5.4 mg/day (1.2-9.6; p = 0.012) of olanzapine. The average dosage of sedatives/hypnotics was 45.5% higher among smokers (13.6%-89.5%; p = 0.008). A high prevalence of smoking was found among patients with severe mental disorders, associated with higher average dosages of sedatives/hypnotics and antipsychotics, particularly clozapine and olanzapine.

Over the last twenty years, the development of antipsychotic medications has progressed from simple dopamine receptor antagonism to more complex, multi-receptor strategies. This evolution reflects an effort to improve therapeutic effectiveness, reduce side effects, and address a broader spectrum of psychiatric symptoms. Traditional first-generation antipsychotics primarily block dopamine D2 receptors, which often results in motor-related side effects and limited benefits for cognitive and negative symptoms. Second-generation agents introduced the combination of dopamine and serotonin receptor modulation, improving outcomes in emotional and social functioning with fewer extrapyramidal side effects. This class represented a significant improvement in tolerability and addressed a wider range of symptoms. Third-generation antipsychotics further refined this approach by acting as partial agonists at dopamine D2/D3 receptors while continuing to influence serotonergic pathways. These medications offer more balanced dopaminergic activity, improved cognitive and mood effects, and reduced metabolic and motor risks. The latest developments, referred to as fourth-generation antipsychotics, signal a major shift in psychopharmacology. These agents, which include novel compounds with minimal direct dopamine activity, act on receptors such as 5-HT2A, TAAR1, muscarinic, glutamate, and sigma. This receptor diversity allows for greater effectiveness in managing negative symptoms and cognitive impairments, while substantially lowering the risks of endocrine disturbances and movement disorders. These emerging agents hold promise for better overall patient outcomes. This review highlights the clinical relevance of third- and fourth-generation antipsychotics and supports the growing trend toward targeted, receptor-specific treatments in managing psychotic disorders.

This prospective 12-week randomized controlled trial tested an adherence promotion approach called Customized Adherence Enhancement in schizophrenia (CAE-S) vs. Enhanced Treatment as Usual (eTAU) in 36 poorly adherent individuals. Patients were randomized to either CAE-S or eTAU at baseline and were assessed at 12-week follow-up. Primary outcomes were program attendance, patient satisfaction and change in schizophrenia symptoms as measured by the Positive and Negative Syndrome Scale (PANSS). Additional evaluations were adherence measured by the Tablets Routine Questionnaire (TRQ), Clinical Global Impression (CGI), Short Form Health Survey (SF-12), Global Assessment of Functioning (GAF), and Strauss-Carpenter Level of Functioning Scale (SCLFS). Mean age was 44.9 (Standard deviation/SD 12) years. 12-week attrition was 19.4%. At screening, mean past 7-day TRQ (proportion of days with missed dose) was 29.7% (SD 23.8) for CAE and 41.7% (SD 26.5) for eTAU. By baseline, mean TRQ improved to 11.3% (SD 15.8) in CAE-S, and to 19.3% (SD 25.7) in eTAU. Mean session attendance (out of a maximum of 6) was 4.89 (SD 1.9) for CAE and 3.88 (SD 2.5) for ETAU. CAE and ETAU satisfaction were both high. From baseline to 12 weeks, mean PANSS improved significantly in both CAE-S (p < .05) and eTAU (p < .01) with no difference between arms. There was no significant change in TRQ, while CGI and GAF improved significantly in both arms with no significant difference between arms. Mean SCLFS improved in both arms, with results favoring CAE (p < .001). Telehealth CAE-S is feasible and acceptable among poorly adherent patients with schizophrenia. Adherence improved rapidly with monitoring, which could explain improvement in schizophrenia symptoms and largely similar outcomes across intervention arms.

Acute alcoholic hallucinosis (ICD-10 F10.52) necessitates urgent antipsychotic treatment but carries high risks of adverse drug reactions (ADRs). While pharmacogenetic clinical decision support systems (CDSS) show promise, their utility is limited by static genotyping and incomplete biomarker integration. This study aimed to develop and validate a multi-omics framework integrating pharmacogenetic testing, CYP phenotyping, and microRNA biomarkers to personalize antipsychotic therapy and improve outcomes in acute alcoholic hallucinosis. In this three-arm study, 300 Russian inpatients with acute alcoholic hallucinosis underwent: 1) Randomized pharmacogenetic-guided vs. standard therapy (n = 100); 2) CYP2D6/CYP3A4 phenotyping via urinary pinoline/cortisol ratios (n = 100); and 3) microRNA quantification (miR-27b, miR-370-3p; n = 100). Efficacy (PANSS) and safety (UKU) were assessed over 6 days. Pharmacogenetic guidance significantly reduced ADRs (UKU day 6: 5.0 [3.0 - 8.0] vs. 12.0 [10.0 - 16.0], p < 0.01) with comparable efficacy (PANSS≈1.0). Phenotyping identified 28% CYP2D6 poor metabolizers (vs. 15% by genotyping), exhibiting 40% higher haloperidol levels (r = 0.72, p < 0.001). Baseline miR-27b inversely correlated with day-3 PANSS (r = - 0.54, p < 0.001), while miR-370-3p predicted poorer day-6 response (ΔPANSS r = 0.48, p < 0.001) and higher UKU scores (r = 0.52, p < 0.001). Integrating microRNAs with phenotyping improved ADR prediction accuracy by 22% versus single modalities. A multi-omics approach synergistically optimizes antipsychotic therapy by addressing genotyping limitations through dynamic phenotyping and microRNA-based prognostication, significantly enhancing safety in this high-risk population.

To analyze patterns of pro re nata (PRN) medication utilization during the seven-day periods preceding and following aggressive incidents in a forensic setting, including both psychotropic and somatic agents, to identify trends in use surrounding aggression. This was a retrospective chart review at a long-term state forensic psychiatric facility. Patients housed on units associated with the New Outlook Program (NOP) within a six-month period who received PRN medications were included. Out of 106 patients evaluated, 42 were included. The mean age for study participants was 37 years old, with 83% being male. Out of 322 aggressive incidents, the overall PRN utilization rate was higher than the baseline in 38.8% of events (N = 125). For the overall seven-day period preceding and following an aggressive incident, there was no significant difference between psychotropic and somatic PRNs (β = -0.16, p = 0.74), and neither type showed a meaningful deviation from baseline (Intercept = -0.25, p = 0.46). Additionally, there was no significant difference in PRN utilization when separately assessing the seven-day period preceding or following an aggressive incident. No consistent group-level trends in PRN utilization were identified in relation to aggression. However, some patient-level variation was observed post-incident, suggesting individualized patterns compared to group-level trends. These findings support the clinical value of monitoring individuals' PRN utilization patterns to inform treatment planning.

Kleine-Levin Syndrome (KLS) is a rare, neurological disorder characterized by episodes of hypersomnia, cognitive impairment, and behavioral abnormalities. The etiology of KLS remains unclear, and treatment responses are highly variable. This report describes a 22-year longitudinal experience with a 40-year-old male diagnosed with KLS at 15 years of age. Treatment trials of all standard KLS medications (lithium, valproic acid, selective serotonin reuptake inhibitors, modafinil) yielded no benefit in attenuating or preventing episodes. Following the onset of overlapping an acute KLS exacerbation and catatonia-like symptoms, the patient's episode was shortened after a trial of intravenous (IV) lorazepam. This response was consistently reproduced, with episodes resolving after approximately 5-7 days of IV lorazepam administration. Notably, the frequency of episodes increased after the patient contracted COVID-19 despite the continued efficacy of IV lorazepam in reducing episode duration. This case highlights the potential utility of IV lorazepam in terminating acute KLS episodes. While short-term outcomes were favorable, the observed increase in episode frequency underscores the need to assess the risks of chronic benzodiazepine exposure, including receptor downregulation and tolerance. These findings support the use of lorazepam in acute KLS management but emphasize caution regarding long-term reliance and encourage further mechanistic and therapeutic research into episodic hypersomnia and benzodiazepine responsiveness.

Drug-assisted interviews have been used in psychiatry for about a century. The use of barbiturates for this purpose has declined, and the use of lorazepam has gained popularity over time for conducting drug-assisted interviews, given a better safety profile. However, the evidence for the use of lorazepam for drug-assisted interviews is fragmented and anecdotal, and mostly in the form of case reports. The current review aims to synthesize available evidence on the use of lorazepam-assisted interviews in psychiatry. For this narrative review, a literature search was conducted using PubMed, Scopus, and Google Scholar. Peer-reviewed articles on the use of lorazepam for drug-assisted interviews for psychiatric patients were identified, and data were manually extracted and synthesized. Eleven case reports and one case series on lorazepam-assisted interviews were identified. Dissociative disorder was the common diagnosis where it was used, with most studies reporting significant improvement after the interviews. Adverse events, though rare, included excessive sedation, disinhibition, agitation, and emotional lability. Interview protocols varied among the studies, with doses ranging from 2 to 18 mg, administered through intravenous routes either as boluses or infusion (rates ranging from 0.05 mg/min to 0.1 mg/min). Most studies involved single sessions, with a maximum of 12 sessions in one case report. Lorazepam-assisted interview may hold potential clinical utility in appropriate cases. Future studies are needed to establish efficacy and safety and to evaluate interview protocols.