This case report describes the clinically underrecognized manifestation of delayed-onset akathisia induced by cariprazine occurring 10 weeks after treatment initiation. The secondary objective was to discuss potential pharmacokinetic and pharmacodynamic mechanisms of the drug-induced side effects. A retrospective review of the patient's medical and psychiatric history was performed in addition to a comprehensive literature review. A 42-year-old female with bipolar disorder and generalized anxiety disorder presented to the emergency department on 3 separate occasions with severe restlessness and insomnia, commonly attributed to her previous history of anxiety. Although initial treatment with lorazepam provided subjective symptom relief, the underlying cause persisted. Psychiatry consultation led to a diagnosis of antipsychotic-induced akathisia and administration of diphenhydramine resulted in rapid improvement. The offending agent, cariprazine, was discontinued, resulting in sustained symptom resolution. This case highlights the challenge of distinguishing akathisia from primary anxiety disorders, in addition to considering this diagnosis beyond the initial treatment period. Akathisia symptoms most commonly present within 4 weeks of initiation or titration of antidopaminergic treatment. However, this timeline may be delayed with cariprazine due to its pharmacokinetic and pharmacodynamic properties.

Neuroinflammation, reflected in hematological and inflammatory biomarkers, plays a role in bipolar disorder. Electroconvulsive therapy (ECT) is effective for treatment-resistant bipolar disorder, but its impact on these biomarkers remains unclear. This study investigated changes in hematological and inflammatory markers before and after ECT in bipolar mania and their association with treatment response. A quasi-experimental study was conducted on 30 inpatients with bipolar mania undergoing ECT. Blood samples were collected before anesthesia induction and 2 hours postseizure at the initial and final sessions. Hematological indices, including mean cell hemoglobin (MCH), red blood cell count (RBC), white blood cell count (WBC), mean corpuscular volume (MCV), and platelet count (Plt), along with inflammatory markers such as C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII), were analyzed. A ≥25% reduction in Young Mania Rating Scale (YMRS) scores defined clinical response. CRP significantly increased after both the first (P=0.01) and final (P<0.001) ECT sessions. NLR (P=0.001) and PLR (P=0.002) showed a transient rise after the first session but not at the final session. Other hematological indices remained largely unchanged. No significant correlation was found between inflammatory marker changes and treatment response, though baseline CRP correlated with baseline YMRS scores (P=0.013). ECT induces a transient inflammatory response, but these biomarker changes did not predict clinical improvement, suggesting systemic inflammation may not be central to ECT efficacy in bipolar mania. Further research is needed.

This study evaluated the effectiveness of topiramate monotherapy in treating episodic and chronic cluster headaches and its impact on headache-related disability and quality-of-life areas not sufficiently addressed in previous literature. A prospective observational study was conducted between October 2023 and December 2024, including 51 adults diagnosed with cluster headache. Exclusion criteria were other headache types, prior anticonvulsant use, malignancy, pregnancy, or lactation. Patients received topiramate starting at 25mg/day, titrated weekly up to 100mg. VAS (0 to 10) and HIT-6 scores were used to assess treatment efficacy and quality of life weekly. The cohort was predominantly male (64.7%) with a mean age of 38.6 years. Significant reductions in both HIT-6 and VAS scores were observed over time in all patients, with similar efficacy between first-line and follow-up users. Chronic patients started with higher HIT-6 scores and showed slower improvement than episodic cases. Somnolence was the most common side effect (19.6%), but no patients discontinued treatment. In this observational cohort, topiramate monotherapy was associated with reductions in pain severity and headache-related disability and was generally well tolerated. These findings suggest that topiramate may be considered as a potential first-line or alternative prophylactic option in selected patients, particularly when treatment choices are limited or polypharmacy is undesirable.

The role of escitalopram on cognition in patients with dementia is inconclusive. In this study effect of low-dose escitalopram on cognition in subjects with dementia without depression is explored. This is a retrospective study of subjects aged 60 years or more with a diagnosis of dementia without depression conducted in a tertiary-care hospital in India. Subjects treated with low-dose escitalopram with a follow-up of 12 weeks duration were included. The parameters extracted were sociodemographic characteristics, duration and type of dementia, comorbidities, other psychotropics, and antidementia drugs. The change in Hindi Mental Status Examination score from baseline to fourth, eighth, and 12th weeks is considered the primary outcome measure. In addition, changes in neuropsychiatric symptoms are the secondary outcome measures. Statistical methods include descriptive and comparative analysis, and repeated measures ANOVA was applied to assess change in cognition over time. A total of 44 subjects were included, with a mean age of 73.5 ± 7.42 years and 56.82%. Among the subjects, 79.55% were diagnosed with AD, 11.36% with FTD, and 9.09% with VD, and the average duration of illness was 4.48 ± 2.28 years. Comparison of HMSE score from baseline to fourth, eighth, and 12th week shows a significant difference with P <0.001, with greater improvement in the first 4 weeks. In addition, the NPI and ADL scores showed significant improvement in week-4 with P <0.001. Escitalopram shows a promising effect on cognition, behaviour, and functionality in subjects with dementia in the short term. However, a larger prospective long-term study is needed to validate the study findings.

Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic condition characterized by vasogenic edema, altered mental status (AMS), seizures, headaches, and visual disturbances. It is commonly associated with hypertension, cytotoxic drugs, and autoimmune disorders. We report a rare case of PRES likely related to linezolid therapy. A 77-year-old female with renal cell carcinoma, rheumatoid arthritis, hypertension, and prior thromboembolic events underwent major abdominal surgery complicated by coagulopathy, hemorrhage, and sepsis. Blood cultures grew Enterococcus faecium, and linezolid was initiated. Within 48 hours, she developed AMS and respiratory distress requiring intubation. EEG showed epileptiform discharges, and MRI revealed subarachnoid and intraparenchymal hemorrhage with features of PRES. Linezolid was discontinued, and follow-up MRI demonstrated improvement in bilateral hemispheric edema and hemorrhage. A literature review identified 2 additional cases of linezolid-associated PRES, both with similar neurological symptoms but without hemorrhagic complications. Unlike prior reports, our patient had a prolonged recovery, with only partial improvement at 19 days, likely influenced by comorbidities and associated hemorrhagic lesion. Linezolid-induced PRES is rare but clinically significant. Our case highlights potential hemorrhagic complications and delayed recovery, underscoring the need for early recognition and prompt management.

This systematic review characterizes drug-induced aseptic meningitis (DIAM), a rare but clinically significant adverse drug reaction. The study synthesizes data from published case reports and case series to enhance diagnostic accuracy and guide management strategies. A comprehensive literature search was conducted in PubMed/MEDLINE, Scopus, Embase, Cochrane Library, ClinicalTrials.gov, and gray literature following PRISMA guidelines. Cases with detailed clinical and therapeutic data were included. A total of 98 reports involving 108 patients were analyzed. The mean patient age was 47 years, with a slight female predominance (55%). The most commonly implicated drugs were nonsteroidal anti-inflammatory drugs, antibiotics, and monoclonal antibodies. Symptoms typically included headache (78%), fever (65%), and neck stiffness (56%), with severe neurological manifestations in 17%. Cerebrospinal fluid analysis showed pleocytosis in 65% and elevated protein in 60%. Magnetic resonance imaging findings were variable. Drug discontinuation led to symptom resolution in all cases, with corticosteroids used in severe presentations. DIAM mimics infectious meningitis, making early recognition critical. A thorough patient history, including medication exposure, is essential for diagnosis. This review underscores the need for clinician awareness to facilitate prompt identification and management. Future research should explore the immunopathogenesis and evidence-based treatment strategies for DIAM.

Objectives:Treatment-resistant depression (TRD) is a serious public health burden in the United States and comes with an extremely high suicide risk relative to the general population. Lamotrigine, though approved for use only in bipolar disorder, has been found to augment the effects of an antidepressant in treatment-resistant individuals. However, studies showing an antisuicidal effect of lamotrigine in the TRD population are limited. The objective of this paper is to describe a case of a 58-year-old male with TRD and chronic suicidality who was treated with lamotrigine augmentation of the serotonin-norepinephrine reuptake inhibitor, duloxetine, and experienced a sustained clinical improvement of his suicidality.Methods:Clinical changes in depression and suicidality after initiation of lamotrigine are presented.Results:The patient experienced a brief improvement in depression and sustained improvement in suicidality for 2 years.Conclusions:While there remains insufficient evidence in the literature for a clinical recommendation of the use of lamotrigine for suicidality in the TRD population, our case report introduces the novel possibility of an antisuicidal effect of lamotrigine at the individual level. We suggest clinicians consider its use when other, more robust treatments for suicidality have failed.

Trichotillomania is a psychiatric disorder characterized by the compulsive pulling of one's own hair, eyelashes, or eyebrows. Depression and obsessive-compulsive disorder comorbidity is frequently observed in patients with trichotillomania. In this case series, we will report how a patient diagnosed with trichotillomania was successfully treated with transcranial magnetic stimulation (TMS) therapy in our clinic. The TMS protocol was delivered using the MagVenture X100 device, with treatment intensity calibrated to 100% of each participant's motor threshold. Following the established treatment protocol for trichotillomania, patients received repetitive TMS at 1Hz, with each train lasting 300 seconds and a 60-second intertrain interval, for a total of 1200 pulses per session. The bilateral supplementary motor area (SMA) was targeted as the site of stimulation. The efficacy of TMS in reducing hair-pulling behaviors in patients with trichotillomania was evaluated in a case series of 3 patients who underwent 20 TMS sessions. The findings demonstrated a significant reduction in hair-pulling behaviors post-treatment. According to the Massachusetts General Hospital Hair Pulling Scale (MGH-HP), over 50% improvement was observed in all patients. The findings suggest that TMS may serve as a promising intervention for trichotillomania, warranting further exploration in larger, controlled trials. The utilization of the MGH-HP scale provided a robust measure for assessing behavioral changes, highlighting the potential of TMS in managing compulsive disorders.

Intractable hiccups, which are hiccups that can last longer than 1 month, may be very debilitating for patients. With limited evidence and a lack of treatment guidelines, refractory hiccups can be difficult to manage. We aim to present a case of refractory idiopathic intractable hiccups treated with amitriptyline in conjunction with other medications shown to produce hiccups relief. The patient's electronic health record, direct patient care experiences, and a systematic literature review were used for this case report. We report a 53-year-old male patient with refractory idiopathic intractable hiccups. Treatment was improved with the addition of amitriptyline to his regimen of medications used for hiccups management. Medline and PubMed were searched using the key terms "hiccup" or "singultus" and "amitriptyline." The literature search yielded 3 unique articles, which resulted in 4 unique cases with intractable hiccups responding to amitriptyline therapy. In all cases, patients tried multiple medications before amitriptyline initiation. This is the first case in over 30 years providing additional evidence for amitriptyline use in the relief of intractable hiccups. Amitriptyline may be more useful in patients experiencing intractable hiccups with comorbid mood disorders and in cases of suspected psychogenic origin.