2D:4D Digit Ratios in Adults with Gender Dysphoria: A Comparison to Their Unaffected Same-Sex Heterosexual Siblings, Cisgender Heterosexual Men, and Cisgender Heterosexual Women.

We compared gender dysphoria (GD) patients and their same-sex siblings in terms of their 2D:4D ratios, which may reflect prenatal exposure to androgen, one of the possible etiological mechanisms underlying GD. Sixty-eight GD patients (46 Female-to-Male [FtM]; 22 Male-to-Female [MtF]), 68 siblings (46 sisters of FtMs; 22 brothers of MtFs), and 118 heterosexual controls (62 female; 56 male) were included in the study. FtMs were gynephilic and MtFs were androphilic. We found that 2D:4D ratios in the both right hand (p < .001) and the left hand (p = .003) were lower in male controls than in female controls. Regarding right hands, FtM GD patients had lower 2D:4D ratios than female controls (p < .001) but their ratios did not differ from those of their sisters or male controls. FtM GD patients had no significant difference in their left-hand 2D:4D ratios compared to their sisters or female and male controls. While there was no significant difference in right hands between FtM's sisters and male controls, left-hand 2D:4D ratios were significantly higher in FtM's sisters (p = .017). MtF GD patients had lower right-hand 2D:4D ratios than female controls (p <.001), but their right-hand ratios did not differ from those of their brothers and male controls. There was no significant difference in left-hand 2D:4D ratios between MtF GD patients, and their brothers, or female and male controls. FtM GD patients showed significantly masculinized right-hand 2D:4D ratios, while there was no evidence of feminization in MtF GD patients.

Toxoplasma gondii infection by serological and molecular methods in schizophrenia patients with and without suicide attempts: An age-sex-matched case-control study.

INTRODUCTION: The opinion that latent Toxoplasma gondii infection is having a broadly asymptomatic projection has now been interrogated, in specific due to the echoed association between the latent infection and an elevated incidence of schizophrenia or even suicide attempts. Notwithstanding conducted studies aimed to understand this feasible link are restricted. METHODS: In the present case-control study, we focused to illuminate the relationship between the serological and molecular presence of T gondii and schizophrenia with or without the suicide attempts by comparing it with healthy individuals. A total of 237 participants (117 in schizophrenia and 120 in healthy control) were included in this study. RESULTS: Overall, latent T gondii infections were found statistically higher in 63 (53.8%) of the 117 patients with schizophrenia and in 33 (27.5%) of the 120 controls (P < .001). In schizophrenia patients, seroprevalence T gondii was again found to be statistically higher in suicide attempters (59.6%), compared with no history of suicide attempts (48.3%; P < .05). The molecular positivity rate of T gondii DNA was higher in the schizophrenia group, compared with the healthy control group (P < .05), whereas the history of suicide attempts was not statistically associated (P = .831) with T gondii DNA positivity by polymerase chain reaction. CONCLUSION: This case-control study enlightens additional demonstration to the belief that T gondii infection would be an underlying component for the pathophysiology of schizophrenia. Regardless of the clarity results of this study, this supposition warrants further endorsement.

Evaluation of the Effectiveness of Psychoeducation Given to Children with Parental Psychiatric Disorders.

This study was aimed to determine the effectiveness of psychoeducation program which was developed to improve the coping skills and to increase the psychological resistance of 12-18 years children/adolescents whose parents' have psychiatric disorders. The study was carried out between May 2018 - November 2019 with children of patients who applied to the outpatient clinic and inpatient treatment at Istanbul University - Cerrahpasa, Cerrahpasa Faculty of Medicine Department of Psychiatry. Total of 40 children (experiment = 20 and control = 20), participated in the study. Data were collected using Personal Information Form, Adolescent Psychological Resilience Scale and Kidcope. The mean age of the children/adolescents in the experimental group was 14.05 ± 1.90, 50% was male and the mean age of the control group was 15.35 ± 2.08, and 55% were male. It was determined that the mean duration of psychiatric disorders were 11.50 ± 6.39 years and 40% of the psychiatric diagnosis was schizophrenia in the experimental group, and the mean duration psychiatric disorders were 6.10 ± 5.16 years and 30% of the psychiatric diagnosis was a depression in the control group. After psychoeducation, the total scores of scales in the experimental group showed an increase compared to the control group and a significant difference in a statistical context. It was found that children/adolescents participating in the psychoeducation program had increased psychological resilience levels and improved coping skills. This result shows that the psychoeducation program for children/adolescents with psychiatric disorders in their parents is effective.

Alterations in Body Uneasiness, Eating Attitudes, and Psychopathology Before and After Cross-Sex Hormonal Treatment in Patients with Female-to-Male Gender Dysphoria.

Body dissatisfaction plays an important role in the development of psychiatric problems such as eating disorders as well as gender dysphoria (GD). Cross-sex hormonal treatment (CHT) alleviates the dissatisfaction by making various changes in the body. We examined the alteration of body uneasiness, eating attitudes and behaviors, and psychological symptoms longitudinally in Turkish participants with female-to-male gender dysphoria (FtM GD) after CHT. Thirty-seven participants with FtM GD and 40 female controls were asked to complete the Body Uneasiness Test to explore different areas of body-related psychopathology, the Eating Attitudes Test to assess eating disturbances, and the Symptom Checklist-90 Revised to measure psychological state, both before CHT and after 6 months of CHT administration. The baseline mean body weight, BMI scores, body uneasiness scores, and general psychopathological symptoms of participants with FtM GD were significantly higher than female controls, whereas baseline eating attitudes and behaviors were not significantly different. Over time, FtM GD participants' mean body weight and BMI scores increased, body uneasiness and general psychopathological symptoms decreased, and eating attitudes and behaviors had not changed at 24th weeks following CHT administration compared to baseline. CHT may have a positive impact on body uneasiness and general psychopathological symptoms in participants with FtM GD. However, CHT does not have an impact on eating attitudes and behaviors.

Total Tau and Phosphorylated Tau Protein Serum Levels in Patients with Schizophrenia Compared with Controls.

Tau protein is located in the axons of neurons and in Alzheimer Disease, is abnormally phosphorylated and aggregates into paired helical filaments (neurofibrillary tangles) reflecting the degree of neurofibrillary pathology and neurodegeneration. Although tau and phosphorylated tau (p-Tau) pathology is a hallmark for dementia, few studies were performed in patients of schizophrenia. This preliminary serum study was designed to compare serum total tau and p-Tau levels of schizophrenia patients with healthy controls. The study was included 42 patients diagnosed with schizophrenia and 42 healthy control subjects. Sociodemographic form was applied to both groups and PANSS was applied to patient group. Serum total tau and p-Tau levels were measured by ELISA method. Total tau and p-Tau levels of patients were significantly lower than healthy controls. There was a positive correlation between amount of past electroconvulsive therapies and total tau level. However total tau and p-Tau levels were positively correlated. Our study results showed that serum total tau and p-Tau levels of patients with schizophrenia were significantly lower than healthy controls.

Serum levels of glial fibrillary acidic protein and Nogo-A in children with autism spectrum disorders.

CONTEXT: Improved biomarkers would facilitate the diagnosis and treatment of autism spectrum disorders (ASD). OBJECTIVE: Our objective was to examine the levels of Nogo-A and glial fibrillary acidic protein (GFAP) in children with ASD. MATERIALS AND METHODS: Serum concentrations of GFAP and Nogo-A were determined by enzyme-linked immunosorbent assay. RESULTS: In this preliminary study, we found that serum Nogo-A was not found significantly different between groups, while serum levels of GFAP were significantly lower in ASD than controls. DISCUSSION AND CONCLUSIONS: It will be of great interest to determine other potential causes of elevated serum levels of GFAP, and whether this elevation has any phenotypic effect.

Relationship between temperament, character and the autistic trait in parents of children with autistic spectrum disorder.

OBJECTIVE: Previous studies have revealed distinct features of autism, with higher harm avoidance and lower reward dependence and novelty seeking. It is assumed that high harm avoidance, and low novelty seeking, reward dependence, cooperativeness, and self-directedness are related with the broad autism phenotype, as seen in autistic individuals. METHOD: This study examined the association between the Temperament and Character Inventory (TCI) and the Autism Spectrum Quotient (AQ), in parents of children with ASD. RESULT: There was significant correlation between total AQ and total harm avoidance, cooperativeness, and self-directedness (p < 0.05). In the stepwise analysis, self-directedness and education emerged significantly (F(2,67) = 19.71, p < .005). This model modestly explained 35% of variance (Adjusted R(2) = .350). CONCLUSION: Our findings suggest that self-directedness may be an autistic trait.

Relationships between IGF-1, schizophrenia, and treatment of metabolic syndrome.

OBJECTIVES: The use of atypical antipsychotic drugs in patients with psychiatric illness may result in dyslipidemia, hypertension, glucose intolerance, and abdominal obesity, which are together referred to as metabolic syndrome (MS). To investigate any correlations among insulin-like growth factor-1 (IGF-1), schizophrenia, and MS, we examined the metabolic profiles of patients with schizophrenia taking atypical antipsychotics. DESIGN: Patients with schizophrenia, their siblings, and controls participated in this study (N=50 in each group). The Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID I) and the Brief Psychiatric Rating Scale (BPRS) were administered to patients, and SCID I was administered to patients' siblings. We drew blood to measure IGF-1 levels and to determine the metabolic profiles of all participants; we also conducted anthropometric measurements. RESULTS: There were no significant differences in IGF-1 levels between groups. By comparing IGF-1 levels with MS-related parameters, we found that IGF-1 levels were negatively correlated with triglyceride levels in the control group, and positively correlated with HDL levels in the patient group (Pearson's correlation: r=-0.291, P=0.04, and r=0.328, P=0.02, respectively). Compared to their siblings, patients with schizophrenia had a significantly different body mass index, waist circumference, and insulin resistance, and showed a trend toward a difference in glucose levels (ANOVA: P=0.004, P<0.0001, P=0.004, P=0.072, respectively). CONCLUSION: A correlation between IGF-1 and MS may significantly influence future therapeutic strategies for MS. In order to determine the role of IGF-1 in schizophrenia, comprehensive longitudinal studies with first-episode drug-naive patients are needed.

Recognition of emotional facial expressions and broad autism phenotype in parents of children diagnosed with autistic spectrum disorder.

OBJECTIVE: Research findings debate about features of broad autism phenotype. In this study, we tested whether parents of children with autism have problems recognizing emotional facial expression and the contribution of such an impairment to the broad phenotype of autism. METHOD: Seventy-two parents of children with autistic spectrum disorder and 38 parents of control group participated in the study. Broad autism features was measured with Autism Quotient (AQ). Recognition of Emotional Face Expression Test was assessed with the Emotion Recognition Test, consisting a set of photographs from Ekman & Friesen's. RESULTS: In a two-tailed analysis of variance of AQ, there was a significant difference for social skills (F(1, 106)=6.095; p<.05). Analyses of variance revealed significant difference in the recognition of happy, surprised and neutral expressions (F(1, 106)=4.068, p=.046; F(1, 106)=4.068, p=.046; F(1, 106)=6.064, p=.016). CONCLUSION: According to our findings, social impairment could be considered a characteristic feature of BAP. ASD parents had difficulty recognizing neutral expressions, suggesting that ASD parents may have impaired recognition of ambiguous expressions as do autistic children.

The Relationship Between Depressive Symptoms and Psychological Variables in Patients With Schizophrenia.

INTRODUCTION: Depressive symptoms are common in schizophrenia and can be seen at any stage of the disease. Although various models have been proposed to explain the development of depression in schizophrenia, studies investigating related psychological factors are scarce and the studies that have been done usually focus on only a small number of possible factors. OBJECTIVE: The goal of this study was to investigate the predictability of some psychological factors on depression in patients with schizophrenia. For this purpose, patients with high and low depression scores were compared. METHODS: Two groups of individuals with schizophrenia, with (n=29) and without (n=31) depression, as determined by scores on the Calgary Depression Scale in Schizophrenia, were compared using a sociodemographic data form, the Positive and Negative Syndrome Scale (PANSS), the Beck Anxiety Inventory, the Rotter Internal-External Locus 2024 of Control Scale, the Multidimensional Scale of Perceived Social Support, and the Stress Coping Styles Scale. RESULTS: No differences were found between the 2 groups in terms of sociodemographic and clinical characteristics, social support scores, and coping styles. Statistically significant differences were found between the groups on the PANSS positive, negative, and general psychopathology subscales, in PANSS total scores, in anxiety scores, and in locus of control scores. CONCLUSIONS: This study showed that high levels of negative, positive, and general psychopathological symptoms, external locus of control, and high anxiety scores may be predictive of depression in individuals with schizophrenia. Studies that examine psychological factors in larger patient groups may provide the opportunity to detect and target these factors earlier in the course of schizophrenia, thereby reducing morbidity and mortality.

Are bipolar disorder, major depression, and suicidality linked with Toxoplasma gondii? A seromolecular case-control study.

OBJECTIVE: The existence of predisposing effects of latent Toxoplasma gondii (T. gondii) infection in bipolar disorder (BD), major depression (MD), and even suicide attempt (SA) has long been debatable. This conjecture remains unclear because there is a lack of evidence regarding how T. gondii manipulates the brain and behavior. METHODS: We investigated the influence of T. gondii infection on BD and MD patients with or without SA compared to age-, sex-, and province-matched healthy controls (HCs) concurrently with serology and molecular-based evaluations. We prospectively assessed 147 volunteers with BD, 161 with MD, and 310 HCs. RESULTS: T. gondii seropositivity rates were 57.1% for BD, 29.2% for MD, 64.8% for SA, and 21.3% for HC. Binary logistic regression analyses revealed that T. gondii positive Immunoglobulin G (IgG) status may be a prominent tendentious agent for BD (OR = 3.52; 95% CI [2.19-5.80]; p < 0.001) and SA (OR = 17.17; 95% CI [8.12-36.28]; p < 0.001), but not for MD (OR = 1.21; 95% CI [0.74-1.99]; p = 0.45). Nevertheless, the T. gondii DNA ratios determined by polymerase chain reaction (PCR) were linked to BD and MD. CONCLUSION: Our findings strongly support the burgeoning interest in the possibility that latent T. gondii infection may be relevant to the etiology of BD and SA, although this connection remains ambiguous.

Evaluation of Depression, Anxiety, and Sexual Function in Rectal Cancer Patients Before and After Neoadjuvant Chemoradiotherapy.

OBJECTIVE: The association of treatment-related side effects and tumor characteristics with sexual function, depression, and anxiety were investigated in patients with locally advanced rectum cancer (LARC) receiving neoadjuvant chemoradiotherapy (CRT). MATERIAL AND METHODS: Thirty-two patients who received neoadjuvant CRT with LARC were included. The Arizona Sexual Experiences (ASEX) Scale was used to determine the sexual function status whereas the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) were used to evaluate the depression and anxiety status of the patient, respectively. The patients were asked to fill these scales before and at least 4 weeks after the neoadjuvant CRT. T-test and Mann-Whitney U test were used for the comparison of values. RESULTS: Median age was 52.5 years (range: 33-76). Twenty-six patients were male, and 6 patients were female. At presentation, the tumor was located mostly in lower third rectum (72%), and 69% of the patients had T3 tumors. There was a statistically significant deterioration in the sexual functions of the patients (p < 0.001), a statistically significant decrease in their anxiety level after CRT (p: 0.037). Depression level was changed from mild to minimal during this process (p: 0.17). A significant deterioration in the ASEX scale was observed especially in patients with grade 2 and above gastrointestinal side effects (p: 0.01). CONCLUSION: This prospective study showed that the patient's anxiety and depression levels had decreased during the treatment process probably due to the decrease in the patient's symptoms. However, deterioration of the sexual function status which might be correlated to increased gastrointestinal side effects during CRT has been observed. So, clinical and psychiatric support including therapies for sexual dysfunctions is needed for LARC patients during and after the neoadjuvant CRT.

Attitudes among medical and nonmedical university students toward the survivors of childhood abuse.

OBJECTIVE: Childhood sexual abuse (CSA) is increasing, and current studies should address issues such as stigmas and casual attitudes that may be amenable to intervention. Thus, we aimed to investigate the effects of education on the attitudes of medical students toward CSA survivors. METHOD: We divided medical students into 2 groups: preclinical and clinical medical students. We compare the attitudes of nonmedical students with the attitudes of medical students with respect to survivors of CSA. All participants were asked to complete a questionnaire about stigmatization. RESULTS: There were 572 students in our study, 347 of whom were enrolled in medical school. Of the 347 medical students, 151 were from the preclinical group, and 196 were from the clinical practice group. The remainder of the participants (n = 225) were in other fields of university. Of the medical students, 68.3% responded negatively about "asking a survivor of abuse to supervise their child for a few hours," whereas 62.7% of the nonmedical students responded negatively. When asked, "What would you think if your child wanted to marry a survivor of sexual abuse?", 72.9% of the medical students and 59.1% of the nonmedical students displayed negative attitudes toward that idea. Our research also found that significantly more preclinical students than clinical students would not want to be in a companionship/friendship with a CSA survivor at work (P = .015) or in their neighborhoods (P = .034). CONCLUSION: Both medical and nonmedical students seem to have negative thoughts about sexual abuse survivors, particularly when the issue involves their own children and/or social situations. Thus, the medical professionals must be careful and should avoid over interpretations of findings on childhood abuse studies that may lead to stigmatization.

Co-existing bipolar disease and 17q12 deletion: a rare case report.

BACKGROUND: 17q12 microdeletion syndrome is a rare autosomal dominant chromosomal anomaly, caused by the deletion of a 1.4 Mb-spanning DNA sequence on the long arm of chromosome 17. Herein, we report the first bipolar disease (BPD) case with a 1.6-Mb deletion in the 17q11.2-17q12 chromosome region. MATERIALS AND METHODS: Physical examination of the case was performed. Karyotype and microarray analyses were performed for the case and the parents. RESULTS: Physical examination revealed mild dysmorphic features such as high and forehead, full cheeks, slightly depressed nasal bridge and arched eyebrow. Chromosomal analysis of the patient revealed 46, XX, del(17)(q12) karyotype, and parents' karyotype were normal. In the microarray analysis of patient, 1.6 megabases deletion was detected in the 17q12 region [arr(hg19) 17q12 (34,611,352-36,248,918) ×1]. The microarray analysis of the mother was normal. The father's microarray showed 473 kilobases duplication in the 11p11.12 region. CONCLUSION: Although 17q12 deletion syndrome has been associated with bipolar disorder, very few such cases have been described in the literature. Genetic counseling should be considered in patients with remarkable phenotype, complex symptomatology, neurodevelopmental disorder and additional conspicuous medical conditions.

Characteristics and outcomes of COVID-19 inpatients who underwent psychiatric consultations.

Patients hospitalized with COVID-19 are at risk of developing many neuropsychiatric disorders, due to the effects of the disease on the brain and the psychosocial pressures of having the disease. The aim of the present study was to evaluate the characteristics and outcomes of patients who were hospitalized with a diagnosis of COVID-19, who underwent psychiatric consultations. The medical records of 892 patients hospitalized due to COVID-19 and the 89 among them who requested psychiatric consultations were analyzed retrospectively. After the psychiatric consultations, patients were most frequently diagnosed with delirium (38.2 %), adjustment disorder (27.0 %), depressive disorder (19.1 %) and anxiety disorder (11.2 %). Patients with delirium had longer hospital stays (p < 0.001), were transferred more frequently to intensive care units (p < 0.001), and had higher mortality rates during their hospital stays (p < 0.001), than all other patients. The need for oxygen (p < 0.001) and mechanical ventilation (p < 0.001) was also significantly higher in delirium patients, as well as in patients who received other psychiatric diagnoses. Neuropsychiatric disorders develop in patients receiving inpatient treatments in COVID-19 wards, and these disorders negatively affect the prognosis of COVID-19. Our findings suggest that the presence of neuropsychiatric disorders in in-patients with COVID-19 might be associated with the negative outcomes of the disease.

Decreased Expression of α-Synuclein, Nogo-A and UCH-L1 in Patients with Schizophrenia: A Preliminary Serum Study.

OBJECTIVE: α-synuclein, Nogo-A and Ubiquitin C-terminal hydrolase L1 (UCH-L1) have neuromodulatory roles for human brain. Therefore, abnormalities of these molecules are associated with neuropsychiatric disorders. Although some serum studies in the other disorders have been made, serum study of α-synuclein, Nogo-A and UCH-L1 is not present in patients with schizophrenia and healthy controls. Therefore, our aim was to compare serum levels of α-synuclein, Nogo-A and UCH-L1 of the patients with schizophrenia and healthy controls. METHODS: Forty-four patients with schizophrenia who is followed by psychotic disorders unit, and 40 healthy control were included in this study. Socio-demographic form and Positive and Negative Syndrome Scale (PANSS) was applied to patients, and sociodemographic form was applied to control group. Fasting bloods were collected and the serum levels of α-synuclein, Nogo-A and UCH-L1 were measured by ELISA method. RESULTS: Serum α-synuclein [patient: 12.73 (5.18-31.84) ng/mL; control: 41.77 (15.12-66.98) ng/mL], Nogo-A [patient: 33.58 (3.09-77.26) ng/mL; control: 286.05 (136.56-346.82) ng/mL] and UCH-L1 [patient: 5.26 (1.64-10.87) ng/mL; control: 20.48 (11.01-20.81) ng/mL] levels of the patients with schizophrenia were significianly lower than healthy controls (p<0.001). CONCLUSION: Our study results added new evidence for explaining the etiopathogenesis of schizophrenia on the basis of neurochemical markers.

Do Low Serum UCH-L1 and TDP-43 Levels Indicate Disturbed Ubiquitin-Proteosome System in Autism Spectrum Disorder?

INTRODUCTION: The mechanism of ubiquitination-related abnormalities causing neural development problems is still unclear. We examined the association between autism and serum transactive response DNA-binding protein-43 (TDP-43) and ubiquitin c-terminal hydrolase-L1 (UCH-L1) levels, both of which are members of the ubiquitin-proteosome system. METHODS: We measured serum levels of TDP-43 and UCH-L1 in 24 children with autism and 24 healthy children. Childhood Autism Rating Scale (CARS) was used to assess symptom severity at admission. RESULTS: The mean serum TDP-43 and UCH-L1 levels in children with autism spectrum disorder (ASD) were found to decrease compared to healthy controls (p<0.001, 506.21±780.97 ng/L and 1245.80±996.76 ng/L, respectively; 3.08±5.44 ng/mL and 8.64±6.67 ng/mL, respectively). A positive correlation between serum TDP-43 levels and UCH-L1 levels was found in the ASD group (r=0.947, n=24, p<0.001). The CARS score of children with ASD was 48.91 points (standard deviation [SD]: 5.82). CONCLUSION: Low serum levels of UCH-L1 and TDP-43 may reflect disturbed ubiquitination in autism.

Neurological soft signs in antisocial men and relation with psychopathy.

Neurological soft signs (NSS) were studied in some axis-I disorders like schizophrenia, obsessive compulsive disorder, bipolar disorder, alcohol and substance abuse disorder. Aim of this study is detection of neurological soft signs in antisocial personality disorder and relation of these signs with psychopathy. The study was included 41 antisocial men and 41 healthy control subjects. Sociodemographic form, neurological evaluation scale and Hare psychopathy checklist was applied to the antisocial subjects, whereas sociodemographic form and neurological evaluation scale were applied to the controls. Antisocial men exhibited significiantly more NSS in total score and subgroups scales (p<0.05). It was shown that there was a significant association with psychopathy scores and NSS sequencing complex motor tasks (r=0.309; p=0.049) and NSS other tests subgroup scores (r=0.328; p=0.037). Similar relation was also observed in comparison between psychopathy subgroups. NSS accepted as being endophenotypes in schizophrenia, were also detected in antisocial group significantly more than controls in our study. Significant relationship between psychopathy and NSS may also hint the role of genetic mechanisms in personality development, though new extended studies with larger sample size are needed for clarification of this relationship.

Effectiveness of ultra-rapid dose titration of clozapine for treatment-resistant bipolar mania: case series.

Treatment of severe and refractory manic episodes in hospital settings can occasionally be very difficult. In particular, severely excited patients showing aggressive, hostile, impulsive behaviours frequently require physical restraint and seclusion, high doses of antipsychotics and benzodiazepines, and sometimes, electroconvulsive therapy. Hospital stay is generally prolonged and such patients cause great emotional distress for other patients in the ward and clinical staff involved in their care. Here we report on three patients with a diagnosis of bipolar disorder and one patient with a diagnosis of schizoaffective disorder bipolar subtype, all of whom were hospitalized for severe manic episodes with psychotic features. These patients were extremely difficult to manage in the ward as no response could be obtained in the first week of treatment despite high doses of antipsychotics and benzodiazepine administration. The introduction and rapid titration of clozapine proved remarkably effective and was well tolerated in the acute management of these patients. We observed that clozapine had a superior and fast mood stabilization effect with rapid titration and could be extremely helpful in the management of such patients.