A two-year longitudinal evaluation of the impact of the COVID-19 pandemic on pre-existing mental health service attenders.

BACKGROUND: To examine if the COVID-19 pandemic was associated with a differential effect longitudinally in relation to its psychological and functional impact on patients with bipolar disorder and Emotionally Unstable Personality Disorder (EUPD). METHODS: Semi-structured interviews were conducted with 29 individuals attending the Galway-Roscommon Mental Health Services with an ICD-10 diagnosis of either bipolar disorder (n = 18) or EUPD (n = 11). The impact of the COVID-19 pandemic was assessed in relation to anxiety and mood symptoms, social and occupational functioning, and quality of life utilising psychometric instruments and Likert scale data, with qualitative data assessing participants' subjective experiences. RESULTS: Individuals with EUPD exhibited significant anxiety and depressive symptoms and increased hopelessness compared to individuals with bipolar disorder. Repeated measures data demonstrated no significant change in symptomatology for either the EUPD or bipolar disorder group over time, but demonstrated an improvement in social (t = 4.40, p < 0.001) and occupational functioning (t = 3.65, p = 0.03), and in quality of life (t = 4.03, p < 0.001) for both participant groups. Themes attained from qualitative data included the positive impact of the discontinuation of COVID-19 mandated restrictions (n = 19), and difficulties experienced secondary to reductions in the provision of mental health services during the COVID-19 pandemic (n = 17). CONCLUSION: Individuals with EUPD demonstrated increased symptomatology over a two-year period compared to those with bipolar disorder. The importance of face-to-face mental health supports for this cohort are indicated, particularly if future pandemics impact the delivery of mental health services.

The impact of fluphenazine withdrawal: a mirror-image study.

BACKGROUND: Fluphenazine decanoate licenced as a long-acting injectable (LAI) first-generation antipsychotic (FGA) was withdrawn from sale in 2018. This study evaluates if its withdrawal resulted in increased relapse rates of psychosis in an Irish patient cohort and examines which prescribed alternative antipsychotic medications were associated with more optimal outcomes. METHODS: Fifteen participants diagnosed with a psychotic disorder were included. A mirror-image study over 24-months' pre-and post-withdrawal of fluphenazine was conducted. Kaplan-Meier survival and proportional hazards analyses were conducted. The impact of alternate antipsychotic agents (LAI flupenthixol compared to other antipsychotic medications) was evaluated. Semi-structured interviews with participants examined subjective opinions regarding the change in their treatment. RESULTS: Seven participants (46.7%) relapsed in the 24-month period subsequent to fluphenazine discontinuation compared to one individual (6.7%) in the previous identical time-period (p = 0.035). Flupenthixol treatment was associated with reduced relapse rates compared to other antipsychotics (χ2 = 5.402, p = 0.02). Thematic analysis revealed that participants believed that the discontinuation of fluphenazine deleteriously impacted the stability of their mental disorder. CONCLUSION: The withdrawal of fluphenazine was associated with increased relapse rate in individuals previously demonstrating stability of their psychotic disorder. While acknowledging the limitation of small sample size, preliminary evidence from this study suggests that treatment with the first-generation antipsychotic (FGA) flupenthixol was associated with a lower risk of relapse compared to SGAs. Reasons for this lower risk of relapse are not fully clear but could be related to dopamine hypersensitivity with this treatment change.

A comparison of rate and methods of probable suicide for 2 years pre and post the onset of the COVID-19 pandemic.

OBJECTIVES: To examine and compare rates and methods of probable suicide in a Western region of Ireland during a 24 month period since the onset of the COVID-19 pandemic compared with a similar period immediately prior to the pandemic onset. METHODS: Post-mortem reports between March 1st 2018 and February 29th 2020 were reviewed and compared with data from March 1st 2020 to February 28th 2022. Relevant demographic data, rates and methods of probable suicide and lifetime engagement with mental health services were compared across the two time points. RESULTS: Identical rates of probable suicide (85 individuals at both time points) were demonstrated with no difference evident in the utilisation of violent compared to non-violent methods. CONCLUSIONS: This study demonstrates that despite previous reports of increased rates of self-harm and some evidence of increased mental distress since the onset of the COVID-19 pandemic, no change in rates of or methods employed by individuals who died by probable suicide were evident in this geographical region.

Kynanthropic and vampirism delusions: a case report and review of the literature.

Zooanthropy (delusional beliefs of turning into an animal) is a rare but well recognised psychiatric phenomenon. This case describes the presence of kynanthropic delusions (delusional beliefs of turning into a dog). Multiple other psychotic symptoms were also evident including unusually the additional presence of delusions of vampirism. Delusional beliefs in this case were associated with behavioural changes including growling and barking, and less commonly an expressed craving for biting people's necks to suck human blood. Symptom intensity was associated with increased psychosocial stressors for this patient, with some benefit noted from very high doses of anti-psychotic medications. Brief admissions to the acute psychiatric inpatient unit and thus removal from environmental stressors has been associated with an amelioration in symptomatology.

A 2-year longitudinal evaluation of the impact of the COVID-19 pandemic on individuals with pre-existing anxiety disorders.

OBJECTIVES: To examine if the COVID-19 pandemic is associated with a differential effect over a 2-year time period in relation to its psychological and social impact on patients with established anxiety disorders. METHODS: Semi-structured interviews were conducted with 21 individuals attending the Galway-Roscommon Mental Health Services in Ireland with an ICD-10 diagnosis of an anxiety disorder. Interviews occurred at three time-points over a 2-year period to determine the impact of the COVID-19 pandemic and associated restrictions on anxiety and depressive symptoms, social and occupational functioning, and quality of life. RESULTS: No statistical difference in symptomatology was noted between the three time-points in relation to anxiety symptoms as measured utilising psychometric rating scales (Beck Anxiety Inventory (BAI), Hamilton Anxiety Rating Scale (HARS) or Likert Scale measures). The greatest impact of COVID-19 at all time-points related to social functioning and quality of life. Significant variability was noted for individual participants. Qualitative analysis noted a tentative optimism for the future in the setting of vaccination and societal re-opening. Fear of re-emerging anxiety symptoms with the removal of societal restrictions was noted. CONCLUSIONS: No significant overall change in symptomatology or functioning over time was noted for individuals with pre-existing anxiety disorders, however variability was demonstrated, with some individuals describing ongoing anxiety, social isolation and concern for their future. A strong theme of hope for the future and less concern regarding the COVID-19 pandemic was evident; however tailored supports including the utilisation of tele-psychiatry is suggested, particularly for those experiencing increased anxiety with the removal of societal restrictions.

The impact of the COVID-19 pandemic on presentations of self-harm over an 18-month period to a tertiary hospital.

OBJECTIVES: To examine and compare rates and methods of self-harm presenting to a tertiary referral hospital during an 18-month period since the onset of the COVID-19 pandemic with a similar period immediately prior to the pandemic onset. METHODS: Data from an anonymized database compared rates of self-harm presentations and methods employed between 1st March 2020 and 31st August 2021 to a similar time-frame prior to the onset of the COVID-19 pandemic. RESULTS: A 9.1% increase in presentations with self-harm was noted since the onset of the COVID-19 pandemic. Periods of more stringent restrictions were associated with higher levels of self-harm (daily rate of 2.10 v 0.77). A higher lethality of attempt was demonstrated post-COVID-19 onset (χ2 = 15.38, p < 0.001). Fewer individuals presenting with self-harm were diagnosed with an adjustment disorder since the onset of the COVID-19 pandemic (n = 84, 11.1%, v. n = 112, 16.2%, χ2 = 7.898, p = 0.005), with no other differences pertaining to psychiatric diagnosis noted. More patients actively engaged with mental health services (MHS) presented with self-harm (n = 239 (31.7%) v. n = 137, (19.8%), χ2 = 40.798, p ≤ 0.001) since the onset of the COVID-19 pandemic. CONCLUSIONS: Despite an initial reduction, an increase in rates of self-harm has occurred since the onset of the COVID-19 pandemic with higher rates evident during periods of higher government mandated restrictions. An increase in active patients of MHS presenting with self-harm potentially relates to reduced availability of supports and particularly group activities. The recommencement of group therapeutic interventions for individuals attending MHS in particular is warranted.

Experiences of international travel in patients with psychotic illness: a case series.

OBJECTIVES: To identify factors influencing successful international travel among patients with psychotic illness. METHODS: Eight individuals participated in a semi-structured interview of 15-20-minute duration with a clinician in relation to their recent experience of international travel. Clinical files were reviewed and a case series was compiled. RESULTS: Four individuals engaged in international travel without any adverse effects. Four other individuals experienced significant psychotic and/or affective symptoms while travelling. Treatment non-adherence, a lack of awareness of how to obtain support and limited or no pre-travel planning were noted in these individuals. CONCLUSIONS: Pre-travel counselling, treatment adherence, provision of information packages relating to their mental illness and having contact details of their treating mental health team increase the likelihood of successful international travel in patients with psychotic illness. Travelling with a companion may reduce fear of relapse.

The association of metabolic syndrome and long acting injectable antipsychotics: A systematic review

Background and ObjectivesLong-acting injectable (LAI) antipsychotics increase patient adherence, reduce relapse rates and facilitate regular interaction with community mental health teams. Antipsychotics are however associated with adverse effects including metabolic syndrome. This review outlines the rates of monitoring for and rates of metabolic syndrome in patients treated with LAI antipsychotics.MethodsWe searched Medline, EMBASE, and Cochrane for Medical Subject Heading (MeSH) terms including metabolic syndrome or MetS and depot or LAI antipsychotics. We included data regarding participants’ clinical characteristics, dose and type of antipsychotics administered, rates of monitoring for- and rates of metabolic syndrome and individual metabolic parameters (body mass index or measure of central obesity, blood pressure, lipid levels, plasma glucose and/or HbA1C levels).ResultsSix studies were included that evaluated rates of monitoring for- and 39 studies examined rates of metabolic syndrome or individual metabolic parameters. Metabolic parameters were not routinely measured in approximately 75% of patients. Rates of metabolic syndrome ranged between 24.3% and 53.2%, with most studies finding no significant differences between oral and LAIs; however, a more preferable weight and lipid profile was detected with LAIs compared to the oral antipsychotics olanzapine and clozapine. Rates of metabolic syndrome and abnormalities of metabolic parameters were comparable among first- and second-generation and between second-generation LAIs.ConclusionsLAI antipsychotics are associated with high rates of metabolic syndrome but low rates of regular monitoring. A robust screening plan to monitor for metabolic syndrome in individuals treated with LAIs is advised including measurement of individual metabolic parameters. (AU)

Quality of life after involuntary psychiatric admission.

Studies seeking predictors of outcomes after involuntary admission, including quality of life (QoL), are limited and results inconsistent. We aimed to describe QoL 3 months after involuntary psychiatric admission and to investigate associated factors. One hundred and fifty-three involuntarily admitted inpatients were assessed for a range of sociodemographic and clinical variables. Structured scales included the Brief Psychiatric Rating Scale (BPRS), the MacArthur Admission Experience Survey, the Heinrichs Quality of Life Scale and the World Health Organisation Quality of Life Brief Assessment (WHOQOL-BREF, n = 124). The mean total score on the Heinrichs QoL scale at 3 months was 69.3 (SD = 24.1). Predictors of higher 3 month QoL after involuntary admission in a multiple regression model (adjusted R2 = 0.37, F = 7.1 (14, 138), p ≤0.001) were less severe negative symptoms on the BPRS at baseline (B = -4.56, p < 0.001), improvement in negative symptom scores between baseline and follow up (B = 4.58, p < 0.001) and higher current social class (B = -14.31, p = 0.001). Events during involuntary admission, such as being subject to coercive experiences, were not significantly associated with QoL after admission. The results suggest that a core determinant of service users' QoL after involuntary admission is negative symptom severity and change over time.

Cognitive Remediation and Social Recovery in Early Psychosis (CReSt-R): protocol for a pilot randomised controlled study.

BACKGROUND: Psychosis, even in its early stages, is associated with significant disability, causing it to be ranked ahead of paraplegia and blindness in those aged 18-35 in terms of years lived with disability. Current pharmacological and psychological interventions intervention have focused primarily on the reduction of positive symptoms (hallucinations and delusions), with little benefit to domains of psychosis such as cognitive difficulties and social and occupational functioning. METHODS/DESIGN: The CReSt-R intervention trial is a single center, pilot randomised controlled study based at the National University of Ireland (NUI), Galway. The trial will recruit participants from four clinical sites with assessment and intervention completed by the primary NUI Galway team. The trial will explore the feasibility, acceptability, and effectiveness of a novel psychosocial intervention for early psychosis based on a combined cognitive remediation training and cognitive behavioural therapy approach focused on social recovery. Participants, aged 16-35 within the first 5 years of a diagnosed psychotic disorder, will be recruited from the Children and Adolescent Mental Health Service and the Adult Mental Health Services in the region. DISCUSSION: Cognitive remediation training (for improving cognition) and social recovery focused cognitive behavioural therapy, have both separately demonstrated effectiveness. This trial will evaluate the feasibility, acceptability, and explore the efficacy of a treatment approach that combines both approaches as part of an integrated, multicomponent intervention. TRIAL REGISTRATION: Cognitive Remediation & Social Recovery in Early Psychosis (CReSt-R): ClincialTrials.gov Identifier NCT04273685. Trial registered Feb 18th, 2020. Last updated April 14th, 2021.

Undertaking a face-to-face objective structured clinical examination for medical students during the COVID-19 pandemic.

INTRODUCTION AND AIMS: Objective structured clinical examinations (OSCEs) play a pivotal role in medical education assessment. The Advanced Clinical Skills (ACS) OSCE examines clinical skills in psychiatry, general practice, obstetrics and gynaecology and paediatrics. This study examined if the 2020 ACS OSCE for fourth year medical students attending the National University of Ireland, Galway, was associated with any significant result differences compared to the equivalent 2019 OSCE. Additionally, we assessed students' satisfaction and explored any organisational difficulties in conducting a face-to-face OSCE during the COVID-19 pandemic. MATERIALS AND METHODS: This study compared anonymised data between the 2019 and 2020 ACS OSCEs and analysed anonymised student feedback pertaining to the modified 2020 OSCE. RESULTS: The mean total ACS OSCE result achieved in 2020 was statistically higher compared to the 2019 OSCE [62.95% (SD = 6.21) v. 59.35% (SD = 5.54), t = 6.092, p < 0.01], with higher marks noted in psychiatry (p = 0.001), paediatrics (p = 0.001) and general practice (p < 0.001) with more students attaining honours grades (χ2 = 27.257, df = 3, p < 0.001). No difference in failure rates were found. Students reported feeling safe performing the 2020 OSCE (89.2%), but some expressed face-mask wearing impeded their communication skills (47.8%). CONCLUSION: This study demonstrates that conducting a face-to-face OSCE during the pandemic is feasible and associated with positive student feedback. Exam validity has been demonstrated as there was no difference in the overall pass rate.

Psychiatric and psychosocial characteristics of suicide completers: A 13-year comprehensive evaluation of psychiatric case records and postmortem findings.

Currently, there are limited data comparing demographic and clinical characteristics of individuals who died by probable suicide and who did and did not previously attend mental health services (MHSs). This study compared demographic and clinical factors for both groups, in a Western region of Ireland over a 13-year period. Postmortem reports between January 1, 2006 and March 31, 2019 were reviewed for 400 individuals who died by probable suicide. Relevant sociodemographic and clinical data were extracted from individuals' lifetime case notes. One hundred and fifty nine individuals (40%) had attended MHSs at some stage ("attendee"). Hanging was the most common method of suicide (61%), followed by drowning (18%) for both attendees and nonattendees of MHSs, with more violent methods utilized overall by nonattendees (p = 0.028). Sixty-eight percent of individuals who previously attempted hanging subsequently died utilizing this method. A higher proportion of attendees were female compared to nonattendees of MHSs (28.9 vs. 14.5%, p = 0.001). Recurrent depressive disorder (55%) was the most common diagnosed mental health disorder. For individuals with a diagnosis of schizophrenia, 39% had antipsychotic medications detectable in their toxicology reports. In conclusion, the majority of people who died by probable suicide had never had contact with MHSs, and nonattendees overall were more likely to utilize violent methods of suicide. Nonconcordance with psychotropic medications in psychotic patients and previous hanging attempt were highlighted as potential risk factors for death by probable suicide.

The impact of service user's suicide on mental health professionals.

OBJECTIVES: Our principle objective was to examine the personal and professional impact of service user (SU) suicide on mental health professionals (MHPs). We also wished to explore putative demographic or clinical factors relating to SUs or MPHs that could influence the impact of SU suicide for MHPs and explore factors MHPs report as helpful in reducing distress following SU suicide. METHODS: A mixed-method questionnaire with quantitative and thematic analysis was utilised. RESULTS: Quantitative data indicated SU suicide was associated with personal and professional distress with sadness (79.5%), shock (74.5%) and surprise (68.7%) particularly evident with these phenomena lasting less than a year for more than 90% of MHPs. MHPs also reported guilt, reduced self-confidence and a fear of negative publicity. Thematic analysis indicated that some MHPs had greater expertise when addressing SU suicidal ideation and in supporting colleagues after experiencing a SU suicide. Only 17.7% of MHPs were offered formal support following SU suicide. CONCLUSION: SU suicide impacts MHPs personally and professionally in both a positive and negative fashion. A culture and clear pathway of formal support for MHPs to ascertain the most appropriate individualised support dependent on the distress they experience following SU suicide would be optimal.

Opinions of key stakeholders regarding the inpatient Individual Care Plan.

OBJECTIVES: In Ireland, regularly reviewed Individual Care Plans (ICPs) for inpatients at all acute psychiatric inpatient units are a requirement of the Mental Health Act 2001. In this study, we comprehensively evaluated and compared opinions of key stakeholders in relation to the ICP as a care delivery tool. METHODS: We employed a descriptive survey design. Questionnaires were distributed to 123 stakeholders (patients and mental health professionals (MHPs)) to evaluate and compare opinions regarding the impact of the ICP in relation to healthcare delivery and health outcomes, and regarding the structure and frequency of use of the ICP. RESULTS: Ninety-eight stakeholders (80%) completed study questionnaires. Stakeholders (patients (58%) and MHPs (85%)) reported that the ICP assisted in healthcare delivery. However, different attitudes between groups were noted in relation to whether the ICP contributed towards healthcare outcomes, with 64% of patients, but only 41% of MHPs reporting that the ICP positively contributed to mental healthcare outcomes. Some free-text comments described patient dissatisfaction with the role of the ICP for healthcare delivery, and MHP dissatisfaction that the ICP was time-consuming and did not significantly enhance standard patient care. CONCLUSION: Whilst the implementation of the ICP is generally viewed positively by both patients and MHPs, considerable dissatisfaction by MHPs was also noted with certain aspects of how the ICP was delivered in practice. Practical adjustments to the implementation of ICP in order to build more positive stakeholder experiences appear warranted and worthy of further research.

A longitudinal evaluation of the impact of the COVID-19 pandemic on patients with pre-existing anxiety disorders.

OBJECTIVES: To examine if the COVID-19 pandemic is associated with a differential effect over time in relation to its psychological and social impact on patients with established anxiety disorders. METHODS: Semi-structured interviews were conducted with 24 individuals attending the Galway-Roscommon Mental Health Services with an International Classification of Diseases (ICD)-10 diagnosis of an anxiety disorder at two time points (six months apart) to determine the impact of the COVID-19 restrictions on anxiety and depressive symptoms, social and occupational functioning and quality of life. RESULTS: No statistical difference in symptomatology was noted between the two time points in relation to anxiety symptoms as measured by utilising psychometric rating scales (BAI and HARS) or utilising a Likert scale. The greatest impact of COVID-19 at both time points is related to social functioning and quality of life. Significant variability was noted for individual participants. Qualitative analysis noted social isolation, concern for the participants' future and increased difficulty managing anxiety with ongoing restrictions. CONCLUSIONS: No significant overall change in symptomatology or functioning over time was noted for individuals with pre-existing anxiety disorders. Variability was, however, demonstrated between individuals, with some individuals describing ongoing anxiety, social isolation and concern for their future. Identifying those with ongoing symptoms or distress and providing multidisciplinary support to this cohort is suggested.

The impact of COVID-19 on a cohort of patients treated with clozapine.

OBJECTIVES: To examine the psychological and social impact of the COVID-19 pandemic and its associated restrictions on a cohort of patients with severe and enduring mental illness treated with clozapine. METHODS: Semi-structured interviews were conducted with 63 individuals attending a clozapine clinic within the Galway-Roscommon Mental Health Services to determine the impact of COVID-19 restrictions on anxiety and depressive symptoms, social and occupational functioning and quality of life, by utilising Likert scale data. The Beck Anxiety Inventory (BAI) and Hamilton Anxiety Rating Scale (HAM-A) were additionally utilised to measure anxiety symptoms cross-sectionally. RESULTS: Anxiety symptoms were low with a median BAI score of 4.0 and HAM-A score of 4.0. Likert scale measurements recorded only a modest adverse impact of COVID-19 restrictions on anxiety and depressive symptoms, quality of life and occupational and social functioning. Free-text comments from patients (n = 55), were grouped into five themes: neutral impact (n = 22), negative psychological impact (n = 13), negative social impact (n = 11), positive psychological impact (n = 5) and media coverage inducing anxiety (n = 4). CONCLUSIONS: Three months into the COVID-19 pandemic and its restrictions, the impact on individuals with treatment-resistant psychotic disorders attending a clozapine clinic has been modest, with preliminary evidence demonstrating minimal increases in subjective symptoms of anxiety and reduced social functioning. Reduced social engagements and supports attainable both within the community and from mental health services were noted by some participants.

Impact of the COVID-19 pandemic on patients with pre-existing anxiety disorders attending secondary care.

OBJECTIVES: To examine the psychological and social impact of the COVID-19 pandemic on patients with established anxiety disorders during a period of stringent mandated social restrictions. METHODS: Semi-structured interviews were conducted with 30 individuals attending the Galway-Roscommon Mental Health Services with an International Classification of Diseases diagnosis of an anxiety disorder to determine the impact of the COVID-19 restrictions on anxiety and mood symptoms, social and occupational functioning and quality of life. RESULTS: Twelve (40.0%) participants described COVID-19 restrictions as having a deleterious impact on their anxiety symptoms. Likert scale measurements noted that the greatest impact of COVID-19 related to social functioning (mean = 4.5, SD = 2.9), with a modest deleterious effect on anxiety symptoms noted (mean = 3.8, SD = 2.9). Clinician rated data noted that 8 (26.7%) participants had disimproved and 14 (46.7%) participants had improved since their previous clinical review, prior to commencement of COVID-19 restrictions. Conditions associated with no 'trigger', such as generalised anxiety disorder, demonstrated a non-significant increase in anxiety symptoms compared to conditions with a 'trigger', such as obsessive compulsive disorder. Psychiatric or physical comorbidity did not substantially impact on symptomatology secondary to COVID-19 mandated restrictions. CONCLUSIONS: The psychological and social impact of COVID-19 restrictions on individuals with pre-existing anxiety disorders has been modest with only minimal increases in symptomatology or social impairment noted.

Routine screening and rates of metabolic syndrome in patients treated with clozapine and long-acting injectable antipsychotic medications: a cross-sectional study.

OBJECTIVES: To examine the rate of monitoring of metabolic syndrome and actual rates of metabolic syndrome in two patient cohorts [clozapine treatment and long-acting injectable (LAI) antipsychotic] who are reviewed on an equally regular basis (1-4 weekly) for administration of treatment. METHODS: Clinical and laboratory data are examined on 119 patients treated with clozapine and 116 patients treated with LAI antipsychotic medications to determine the rates of metabolic syndrome and evidence of monitoring for metabolic syndrome in the previous 6 months. Individuals with insufficient data from these cohorts were invited to attend for metabolic screening to determine actual rates of metabolic syndrome in these two cohorts of patients. RESULTS: All metabolic parameters were monitored to a significantly greater extent in the clozapine cohort (>90%), compared to those treated with LAI antipsychotic medications (<50%) (blood pressure, weight, lipid and glucose levels; p < 0.001). Metabolic syndrome was present in 38.9% of those treated with clozapine compared to 31.1% of patients treated with LAI antipsychotic medications (X2 = 0.54, p = 0.46). CONCLUSIONS: These findings suggest that a robust screening plan should be in place to monitor for metabolic syndrome in individuals treated with LAI antipsychotic medications. This screening should include measurement of body weight, waist circumference, fasting glucose, lipids and fasting insulin levels. Early recognition of abnormal metabolic parameters allows early intervention, therefore, improving long-term cardiovascular outcomes.

A clozapine-induced hypersensitivity reaction.

A 57-year-old female patient with a diagnosis of schizo-affective disorder since 1986 was commenced on clozapine due to persistent positive and negative psychotic symptoms in September 2014. After commencement of clozapine she was delusion free and demonstrated an improvement in negative symptoms. Three months after commencement of clozapine she developed a hypersensitivity reaction. Her symptoms continued to deteriorate despite being prescribed an anti-histamine. Clozapine was discontinued 6 days after the appearance of a generalised pruritic rash, as it was believed to be the probable cause. There was complete resolution of symptoms 1 week after discontinuation of clozapine. Clozapine was replaced with olanzapine and amisulpride. There has been no similar cutaneous or allergic reactions for the past 30 months.