Background Little is known about the role of protective factors in suicidal ideation among medical students. This study aimed to examine the association between suicidal ideation and protective (self-esteem/ego-resiliency/social support) and risk (depression/social anxiety) factors. Methods Data on sociodemographic factors, depression, social anxiety, self-esteem, ego-resiliency, social support, and current suicidal ideation were collected from 408 medical students. A logistic regression model was constructed to identify the independent impact of potential influencing factors on suicidal ideation. Potential moderating effects were also explored. Results Thirty-eight participants (9.3%) reported experiencing suicidal ideation. Younger age, higher levels of depression, social anxiety, and lower levels of self-esteem, ego-resiliency, and social support were found to be significantly correlated with suicidal ideation. In the final model, higher levels of depression and social anxiety were associated with an increased risk of suicidal ideation, while higher levels of self-esteem and social support were associated with a decreased risk of suicidal ideation. Although the independent effect was not significant, the interactions of ego-resiliency with both depression and social anxiety on suicidal ideation were significant. Higher levels of ego-resiliency acted as a buffer against suicidal ideation among those with higher levels of depression or social anxiety. Conclusions In addition to risk factors, this study revealed the underlying protective and moderating factors of suicidal ideation among medical students. Mental health programs focusing on enhancing ego-resiliency, self-esteem, and social support may contribute to suicide prevention in medical students.

on pathological on-line gaming has increased substantially over the past two decades. 1,2 Internet gaming disorder (IGD) was included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a tentative disorder needing further research. 3 The DSM-5 defines IGD as "persistent and recurrent use of the internet to engage in games, often with other players, leading to clinically significant impairment or distress. " The nine criteria for IGD in the DSM-5 are based on preliminary studies outlining the criteria for substance use disorder and gambling disorder. IGD, as a form of behavioral addiction, shares typical characteristics with substance addiction, including withdrawal, tolerance, loss of control, and cravings. 4 Before the DSM-5 criteria, var-

Background Akathisia tends to develop as an early complication of antipsychotic treatment in a dose-dependent manner. Although withdrawal akathisia has been reported after the discontinuation or dose reduction of typical antipsychotic drugs, akathisia following atypical antipsychotic drug withdrawal remains a rare phenomenon. Case presentation A 24-year-old woman with an acute psychotic episode was admitted and initially treated with aripiprazole. The aripiprazole dose was titrated up to 30 mg/day over 9 days and maintained for the next 3 days; however, her psychotic symptoms persisted without change. She was switched to amisulpride, with the dose increased over 2 weeks to 1000 mg/day. Subsequently, although the patient’s psychotic episode subsided, her serum prolactin levels increased markedly. After discharge, the amisulpride dose was increased to 1200 mg/day owing to auditory hallucinations and was maintained with quetiapine (100–200 mg/day) and benztropine (1 mg/day) for 13 weeks. Given the potential for hyperprolactinemia as a side effect, the amisulpride dose was reduced to 800 mg/day concurrently with the discontinuation of benztropine; however, these changes resulted in severe restlessness without other extrapyramidal symptoms. The withdrawal akathisia disappeared over 2 weeks after switching to aripiprazole (10 mg/day) with propranolol (40 mg/day) and the patient’s prolactin levels had normalized after 6 months of aripiprazole monotherapy. Conclusions The present case highlights the potential for the development of withdrawal akathisia when the dose of amisulpride is tapered abruptly. Thus, a slow tapering and careful monitoring are recommended when switching from amisulpride to other antipsychotic drugs. Furthermore, this case suggests that changing the regimen to aripiprazole with propranolol may be a potential option for amisulpride withdrawal akathisia superimposed on pre-existing hyperprolactinemia.

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