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Background and Aims:Clozapine remains the gold standard for the management of treatment-resistant schizophrenia. Due to the need for close medical supervision at initiation it is usually started in hospital although this is no longer mandatory. It is estimated that speed of up-titration will affect length of stay.Methods:Retrospective study of prescription charts of 14 patients representing the most recent who have been prescribed clozapine as in-patients. Data would be compared against the titration doses recommended by the British National Formulary and by the manufacturers (Novartis).Results:5/14 patients were admitted solely for clozapine initiation. 1/14 did not tolerate it after 5 days. 2/14 patients were re-started clozapine following a period of discontinuation and their discharge dose was achieved faster than initial titration as recommended. 9/14 patients’ titration was slower than recommended by the guidelines with a minimum difference of 113 days if using the slower recommended titration or a maximum of 208 days if using the faster one. None of the patients’ titration appeared to be slowed down due to the presence of emerging side-effects.Conclusions:Prescribing practice appears to lengthen hospital admissions due to delays in changing doses. This was less relevant for patients admitted exclusively for clozapine initiation. The development of a policy for community initiation and the development of a pre-printed up-titration chart for clozapine are potential solutions to minimise bed occupancy therefore improving both patients’ experiences and bed management.

Background:Serotonin syndrome is a disorder caused by drug induced excess of intra-synaptic 5-hydroxytryptamine (5-HT). Combination of drugs with different mechanisms of action is the most common cause of the reaction.Aims:To report a case of serotonin syndrome in order to underline the interactions between antidepressant and pain relief medication.Methods:Case study and description of a patient treated in out-patient clinic.Results:A 48 year old gentleman was referred to a community mental health team for review of his depressive disorder and medication. The patient had a 15 year history of recurrent depressive disorder and a 10 year history of chronic back pain and migraine. The patient had been on medication for both conditions requiring frequent changes in drugs and doses. A recent episode of depression was managed by changing from sertraline to venlafaxine. His pain relief medication included sumatriptan and tramadol. He soon experienced agitation, confusion, restlessness, dry mouth, and sweatiness. The symptoms worsened for 10 days until the patient stopped venlafaxine and returned to sertraline.Conclusions:In patients with chronic pain and depression a detailed drug history and awareness from clinicians to the risk of serotonin syndrome are vital due to potentially fatal complications.