[Bipolar I disorder in France: prevalence of manic episodes and hospitalisation-related costs]

Bipolar disorder is a chronic, highly disabling illness. However, few studies have evaluated the economic impact of this illness. The objective of this study was to estimate: 1) the annual number of manic episodes in patients with bipolar I disorder, and 2) the costs of hospitalisations related to manic episodes in France. We only included data on bipolar I disorder, as there is greater consensus and better documentation for this subgroup of patients with bipolar disorder. The prevalence of manic episodes was estimated using published epidemiological data. A computerised literature search was performed using the traditional scientific and medical databases. Additional epidemiological references were identified from published studies and textbooks. For hospitalisation data, we used the statistics of the Medical Information Department of a large psychiatric hospital in Paris for the year 1999. We estimated the annual number of manic episodes in France based on: 1) the lifetime prevalence of bipolar I disorder, 2) the average cycle duration, 3) the proportion of rapid cycling patients, and 4) the proportion of depressive vs. manic episodes for patients with bipolar I disorder. In order to estimate the prevalence of bipolar I disorder, we conducted a random effects meta-analysis using published international data. Results of the meta-analysis, which was based on a total of 62 736 patients, showed the lifetime prevalence of bipolar I disorder to be 0.82% [95% CI: 0.42, 1.21]. Applied to the adult population in France, this prevalence implies that the number of persons who have ever experienced a bipolar I -disorder is approximately 390,000 [95% CI: 200,000, 575,000]. Few studies provide information on the duration of cycles in patients with bipolar I disorder. Available estimates suggest the cycle duration to be approximately 12 months. Regarding the proportion of rapid cyclers, data from the meta-analysis by Tondo et al. show that 18% of patients with bipolar disorder experience at least four episodes of mood disorder per year. Finally, based on findings provided by cohort studies, the number of depressive episodes appears to be roughly equal to the number of manic episodes during the course of bipolar disorder. A rapid cycling rate of 18% and a cycle duration of 12 months imply that, on average, among 100 bipolar patients, 18 will have a 3-month cycle duration and 82 a 14-month cycle duration. Given an equal proportion of manic and depressive episodes, the annual number of manic episodes would then be 68 for a cohort of 100 bipolar patients (0.68 episode per patient per year). Applying this figure to the estimate of the total number of patients with bipolar I disorder in France suggests that the annual number of manic episodes in France is 265,000 [95% CI: 136,000, 391,000]. Based on data from a psychiatric hospital in Paris, the proportion of manic episodes that require hospitalisation was estimated to be around 63% with an average length of stay of 32.4 days. Hence the annual number of hospitalisations for manic episodes in France is estimated to be 167 000 [95% CI: 86 000, 246 000] and the hospitalisation-related costs 1,3 billion euros approximately. Our review of literature highlights the lack of medical and economic data at the national level on the frequency and hospitalisation-related costs of manic episodes in patients with bipolar I disorder in France. Given the lifetime prevalence of bipolar I disorder which may be as high as 3% among adults, further studies are required in order to provide representative national data and to allow economic evaluations of costs related to bipolar disorder in France.

Three-dimensional structure of the Hospital Anxiety and Depression Scale in a large French primary care population suffering from major depression

Few studies have been specifically carried out to characterize the dimensional structure of the Hospital Anxiety and Depression Scale (HADS) and those that have, have yielded contradictory results. We have examined the factor structure and sensitivity to change of the HADS in a large French outpatient primary care population treated with sertraline for major depression (DSM-IV criteria). Factor analysis of the HADS was performed in 2669 outpatients and in subsamples using a principal component procedure with Varimax rotation. Concurrent change sensitivity of the HADS was compared with that for the Hamilton Depression Rating Scale (HDRS) after at least 45 days of sertraline treatment. Three distinct factors emerged from the HADS factor analysis: a "depression" factor and two separate anxiety subscales: "psychic anxiety" and "psychomotor agitation" whose mean reductions in scores from baseline were significantly correlated (0.36-0.45) with the reduction of the HDRS baseline score. These new data provide support for the use of the HADS's three-dimensional structure to measure improvement of selected symptoms of anxiety during antidepressant therapy.

[Actual approaches to post-psychotic depression]

Clinical features of post-psychotic depression in schizophrenia have been described since the beginning of the century. However, international nosographies mention this concept only since the ICD 10 and the DSM IV. In clinical practice, post-psychotic depression is a real challenge. Currently, the exact prevalence remains undetermined and is estimated about 25%, varying from 7 to 70% in the literature. The diagnostic criteria nowadays available will encourage searchers to determine the exact prevalence of post-psychotic depression. This is surely due to difficulties in the diagnostic approach. The clinical picture resembles that of major depression. However, there are confounding factors such as negative symptoms and extrapyramidal symptoms. With regard to psychometrics, two specific rating scales are thought to measure depressive symptoms in schizophrenia: the Calgary Depression Scale (CDS) and the Psychotic Depression Scale (PDS). Nonetheless, the scales are not specific for post-psychotic depression. Prognosis of an acute schizophrenia is linked among other factors with the emergence of a post-psychotic depression that is in turn influences suicidal risk and quality of life. Genetic, therapeutic, psychodynamic and psychological factors have been invoked in the etiopathogenesis of post-psychotic depression. In clinical practice, post-psychotic depression can be successfully treated with antidepressive medication. Some antidepressants have shown their efficacy.

[Tricyclic antidepressants dosage and depressed elderly inpatients: a retrospective pharmaco-epidemiologic study]

It is recommended to reduce by one half the dosages of tricyclic antidepressants for patients over 65 years of age, in order to avert the occurrence of side-effects. The question we studied was: is it rightful to prescribe tricyclic antidepressants at half-dose to hospitalized elderly people? It is important, for the following reasons, to specify the rules of prescription of tricyclics in elderly patients: 1) The elderly population is on the increase; 2) There is a high prevalence of depression in elderly patients; 3) Depression exposes the elderly person to an increased risk of suicide; 4) Depression influences the prognosis of associated organic disorders 5) Recourse to tricyclic antidepressants is often necessary within this population group because of treatment resistant forms of depression which impose the use of different families of antidepressants and thus resort to tricyclics despite their lower tolerance.

OBJECTIVES AND METHODS

The aim of our study is to evaluate whether the half doses of tricyclics recommended for an elderly person are sufficient in the case of an hospitalized patient. In order to provide some answer to this question, we have carried out a retrospective study. We have studied a sample of patients over-65, hospitalized at the Clinique des Maladies Mentales et de l'Encéphale, over a period of two years, with a ICD 10 diagnosis of moderate or severe intensity major depressive episode, and treated effectively with return to the euthymia. Creatinemia was prescribed systematically to each patient on entry. Only patients with normal renal function were retained. Laboratory norms are between 45 and 120 micromol/liter. The routine practice of imipraminic blood dosages allowed the comparison of blood levels obtained among patients treated with posologies inferior or equal to 75 mg/day imipraminic, to those treated with more than 75 mg/day imipraminic for a least a week. The percentage observed were compared using the Khi2 test with Yates correction. We retained the blood concentrations of the mother molecule for tertiary amines (imipramine, clomipramine and amitriptyline). The samples were taken after at least seven days of treatment at the same dose, and twelve to thirteen hours after the last taking. The maxima of blood levels were respectively: desipramine 200 ng/ml, clomipramine 258 ng/ml, imipramine 163 ng/ml, amitriptyline 129 ng/ml. Research for evidence in favor of toxicity (fall, delirium, convulsion, reduction of dosage before discharge), was done through revision of patients' clinical files.

RESULTS

The test group consisted of 87 individuals. The average age was 71.3 years (SD: 5.09). Mean creatinemia was 83.73 mmol/l (SD: 26.89). The population thus selected divided into 4 groups: 61 (70.1%) were given imipraminics, 10 (11.5%) serotonin recapture inhibitors, 11 (12.7%) other antidepressants essentially of mianserine and 5 (5.7%) treatment by electroconvulsivotherapy. The imipraminics prescribed were desipramine, imipramine, clomipramine and amitriptyline. Among the 61 patients treated with imipramine, blood level dosage was practised on 48 patients (79%). Two subgroup were distinguished: 13 (21%) received dosages inferior ou equal to 75 mg/day and 48 (79%) superior to 75 mg/day. The mean dosage found in the sub-group of patients treated with dosages superior to 75 mg/day was 140 mg/day (SD: 30). The subgroup treated with dosages superior to 75 mg/day was more frequently monitored than the subgroup receiving dosages inferior or equal to 75 mg/day, respectively 40/48 (83%), and 8/13 (62%). This difference is statistically nonsignificant (p > 0.10). The analysis of dosages used showed that:--among the dosages effected upon patients receiving doses inferior or equal to 75 mg/day, 1 (12.5%) exceeded the maximal value of therapeutic range.--Among the dosages effected upon patients receiving dosages superior to 75 mg/day, 9 (22%) exceeded the maximal value of the therapeutic range. The difference is statistically significant (p < 0.001). On revision of clinical files, no patient presented any element that might lead one to suspect toxicity such as defined in "Objectives and Methods".

CONCLUSION

In our study, patients were hospitalized and so benefited from closer observation than one can expect in outpatients. In this particular context, the dosages used are close to those advocated for the general population. With the elderly subject, the systematic prescription of half-dose tricyclics runs the risk of infratherapeutic dosage. It is thus preferable to resort to blood level dosage and to look for a maximum dose tolerance before concluding ineffectuality. This allows one to monitor whether the blood levels obtained are included in the therapeutic range; to avoid toxic doses and to check weak compliance in the elderly patient. Our findings do not oppose the use, for the elderly hospitalized depressive, of doses of imipraminics close to those of a young subject. To confirm these results it would be desirable to carry out o prospective study, including a systematised evaluation of adverse effects and a comparison of clinical effectiveness for parallel groups of elderly patients receiving different doses of imipraminic antidepressants.

Fear as the main feature of epileptic seizures

OBJECTIVES

There are circumstances in which partial seizures may be misdiagnosed as acute psychiatric disturbances. In particular, when fear is the prominent feature the patient may be considered for years as having panic attacks. Eight patients in whom fear was the main symptom of the seizures are reported on. Patients who had a proved lack of consciousness during the fits and patients in whom fear was just fear of having a seizure were excluded. The ictal involvement of temporal limbic and frontal structures in those patients with fear of particular intensity was studied.

METHODS

The localisation of the epileptogenic zone was assessed by prolonged interictal EEG recordings as well as ictal video-EEG recording of at least one seizure in every patient; five had ictal SPECT and four had chronic stereotactic implantation of depth electrodes (SEEG). In six patients, a cortical resection was performed with an Engel's class 1 outcome (minimum 28 months follow up, except for two patients).

RESULTS

Localisations of primary epileptogenic zones were right temporal in three patients, left temporal in three, bitemporal in one, and frontal in one. In all cases, diagnosis of epileptic seizures could be clinically evoked because of the stereotypy of fits and of associated symptoms. The association of a fear sensation, autonomic symptoms, and coordinated behaviour suggests disturbance of a particular system. The SEEG data argue for temporolimbic and prefrontal lobe involvement in the expression of ictal fear.

CONCLUSIONS

In intense ictal fear, with coordinated behaviour and autonomic features, the discharge may involve or interfere with a physiological complex information processing network. This network involves orbitoprefrontal, anterior cingulate, and temporal limbic cortices.

Are washout periods useful in antidepressant trials?

Single-blind placebo washout periods before randomisation enable the elimination of the psychotropic agents previously received. They subdue carryover effects which could be achieved without using a placebo. Washout periods also purport to identify and eliminate the placebo responders. Trivedi et al. performed a meta-analysis which included 101 studies. They demonstrated that placebo washout periods do not reduce the response rate in the placebo group and do not increase the difference between the placebo and the treated group. This held true for all the different antidepressant classes. In another study, Greenberg et al. analysed 28 antidepressant controlled trials published between 1983 and 1992 and found no difference between trials with or without a placebo washout period in terms of response rate in either the placebo or the treated group. Therefore, placebo washout periods, although appealing and widely used, may not reduce the number of patients who respond to placebo. Besides, the patients who respond during the washout period have very diverse outcomes after three months. This subgroup is likely to be heterogeneous and should be better studied. Some authors have stated that washout periods may bring in confounding effects such as lowering the observed difference between the treated and placebo group. Their explanation was that response to placebo is not a stable characteristic and that responding to placebo during the washout period may subsequently lower the level of placebo-induced improvement. It would also be cumbersome if washout periods covered the problems related to the placebo and blindness issues, which are often neglected. Finally, it appears necessary to further assess the usefulness of single-blind washout periods.

Critical approach to antidepressant trials. Blindness protection is necessary, feasible and measurable

BACKGROUND

Double-blind placebo-controlled trials are the academic standard for clinical psychopharmacology research.

AIMS

To identify the potential defects of current double-blind procedures in trials involving antidepressants and to investigate whether safeguards for blindness protection are used.

METHOD

We reviewed the literature and devised a short seven-item checklist for evaluating the quality of blindness protection. We performed a computerised search for 1998 to identify the placebo-controlled studies that evaluated the efficacy of an antidepressant. The checklist was used to assess all traceable antidepressant trials published in 1998.

RESULTS

Relevant criticisms question the blindness procedures. The available methods which may bolster blindness are very seldom used.

CONCLUSIONS

Improvement in the blindness procedures used for antidepressant trials is necessary, feasible and measurable.

Prevalence of electrocardiographic and echocardiographic abnormalities in ambulatory ischemic colitis

The aim of this study was to evaluate the prevalence of cardiac arrhythmia and intracardiac embolic process in ambulatory ischemic colitis. From November 1994 to November 1997, 33 consecutive cases of ambulatory ischemic colitis were detected. This study included 21 women and 12 men with a mean age of 71 years. All patients underwent a cardiovascular investigation including questioning, electrocardiogram, 24-hr ambulatory electrocardiography and transthoracic echocardiography. A prior history of ischemic colitis was found in four cases (12%). Cardiac arrhythmia was detected in eight cases. Transthoracic echocardiography showed an intracardiac process, potentially responsible for a peripheral embolism, in four cases. In conclusion, the aggregate, in 33% of the patients, there was potential cardiac etiology. This suggests that when ambulatory ischemic colitis occurs, it is necessary to perform an exhaustive cardiovascular evaluation similar to those performed in other ischemic diseases.

A pilot study of iron depletion as adjuvant therapy in chronic hepatitis C patients not responding to interferon

The aim of this study was to assess the efficacy of iron depletion obtained by phlebotomy to enhance interferon response in 11 patients who had failed to respond to a standard 3-month interferon treatment. Despite a significant effect on serum aminotransferase levels, there was no effect on viremia, and iron depletion was unable to trigger interferon response.

[determining factors of depression in multiple sclerosis: review of the literature]

Depression is considered to occur more frequently in multiple sclerosis than in other chronic organic disorders. The determining factors of this specific association have been appraised by most authors in a dichotomic manner, confronting organic to psychogenic hypotheses. To assess these hypotheses two investigational methods have been used in the literature: either the search for correlations between depression and other parameters linked to the neurologic process, or the comparison of the course of neurologic and thymic symptoms. Systematically scrutinizing this literature enabled us to discuss its findings as well as its methodologic and conceptual limitations.

[Current trends in the therapeutic use of thymic regulators]

LITHIUM: Current research in the field of dysthymia therapy is dominated by the discovery of alternatives to lithium. Lithium remains however the gold standard, whether used alone or combination with anti-seizure drugs such as carbamazepine, valpromide or valproate. The most recent data on lithium therapy emphasize the need for precaution in case of pregnancy. New interactions, particularly with converting enzyme inhibitors, have also been evidenced. Finally, like beta blockers, lithium should be tapered off progressively over a two-month period to avoid early relapse. OTHER TREATMENTS: New candidate drugs such as lamotrigine offer some promising perspectives. For severe states, long-term electroconvulsivotherapy can be proposed. Finally, drug therapy should be integrated into a structured psychotherapy program in order to favor the prevention of relapse and reduce the negative psychosocial consequences of mood disorders. Both the patient and close family and friends should participate in the psychotherapy; several methods have been developed with promising efficacy to be confirmed by controlled studies.

[Superficial cancer of the stomach in the area of Calvados from 1978 to 1990. Epidemiology and prognostic factors]

AIMS OF THE STUDY

The 5-year survival rate of gastric cancer is less than 20% in cancer registries. The prognosis of early gastric cancer is much better but this diagnosis is rare in Europe. The aim of the study was to evaluate the prognosis and trends in the incidence of early gastric cancer in the area of Calvados (France) during a 13-year period.

METHODS

Between 1978 and 1990 the Digestive Cancer Registry of Calvados recorded 1,160 new cases of gastric cancer. The diagnosis of early gastric cancer was defined according to the Japanese Gastroenterological Society criteria. Prognostic factors were determined with univariate and multivariate analysis.

RESULTS

One hundred patients had early gastric cancer (8.6%). This rate did not change significantly during the period. The mean age was 64.2 +/- 1.5 in males and 64.8 +/- 2.2 in females and 39% of patients were older than 70. A precancerous condition was present in 56% of cases on the surgical specimen. A total gastrectomy was performed in 23% of cases and a subtotal gastrectomy in 72% of cases. The postoperative mortality was 5% and the 5-year relative survival was 86.8% +/- 4.6. Univariate and multivariate analysis found a better prognosis in patients younger than 75 or in patients with a superficial or excavated gross appearance compared with those older than 75 or with a protruded type. Lymph node metastasis, depth of invasion, size of the tumor and histologic differentiation did not influence significantly the outcome.

CONCLUSION

According to the data of the Cancer Registry of Calvados the proportion of Early Gastric Cancer was low and did not change between 1978 and 1990. The prognosis of EGC is good, mainly altered in elderly and in cases with a protruded type.

[Epidemiology of hepatocellular carcinoma in the department of Calvados]

OBJECTIVES

The aim of this study was to determine the epidemiological characteristics of hepatocellular carcinoma in a non-selected population.

METHODS

Between 1984 and 1990, all cases of hepatocellular carcinoma were registered at the Registry of Digestive Tumors of Calvados. Standardized incidence rates were calculated for males and females. Prognostic factors were determined by the Cox multivariate method.

RESULTS

213 patients with hepatocellular carcinoma were registered. Standardized incidence rates were 7.5/100,000 in men and 0.4/100,000 in women. Sex-ratio was 18.3. Mean age was 66.4 years; hepatocellular carcinoma was uncommon (3%) before the age of 50. Cirrhosis was associated in 85.9% of patients. The cause of cirrhosis was known in 150 cases: alcoholic: 73.3%, cryptogenetic: 8.7%, viral B or C: 7.3%, alcoholic and viral B or C: 5.3%, and genetic hemochromatosis: 4.7%. The overall survival rate in 203 patients was 21%, 8% and 3% at 1 year, 3 years and 5 years, respectively. The multivariate study identified 4 prognostic factors: number of tumors < or = 2, lack of ascites, serum alpha-fetoprotein < or = 10 mg/mL, and hepatocellular carcinoma revealing a well-compensated liver disease until the time of diagnosis.

CONCLUSION

The occurrence of hepatocellular carcinoma seems to be linked to cirrhosis, male sex, and age > 50, which could be used as the main selection criterias for the screening of hepatocellular carcinoma.

[Bipolar affective disorder and Ekbom syndrome: apropos of a case]

A delusion of parasitosis may be seen in patients with a variety of organic and psychiatric disorders. It may also be a primary delusion often referred to as the "Ekbom syndrome". The nosological categorization of this rare condition is still under debate. We report the case of a 81 year-old woman followed in our department during more than 20 years for a bipolar affective disorder. Five years ago she developed a persistent delusion of parasitosis displaying phenomenological characteristics that are typical of the Ekbom syndrome. Given the complete independence of the respective courses of affective and delusional symptoms, we concluded in favour of a genuine comorbid association between two independent disorders. To our knowledge this association has not heretofore been described in the French or English language literature. It raises questions regarding the connections between affective disorders and delusions of parasitoris.

Lactate dehydrogenase-elevating virus (LDV): lifelong coexistence of virus and LDV-specific immunity

Viruses have developed various strategies to coexist with vertebrate hosts. Lactate dehydrogenase-elevating virus (LDV) is a highly cytopathic virus exhibiting an extraordinary rate of replication; LDV nevertheless establishes a persistent infection without harming the host. The cytotoxic and helper T cell responses to LDV were monitored in mice with different genetic backgrounds. LDV-specific cytotoxic and helper T cells were found in all strains tested. These responses persisted for at least up to 250 days despite high levels of LDV in the blood. Thus, the cytopathic LDV induces and maintains an inefficient immune response that is not exhausted. LDV infection in mice reveals a special type of host-virus equilibrium where LDV quickly establishes persistence despite continuously induced LDV-specific helper and cytotoxic T cell responses, which apparently are too slow to control the highly cytopathic and extremely fast replicating virus.

Lactate dehydrogenase-elevating virus (LDV): lifelong coexistence of virus and LDV-specific immunity

Viruses have developed various strategies to coexist with vertebrate hosts. Lactate dehydrogenase-elevating virus (LDV) is a highly cytopathic virus exhibiting an extraordinary rate of replication; LDV nevertheless establishes a persistent infection without harming the host. The cytotoxic and helper T cell responses to LDV were monitored in mice with different genetic backgrounds. LDV-specific cytotoxic and helper T cells were found in all strains tested. These responses persisted for at least up to 250 days despite high levels of LDV in the blood. Thus, the cytopathic LDV induces and maintains an inefficient immune response that is not exhausted. LDV infection in mice reveals a special type of host-virus equilibrium where LDV quickly establishes persistence despite continuously induced LDV-specific helper and cytotoxic T cell responses, which apparently are too slow to control the highly cytopathic and extremely fast replicating virus.

Migraine and angina pectoris by coronary artery spasm

A migrainous patient who experienced chest pain attributed to angina pectoris by coronary artery spasm during a migraine attack is reported. Previous reports have already mentioned the association of these two conditions and suggested that it might be the manifestation of a generalized vasospastic disorder. This new report offers an opportunity to review and discuss the available data on such an association.

Differential glycosylation of the ectodomain of the primary envelope glycoprotein of two strains of lactate dehydrogenase-elevating virus that differ in neuropathogenicity

ORF 5 encoding the primary envelope glycoprotein, VP-3P, of a highly neuropathogenic isolate of lactate dehydrogenase-elevating virus (LDV-v) has been sequenced. It exhibits 92% nucleotide identity with the ORF 5 of an LDV isolate that lacks neuropathogenicity, LDV-P, and the amino acid identities of the predicted VP-3Ps of the two strains is 90%. Most striking, however, is the absence in the ectodomain of LDV-v VP-3P of two out of three potential N-glycosylation sites present in the ectodomain of VP-3P of LDV-P. The ectodomain of VP-3P has been implicated to play an important role in host receptor interaction. VP-3P of another neuropathogenic LDV strain, LDV-C, lacks the same two N-glycosylation sites (Godeny et al., 1993). In vitro transcription/translation of the ORFs 5 of LDV-P and LDV-v indicated that all three N-glycosylation sites in the ectodomain of LDV-P VP-3P became glycosylated when synthesized in the presence of microsomal membranes, whereas the glycosylation of the ORF 5 proteins of LDV-v and LDV-C was consistent with glycosylation at a single site. No other biological differences between the neuropathogenic and non-neuropathogenic strains have been detected. They replicate with equal efficiency in mice and in primary macrophage cultures.

Mouse hepatitis virus infection of mice causes long-term depletion of lactate dehydrogenase-elevating virus-permissive macrophages and T lymphocyte alterations

Intraperitoneal injection of pathogen-free B10.A mice with mouse hepatitis virus (MHV)-A59 resulted in a short subclinical infection which was terminated by a rapid antiviral immune response. The infection resulted in a rapid, but transient, about 10-fold increase in the number of macrophages and total cells in the peritoneum of the mice. This increase was preceded by a complete depletion of the peritoneum of the subpopulation of macrophages that supports a productive infection by lactate dehydrogenase-elevating virus (LDV). The depletion of LDV-permissive macrophages was a long-term effect; at 50 days post-infection with MHV, the proportion of LDV-permissive macrophages in the peritoneum had reached only 20% of that observed in the peritoneum of uninfected mice, whereas the total number of macrophages in the peritoneum had returned to normal. Furthermore, MHV infection resulted in a long-term alteration in the proliferative response of spleen T cells to concanavalin A (ConA) and in their ability to produce interferon gamma; several times higher concentrations of ConA were required to induce a maximum proliferative response in spleen T cell populations from 5-week MHV-infected B10.A mice than in spleen T cell populations from infected companion mice but the former produced 5 times more interferon gamma than the T cells from uninfected mice.