AB1120 PSYCHOLOGICAL ASSESSMENT IN PATIENTS WITH CHRONIC RHEUMATIC, SYSTEMIC AUTOIMMUNE, OR AUTOINFLAMMATORY DISEASES PRESENTED WITH COVID-19: THE MentCOVRMD STUDY

Background

The COVID-19 pandemic has raised concerns about its psychological effects. Sleep disturbances, anxiety and/or depressive symptoms, post-traumatic stress symptoms have been reported in general population. Patients with chronic rheumatism, systemic autoimmune disease or auto-inflammatory disease, due to immunosuppression, are at risk of severe forms of infection. Currently, there is little information on psychological impact of the pandemic on the mental health of these more vulnerable patients.

Objectives

To compare psychological assessment between patients with chronic rheumatic, autoimmune and/or autoinflammatory diseases who presented with COVID-19 infection between March and September 2020, first wave of French pandemic, and patients with same diseases who did not presented with infection to date.

Methods

The MentCOVRMD study was a multicenter descriptive study. Cases were patients with chronic rheumatic, autoimmune and/or autoinflammatory diseases from the French RMD cohort who presented COVID-19 infection between March and September 2020. Controls were patients with same diseases who did not develop infection. The study is registered in Clinical Trials under number 2020-A02058-31.

For participants, following criteria were collected: demographics (age, gender, smoking status); psychological assessment questionnaires: Insomnia Severity Index (ISI); Post-traumatic stress disorder (PTSD) checklist; Patient Health Questionnaire (PHQ9) Depression; Generalized Anxiety Disorder (GAD7) Anxiety; Patient Health Questionnaire-15 (PHQ-15) and Somatic Symptom Disorder (SSD)-12.

Results

Between February and December 2021, 60 cases (46 (76.7%) women), median age 52.0 (39.0; 63.0) were included, of which 15 (25%) had been hospitalized during infection, and 169 controls (148 (87.6%) women), median age of 52.0 (38.0; 63.0). There were more smokers in the group of cases 12 (20%) than controls 14 (9.1%) (p=0.028) as well as more cases on ARA2 treatment (8 (13.3%)) than controls (7 (4.5%)) (p=0.035) with no statistically significant difference in others comorbidities or treatments.

There was no statistically difference concerning the ISI scores between cases (11.83 ± 7.31) of which 60% had sleep disorders and controls (11.64 ± 6.82) of which 70.4% had sleep disorders. There was no statistically significant difference in PTSD scores of 15.5 (5.0 to 28.0) for cases and 18.0 (8.0 to 35.0) for controls, of which respectively 12 (20%) had values indicating possible PTSD for cases and 50 (29.6%) for controls. There was no statistically significant difference in PHQ-9 scores (5.5 (1.5 to 11.0)) of which 50% had depressive symptoms and controls (6.0 (2.0 to 11.0)) of which 54.5% had symptoms. There was no statistically significant difference in GAD-7 scores (3.5 (0.0 to 8.0)) of which 40% had anxiety symptoms and controls (4.0 (0.0 to 8.0)) of which 43.2% had symptoms. There was no statistically significant difference in PHQ-15 scores (11.4 ± 6.7), 85% of whom reported presence of symptoms, and controls (10.9 ± 6.2), 82.3% of whom reported symptoms. There was no statistically significant difference in SSD scores between cases (17.7 ± 10.9) and controls (18.4 ± 10.9).

There was a statistically significant difference in reported VAS scores of pain related to inflammatory rheumatism in cases with a median of 4.5 (3.0 to 6. 0) compared to controls with a median of 4.0 (1.0 to 6.0) (p=0.011).

There was no statistically significant difference in any of the psychological assessment scores between the inpatient and outpatient COVID cases.

Conclusion

There was no statistically significant difference between COVID cases and controls in the evaluation of these psychological parameters. Prevalence of all these variables were high in the whole study population, testifying to the need to manage these psychological aspects for patients with chronic rheumatisms, autoimmune and/or autoinflammatory diseases.

Disclosure of Interests

None declared

Effects at 3 months of a large-scale simulation-based training for first year medical residents on the knowledge of suicide

BACKGROUND

Suicide is a leading yet underestimated cause of death in the world and in France. The goal of our study was to determine the impact at 3 months of a large-scale simulation program on suicide risk assessment for first-year medical residents.

METHODS

All the first-year medical residents participated in the simulation program that included a session on suicide risk assessment. The scenario was carried out by a standardized patient (professional actor) who had a normal check-up at the ER after a chest pain. He verbalized suicidal thoughts to an ER nurse due to a recent divorce and social difficulties, who then reported it to the resident. The latter had to assess suicide risk on his own. The QECS "Questionnaire de connaissances relatives au suicide" was used to assess knowledge of suicide before the training session (T0) and 3 months later (T1). A pre/post comparison was performed with a paired t-test.

RESULTS

420 residents participated in this study. A total of 273 matching questionnaires was obtained. A statistically significant theoretical knowledge improvement was found at 3 months of the session for all the residents.

LIMITATIONS

The absence of a control group and data loss were some of the major limitations of our study. Another limitation corresponds to the lack of additional questions, such as levels of interest, former and recent training, level of experience, attitudes, and self-competency in suicide risk assessment before and after the simulation program that could have helped to interpret the obtained results and their variation. Moreover, the exact effects of this increased knowledge on clinical practice has not been measured in our study.

CONCLUSION

This is an unprecedented, large-scale attempt in France to allow all the medical residents to practice suicide risk assessment. This simulation-based training had a positive impact at 3 months on the knowledge of suicide in medical residents.

Effectiveness of a French Program to Prevent Suicide Reattempt (VigilanS)

AIM

Brief contact interventions (such as letters, green cards, telephone calls or postcards) for reducing suicide reattempt (SR) and suicide have been evaluated since the 1980s, but results have been inconsistent. VigilanS is one of these programs that has benefited patients hospitalized for suicide attempt (SA) after discharge in 2 departments of northern France since 2015. The purpose of this study is to demonstrate its effectiveness in reducing SR.

METHODS

Patients exposed to VigilanS in 2016 were recruited from the medical administrative database of the program, and the nonexposed patients from a database of the medico-surgical ward outside the scope of the program. First, a Cox model was used to compare the probability of SR during the 12-month follow-up period between the 2 groups. Second, a propensity score using the variables sex, age, source, SA history and SA method was used to match the VigilanS-exposed and the nonexposed patients. A Cox model propensity score adjusted analysis was reiterated on the matched data.

RESULTS

The exposed and nonexposed groups included 3,068 and 3,694 individuals, respectively. In the bivariate analyses, the cumulative probability of SR at 12 months was significantly lower in the exposed group (6.0%, 95% confidence interval (CI): 5.5-6.5%) than in the nonexposed group (16.8%, 95% CI: 15.9-17.7%; p < 0.001). In the Cox model, the hazard ratio of SR was 0.38 in the exposed patients (95% CI: 0.36-0.40, p < 0.001). After matching, the cumulative probability of SR at 12 months was 5.2% in exposed versus 22.2% in nonexposed patients (p < 0.001). In the propensity score-adjusted Cox model, the hazard ratio of SR in the exposed patients was 0.19 (95% CI: 0.14-0.24, p < 0.001).

CONCLUSION

The results suggest the effectiveness of this real-life program for reducing SR. However, VigilanS only benefits a portion of the patients hospitalized for SA and therefore could be extended.

Prevalence and impact of patient suicide in psychiatrists: Results from a national French web-based survey

BACKGROUND

Patient suicide (PS) is known to be a frequent and challenging occupational hazard for mental health professionals. No study previously explored the prevalence and impact of PS in a large sample of French psychiatrists.

METHOD

A national web-based survey was performed between September and December 2019 to assess (a) the prevalence of the exposure to PS, (b) the emotional, traumatic and professional impacts of PS, and (c) the perceived support in the aftermath of PS in French psychiatrists. Participants were contacted through email to answer the online 62-item questionnaire, including a measure of traumatic impact through the Impact of Event Scale-Revised. Emotional and professional impacts and perceived support were assessed through dedicated items.

RESULTS

A total of 764 psychiatrists fully completed the survey. Of them, 87.3% reported an exposure to PS and 13.7% reported PTSD symptoms afterward. Guilt, sadness and shock were the most frequent emotions. Among the exposed psychiatrists, 15.1% have temporarily considered changing their career path. The most emotionally distressing PS occurred during their ten first years of practice or during residency. A total of 37.1% of respondents felt unsupported and 50.4% reported that no team meeting had been organized in the aftermath. The feeling of responsibility for the death was strongly associated with negative impacts.

CONCLUSION

Our results entail considerations to prevent negative mental health outcomes in psychiatrists after PS. Notably, our results advocate for the implementation of educational programs during psychiatric residency and postvention programs in healthcare settings to effectively help psychiatrists in dealing with PS.

[Psychopathological consequences of confinement]

The psychological effects of isolation have already been described in the literature (polar expeditions, submarines, prison). Nevertheless, the scale of confinement implemented during the COVID-19 pandemic is unprecedented. In addition to reviewing the published studies, we need to anticipate the psychological problems that could arise during or at a distance from confinement. We have gone beyond the COVID-19 literature in order to examine the implications of the known consequences of confinement, like boredom, social isolation, stress, or sleep deprivation. Anxiety, post-traumatic stress disorder, depression, suicidal or addictive behaviours, domestic violence are described effects of confinement, but the mechanisms of emergence of these disorders and their interrelationships remain to be studied. For example, what are the mechanisms of emergence of post-traumatic stress disorders in the context of confinement? We also remind the reader of points of vigilance to be kept in mind with regard to eating disorders and hallucinations. Hallucinations are curiously ignored in the literature on confinement, whereas a vast literature links social isolation and hallucinations. Due to the broad psychopathological consequences, we have to look for these various symptoms to manage them. We quickly summarize the diagnostic and therapeutic approaches already in place, such as telemedicine, which is undergoing rapid development during the COVID-19 crisis.

A blended cognitive behavioral intervention for patients with adjustment disorder with anxiety: A randomized controlled trial

Adjustment disorder with anxiety (ADA) is a common psychiatric pathology worldwide, but it is often undertreated. Cognitive behavioral therapy (CBT) is the first-line treatment, but very few studies have been carried out for the treatment of ADA. Internet-delivered CBT (iCBT) appears to be an effective treatment option, with the potential to reach a larger proportion of individuals suffering from ADA. Guidance is a beneficial feature of iCBT, provided in most studies by email or telephone (traditional guided iCBT). Blended CBT, which combines an online intervention and therapeutic guidance provided in person (face-to-face), could be a way to benefit from both the advantages of face-to-face CBT regarding human interactional quality and the advantages of internet-based CBT in terms of improved access to treatment. In this randomized controlled trial, the effectiveness of two forms of administration of Seren@ctif, a 5-week CBT program for patients with ADA according the DSM-5, was examined: one delivered through face-to-face sessions (face-to-face CBT) and the other delivered online and guided with face-to-face contact with a nurse (blended CBT); these formats were compared with a wait-list control group (WLC). A total of 120 patients were included and randomized to one of these three conditions. Measures were administered before treatment, after treatment and 6 months after inclusion in the study. Both treatment conditions displayed significant decreases in anxiety, depression, worry and perceived stress at posttreatment when compared to the WLC group. The decrease in symptoms was mostly maintained 6 months after inclusion for the two experimental groups. Blended CBT showed significantly greater reductions in anxiety and depression than did face-to-face CBT on some secondary outcome measures. We conclude that both face-to-face CBT and blended CBT are effective treatments for patients with ADA, and we suggest that blended CBT may be slightly more effective than classical face-to-face CBT. Trial Registration: Clinicaltrials.gov NCT02621775;https://clinicaltrials.gov/ct2/show/NCT02621775(Archived by WebCite at http://www.webcitation.org/6tQrkPs1u).

[Evolution of electro-convulsive therapy activity in France since the beginning of the COVID-19 pandemic]

La pandémie récente de COVID-19 a entraîné des changements organisationnels majeurs dans les lieux de soins et notamment en hospitalisation en psychiatrie. Pour évaluer l’évolution de l’activité des différents centres pratiquant l’ECT, une enquête nationale en ligne a été réalisée. 65 réponses de toute la France ont été analysées. Plus de 90 % des centres pratiquant l’ECT ont connu une diminution de leur activité. Plus inquiétant encore, la moitié des centres ont subi un arrêt total de leur activité et un quart des centres accusent une diminution de plus de la moitié de leur activité habituelle. Les soins psychiatriques post-pandémie COVID-19 s’annoncent difficiles. Il est essentiel de ne pas ajouter à cette difficulté les complications, souvent graves, qui seront liées au retard ou à l’arrêt de la pratique de l’ECT. Il conviendra aussi de rester vigilant quant aux conséquences spécifiques neuropsychiatriques qui feront suite à la pandémie.

Are there specific care requirements for patients with schizophrenia and diabetes or with a risk of diabetes?

An interactive workshop was held to discuss the risk of diabetes in patients with schizophrenia, to evaluate the available data concerninghow such patients should be managed in terms of minimising the risk of diabetes and of optimising their care where diabetes to develop. The subjects discussed covered monitoring of risk factors, education about lifestyle and the risk of diabetes, patient care and treatment options, and interfaces between psychiatry and diabetology. The workshop noted that all patients with a diagnosis of schizophrenia had an elevated risk of developing diabetes and that this needed to be reflected in the follow-up of the patients in order to reduce the chances of the emergence of disease. The risk of diabetes is complicated by the presence of other risk factors and the intensity of the diabetes prevention programme needs to reflect adequately the overall risk. The most important prevention methods relate to lifestyle changes that patients with schizophrenia may be spontaneously unlikely to adopt and therefore necessitate the implementation of specific education measures aimed at patients and their families. The workshop proposed follow-up intensities, monitoring procedures and prevention programmes stratified according to the risk of developing diabetes. It was not considered that there was sufficient data available to orientate treatment choices between individual antipsychotic drugs according to the potential risk of developing diabetes.

Data on diabetes from the French cohort study in schizophrenia

To establish the impact of antipsychotic medication on the incidence of diabetes, we have analysed data from the prospective French Cohort study of mortality in schizophrenia. This generated a large database of 3470 patients with schizophrenia initially enrolled in 1993 for which data collection on comorbidity has been collected systematically every three years since. The primary objective of the study was to evaluate the mortality rate in the study cohort. From this database, the prevalence and incidence of diabetes can be studied. In 1993, nine patients in 10 were prescribed conventional antipsychotics and the remainder amisulpride and clozapine. Since the introduction of risperidone and olanzapine, atypical antipsychotics are now used in one-third of patients. Multiple antipsychotic medications are used in many patients, with the exception of those receiving clozapine. At inclusion, 2.2% of patients in the study cohort had a diagnosis of diabetes. Morbidity rates were higher in females than in males (3.4% and 1.6%, respectively) and it was only in females that the standard morbidity ratio with respect to the general population was significantly elevated (2.2; 95% confidence intervals: 1.6 and 2.9). The prevalence of diabetes in the study cohort rose over the course of the study. Multivariate regression analysis was performed in order to identify potential determinants of diabetes. For pre-existing diabetes, four factors were identified: age at first hospitalisation, age, obesity and duration of schizophrenia. The same factors with the exception of length of illness were identified for the incident cases. There was no evidence for an interaction between the class and type of antipsychotic medication and risk of treatment emergent diabetes. However, the use of multiple antipsychotic treatments makes the individualisation of specific risks associated with any other antipsychotic drug impossible.

Paris MEM: a study protocol for an effectiveness and efficiency trial on the treatment of traumatic stress in France after the 2015-16 terrorist attacks

BACKGROUND

The Paris and Nice terrorist attacks affected a thousand of trauma victims and first-line responders. Because there were concerns that this might represent the first of several attacks, there was a need to quickly enhance the local capacities to treat a large number of individuals suffering from trauma-related disorders. Since Reconsolidation Therapy (RT) is brief, relatively easy to learn, well tolerated and effective, it appeared as the ideal first-line treatment to teach to clinicians in this context.

METHODS

This study protocol is a two-arm non-randomized, multicenter controlled trial, comparing RT to treatment as usual for the treatment of trauma-related disorders. RT consists of actively recalling one's traumatic event under the influence of the ß-blocker propranolol, once a week, for 10-25 min with a therapist, over 6 consecutive weeks. This protocol evaluates the feasibility, effectiveness, and cost-utility of implementing RT as part of a large multi-center (N = 400) pragmatic trial with a one-year follow-up.

DISCUSSION

Paris MEM is the largest trial to date assessing the efficiency of RT in the aftermath of a large-scale man-made disaster. RT could possibly reinforce the therapeutic arsenal for the treatment of patients suffering from trauma-related disorders, not only for communities in western countries but also worldwide for terror- or disaster-stricken communities.

TRIAL REGISTRATION

Clinical Trials (ClinicalTrials.gov). June 3, 2016. NCT02789982.

Distress, Suicidality, and Affective Disorders at the Time of Social Networks

PURPOSE OF REVIEW

We reviewed how scholars recently addressed the complex relationship that binds distress, affective disorders, and suicidal behaviors on the one hand and social networking on the other. We considered the latest machine learning performances in detecting affective-related outcomes from social media data, and reviewed understandings of how, why, and with what consequences distressed individuals use social network sites. Finally, we examined how these insights may concretely instantiate on the individual level with a qualitative case series.

RECENT FINDINGS

Machine learning classifiers are progressively stabilizing with moderate to high performances in detecting affective-related diagnosis, symptoms, and risks from social media linguistic markers. Qualitatively, such markers appear to translate ambivalent and socially constrained motivations such as self-disclosure, passive support seeking, and connectedness reinforcement. Binding data science and psychosocial research appears as the unique condition to ground a translational web-clinic for treating and preventing affective-related issues on social media.

[Elaboration and psychometric properties of a well-being scale at work. The Serenat study among employees in occupational medicine unit]

BACKGROUND

Well-being at work is nowadays a major public health challenge. It includes, among others, absence of psychological (anxio-depressive) symptoms, perceived positive work conditions (environment and organization), happiness and good quality of life at work. Many studies have shown that social support and control at work protect mental health while high job demands and effort-reward imbalance are risk factors for anxiety and depression. There is currently no global indicator to measure both the state of mental health and social working conditions. The main objective of this work is to construct and explore the psychometric properties of scale of well-being at work called "Serenat" in order to validate it.

METHODS

The Serenat Scale is a self-report questionnaire composed of 20 items. All items are scored on a four-point Likert scale ranging from 0 (strongly disagree) to 3 (strongly agree) resulting in a range of 0 to 60. It was constructed from data collected from the literature and from consultations in an Occupational Health Unit. From January 2014 to May 2017 193 subjects who have consulted an occupational doctor are included in this cross sectional survey. Validation included item quality and data structure diagnosis, internal consistency, intraobserver reliability evaluation and external consistency.

RESULTS

The Serenat scale showed very good item quality, with a maximal non-response rate of 0.01 % per item, and no floor effect. Factor analysis concluded that the scale can be considered unidimensional. Cronbach's alpha of internal consistency was 0.89. The intraclass correlation coefficient for intraobserver reliability was 0.89. Serenat scale was correlated with HADS (r=-0.54; P<0.001), STAI-Y (r=-0.78; P<0.001) and BDI-13 (r=-0.57; P<0.001).

CONCLUSION

Serenat's well-being at work scale shows good psychometric properties for final validation. It could be useful to occupational physicians for individual and collective screening.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02905071.

Sleep and circadian rhythms as possible trait markers of suicide attempt in bipolar disorders: An actigraphy study

BACKGROUND

The poor prognostic of Bipolar disorders (BD) is closely linked to deaths by suicide. Sleep and circadian abnormalities are observed during all phases of BD and are also associated with suicide attempt (SA). In this context, this study sought to identify specific sleep and circadian rhythms markers associated with suicidal attempt in euthymic patients with BD.

METHODS

The sample (N = 236) comprised 3 groups: 147 patients with BD including 57 with a history of SA and 90 without (NoSA), and 89 healthy controls (HC). All participants were recorded during 21 days with actigraphy.

RESULTS

SA was associated with women gender (p = 0.03), familial history of SA (p = 0.03), mixed episodes (p = 0.001), and benzodiazepines (p = 0.019). SA, compared to noSA, had a morning phase preference (p = 0.04), and were more vigorous on the circadian type inventory (p = 0.04), and tended to suffer more from insomnia (45% versus 25% respectively, p = 0.10). SA was also associated with an earlier onset of daily activity assessed with actigraphy (M10 onset: p = 0.01). Backward stepwise linear regression indicated that a combination of four variables (Gender, vigour, insomnia, M10onset) significantly differentiated patients with SA from NoSA (p = 0.03).

LIMITATIONS

Cross-sectional design, and no examination of suicidal behaviors' subgroups such as first attempters or repeaters, or violent suicide attempt.

CONCLUSIONS

Woman gender, vigorous circadian type, insomnia and an earlier daily activity appeared independently associated with SA in BD. If these biomarkers are confirmed in prospective studies, they should be screened and used to prevent suicide, with the development of personal and targeted chronobiological treatments.

Clinical guidelines for the management of depression with specific comorbid psychiatric conditions French recommendations from experts (the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental)

BACKGROUND

Recommendations for pharmacological treatments of major depression with specific comorbid psychiatric conditions are lacking.

METHOD

The French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental developed expert consensus guidelines for the management of depression based on the RAND/UCLA Appropriatneness Method. Recommendations for lines of treatment are provided by the scientific committee after data analysis and interpretation of the results of a survey of 36 psychiatrist experts in the field of major depression and its treatments.

RESULTS

The expert guidelines combine scientific evidence and expert clinician's opinion to produce recommendations for major depression with comorbid anxiety disorders, personality disorders or substance use disorders and in geriatric depression.

CONCLUSION

These guidelines provide direction addressing common clinical dilemmas that arise in the pharmacologic treatment of major depression with comorbid psychiatric conditions.

[Impacts of a brief contact intervention in suicide prevention on medical care consumptions]

INTRODUCTION

Suicide prevention is a major objective in public health. The development of alternative approaches to the prevention of suicide, such as monitoring systems, is growing quickly. The results are encouraging, but the analysis of the effectiveness remains complex. The objective of this study is to evaluate the medico-economic impact of the ALGOS brief contact intervention (BCI) on the consumption of medical care.

METHOD

ALGOS is a prospective, comparative, multicentre, single-blind, randomized, controlled trial, which compared two groups after a suicide attempt (SA). The ALGOS algorithm assigned each BCI to the subgroup of participants. The medico-economic impact of each intervention was evaluated at 6 and 13 months after inclusion.

RESULTS

In all, 987 patients were included. There was no significant difference between the two groups at 6 months and at 13 months after SA in the total number of patients who had been hospitalized in psychiatry or other care services. However, the average number of rheumatology visits was significantly higher in the control group (P=0.01) at 13 months. The total number of rheumatologist and physiotherapist visits was significantly higher in the control group at 6 and 13 months.

CONCLUSION

Our results suggest that the use of a BCI after SA does not lead to increased consumption of medical care.

[Changes in the number of suicide attempts in the NPC region since the start of VigilanS: First estimates]

BACKGROUND

The implementation of a surveillance program after a suicide attempt (SA) is a very innovative step in the evolution of our system of care. It was interesting to know if we observe a decline in suicide attempts in the region, in particular of recurrences of SA.

METHOD

We measured the evolution of the number of suicide attempts before and after implantation of VigilanS, using two types of analysis: a first from the national medical information systems in Medicine-Surgery-Obstetrics (PMSI-MCO) and a second from the collection of the ER stays for SA in the hospitals involved in the VigilanS program.

RESULTS

In 2014 (year before start of VigilanS), a total of 10 119 ER stays for SA was observed (5626 women and4463 men); in 2017, the total was 9.230 stays for SA (5047 women and 3 839 men), representing a decrease of 13.5%. The reduction was balanced between men (-14%) and women (-10%). Based on the figures of PMSI, we see an acceleration of the reduction of stay for SA in the Nord-Pas-de-Calais after 2014 (-16% instead of -6%), instead of the two Picardy departments the most comparable which show a degradation of the phenomenon (+13%), and opposed to the Department of the Oise which shows a stable maintenance of the current decline (-12%).

CONCLUSION

These two indicators are imperfect, but evolution over three years since the implementation of VigilanS goes in the same direction. We find a uncoupling of a hospital stay in connection with a SA. The intensity of this decline seems correlated to the penetrance of the program.

[Involuntary hospitalization: A survey of liberty and custody judges]

The procedure of involuntary hospitalization in France has been recently modified by the law of 5 July 2011. Since that time, a liberty and custody judge has been appointed to guarantee the rights of psychiatric inpatients and to prevent abusive hospitalizations. Currently, for one involuntary hospitalization in ten a release is decided by the liberty and custody judge although psychiatrists consider that psychiatric care is necessary. In order to improve our understanding of the role of liberty and custody judges, and how they make their decisions, we conducted a qualitative survey of liberty and custody judges in the Tribunal de Grande Instance of Lille. Three judges were questioned, based on a semi-structured interview. Judges' responses have highlighted the need for psychiatrists to strictly respect the legal procedures and to accurately describe the clinical signs and symptoms that justify the procedure of involuntary hospitalization in the medical certificates. The intervention of liberty and custody judges for patients with psychiatric disorders represents a breakthrough for patients' rights in France, reflecting that they are considered as citizens, with the same rights as others. Nonetheless, this new mission needs a progressive learning, based on mutual exchanges with doctors and caregivers.

[French Society for Biological Psychiatry and Neuropsychopharmacology and Fondation FondaMental task force: Formal Consensus for the management of treatment-resistant depression]

Major depression represents among the most frequent psychiatric disorders in the general population with an estimated lifetime prevalence of 16-17%. It is characterized by high levels of comorbidities with other psychiatric conditions or somatic diseases as well as a recurrent or chronic course in 50 to 80% of the cases leading to negative repercussions on the daily functioning, with an impaired quality of life, and to severe direct/indirect costs. Large cohort studies have supported that failure of a first-line antidepressant treatment is observed in more than 60% of patients. In this case, several treatment strategies have been proposed by classical evidence-based guidelines from internationally recognized scientific societies, referring primarily on: I) the switch to another antidepressant of the same or different class; II) the combination with another antidepressant of complementary pharmacological profile; III) the addition of a wide range of pharmacological agents intending to potentiate the therapeutic effects of the ongoing antidepressant medication; IV) the association with appropriate psychological therapies; and, V) the use of non-invasive brain stimulation techniques. However, although based on the most recently available data and rigorous methodology, standard guidelines have the significant disadvantage of not covering a large variety of clinical conditions, while currently observed in everyday clinical practice. From these considerations, formalized recommendations by a large panel of French experts in the management of depressed patients have been developed under the shared sponsorship of the French Association of Biological Psychiatry and Neuropsychopharmacology (AFPBN) and the Fondation FondaMental. These French recommendations are presented in this special issue in order to provide relevant information about the treatment choices to make, depending particularly on the clinical response to previous treatment lines or the complexity of clinical situations (clinical features, specific populations, psychiatric comorbidities, etc.). Thus, the present approach will be especially helpful for the clinicians enabling to substantially facilitate and guide their clinical decision when confronted to difficult-to-treat forms of major depression in the daily clinical practice. This will be expected to significantly improve the poor prognosis of the treatment-resistant depression thereby lowering the clinical, functional and costly impact owing directly to the disease.

Impact of emotional and cognitive saliency on visual search in post-traumatic stress disorder

Introduction

Patients with post-traumatic stress disorder (PTSD) have shown disturbances in visual information treatment. However, most of studies demonstrated attentional bias towards emotional stimuli by using non-ecological paradigm. The paradigm of change blindness offers the possibility of studying sensitivity to the sudden irruption of visual information with ecological stimuli.

Objectives/Aims

To compare the explicit detection with the implicit detection by using respectively motor response and eye tracking in patients with PSTD and controls.

Methods

Fifteen patients with PTSD and fifteen healthy controls had to detect changes in 96 scenes with (1) no change, (2) one neutral change or (3) one emotional pleasant or unpleasant change. We measured the participant's speed and accuracy in explicitly reporting the changes via motor responses, and their capacity to implicitly detect changes via eye movements.

Results

The patients showed a trend towards slower explicit detection for the emotional change (P = 0.06) and more specifically for unpleasant change (P = 0.054). The two groups did not differ for implicit detection.

Conclusion

Patients tend to explicitly detect more slowly emotional change (but not neutral), especially for unpleasant change. This could be the result of a lack of access to consciousness of the emotional information. The emotional visual information treatment in PSTD could require more attentional processes than the non-emotional visual information and then lead to a decrease of the available attentional resources for the explicit task.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

[Prevalence of psychiatric and substance use disorders among three generations of migrants: Results from French population cohort]

INTRODUCTION

Mental health of migrant populations has become a major public health issue since these populations more often suffer from mental health problems than host populations. The influence of the migration process on the emergence of these disorders and its impact on future generations is uncertain. This study provides an estimate of the prevalence of mental disorders among three generations of migration.

METHOD

The study was conducted in the general population by the French Collaborating Center of the World Health Organization, in France, on a sample of 37,063 people aged 18 and older. The subjects interviewed were selected by a quota sampling method and, thus, were representative of the general population in the 47 study sites in France. This method develops a sample of subjects with the same characteristics as the general population on predefined issues, such as age, sex, educational level and socioprofessional category. The designation of migrant status was based on the country of birth of the subject, the subject's parents and the subject's grandparents. We defined a migrant as first generation (a subject born abroad; n=1911), second generation (at least one parent born abroad; n=4147), or third generation (at least one grandparent born abroad; n=3763) of migrants. The diagnostic tool used was the Mini International Neuropsychiatric Interview (MINI). The MINI is a brief structured diagnostic interview developed by psychiatrists for ICD-10 and DSM-IVTR psychiatric disorders in the general population. The comparisons by generation of migrants were performed by chi-square test for qualitative variables and by an analysis of variance for quantitative variables. The same tests were used to compare the presence of mental disorders according to the characteristics of the population. Factors with a P-value less than 0.2 were entered in a multivariable logistic regression to assess the relationship between the generation of migrants and the presence of mental disorders, adjusting for the confounding factors.

RESULTS

Thirty-eight per cent of migrant subjects have psychological difficulties, versus 30 % in the host population. These results are observed on three successive generations of migrants. Migration status increases risk of depressive disorders (OR=1.555), bipolar disorder (OR=1.597, CI=1.146-2.227), post-traumatic stress disorder (OR=1.615), substance abuse (OR=2.522) and alcohol abuse (OR=1.524), and drug dependence (OR=2.116). This risk is maintained at the second and third generation. The migration process affects mental health of population regardless of socioeconomic status or geographic origin.

CONCLUSION

The consideration of migration and generation of migration shows a specific psychopathological risk profile. This is related to the joint action of a migratory past and precarious socioeconomic situation.

[Interest of computer-based cognitive behavioral stress management. Feasability of the Seren@ctif program]

INTRODUCTION

Cognitive-behavioural stress management programs have been studied in many countries. Many reports have shown beyond a doubt their efficacy to reduce perceived stress, anxiety symptoms and to improve quality of life of patients. Considering the very large number of people who could benefit from such programs but are unable to reach them, self-help programs have been offered. First presented as books (bibliotherapy), these programs then became enriched by computing and digital supports. Regrettably, many of the programs of stress management based on the Cognitive behavioural therapy (CBT) both in face-to-face and on digital support have been little evaluated in France. To our knowledge, the Seren@ctif program is the first French language self-help program of stress management proposed on digital support.

AIM OF THE STUDY

We led a feasibility study of this program on 10 patients responding to the diagnosis of adjustment disorder with anxiety according to the DSM IV criteria.

METHODS

The program includes 5 weekly sessions that the patient follows in our unit from a web site. He benefits from minimal contact with a medical member of staff before and after every session. Right from the first session an USB key is supplied to the patient containing videos, audio files, self-help book portfolio in the form of an e-guide, and log books with the exercises to be realized between each sessions of the 5 session program. The patient is encouraged to practice 20 minutes of exercises 5 or 6 days per week. The program's feasibility has been assessed in accordance with a standard satisfaction scale. Anxiety symptomatology has been quantified thanks to the Spielberger State-Trait Anxiety Inventory (STAI-Y-S).

RESULTS

After the scheduled 5 weeks, good results were found in terms of acceptability and attractiveness. The average score to the satisfaction survey was at least equal to 4 out of 5 for each item. The mean score on the STAI-State decreased from 53,4 (SD: 8,29) to 44,2 (SD: 7,73) following the intervention.

DISCUSSION

The Seren@ctif program may be useful within the framework of a psychoeducative approach. It could also be advised for people suffering from anxiety related to stress. Soon, the program will be tested on patients with usual care suffering from adjustment disorder with anxiety in order to precisely assess its benefits.

[Serious game as a therapeutic tool in psychiatry: A systematic review]

CONTEXT

The growing field of new technologies offers new ways to tackle psychiatric disorders (e.g. virtual reality therapy, neurofeedback, etc.). Serious games (SG) are computer applications combining serious aspects with the fun side of video games. This kind of new media could find applications to treat psychiatric disorders.

OBJECTIVE

This paper summarizes available data in the literature about therapeutic interventions using SG in psychiatry.

METHOD

A Medline search was conducted in May 2014 using the following Medical Subject Headings (MESH) terms: "video games", "mental disorders", and "psychotherapy".

RESULTS

Only 10 relevant references were identified according to our inclusion criteria. These studies show that SG are very interesting tools to improve the management of psychiatric disorders. However, only low-level evidence is available to support treatment with SG in patients suffering from psychiatric disorders. Indeed, randomized controlled trials are rare in this field of research.

CONCLUSION

SG provide promising therapeutic innovations for the management of psychiatric disorders. Moreover, they could easily be developed in accordance with current dimensional approaches. Finally, major issues to facilitate the implementation of future work on SG in psychiatry are discussed.

Intérêt d’un outil de dépistage infirmier d’un état de stress post-traumatique (ESPT) après un accident de la voie publique (AVP) : étude DEPITAC

Les AVP sont le principal pourvoyeur d’ESPT (Kupchik et al., 2007), dont la prévalence fluctue de 6 à 45 % entre les études (Heron-Delaney et al., 2013). En l’absence de repérage clinique, l’ESPT peut se chroniciser (Kessler et al., 1995). Les outils actuels permettent son diagnostic (Jackson et al., 2011), mais pas de dépister précocement les sujets à risque de développer un ESPT post-AVP en aigu (8 semaines) comme en chronique (6 mois) ou en tardif (1 an). Nous présentons une étude longitudinale réalisée sur 274 patients répartis sur 6 centres de traumatologie ayant pour objectif principal de valider un outil infirmier de dépistage précoce d’ESPT après un AVP (DEPITAC). Dix questions ont été soumises à tout patient hospitalisé dans les 15 jours après un AVP, ainsi qu’une PDI et un MINI DSM-IV. La PCL-S (cut-off à 44) a permis le diagnostic à 8 semaines, 6 mois et 1 an. L’analyse statistique a été réalisée avec le logiciel SAS Institute 9.4. Le score total DEPITAC était significativement associé au diagnostic d’ESPT à 1 an (OR : 1,43 ; IC95 % : 1,14–1,79) avec un pouvoir discriminant de 0,64 (IC95 % : 0,56–0,72). DEPITAC était corrélé à l’échelle PDI (p < 0,0001) avec un faible coefficient de corrélation (r = 0,32) montrant une faible redondance. Seules 3 questions après analyses bivariées s’avèrent significatives : « présence d’autres blessés ou décédés lors de l’AVP », « présence d’une dissociation post-AVP » et « s’être vu mourir lors de l’AVP » avec un pouvoir discriminant de 0,65 (IC95 % : 0,57–0,73). Aucun effet centre n’a été mis en évidence (p = 0,90). Nos résultats semblent montrer qu’à l’aide de seulement 3 questions de dépistage, les équipes infirmières pourraient repérer les patients à risque de développer un ESPT aigu ou tardif, leur permettant ainsi d’alerter précocement les équipes psychiatriques de liaison ou de pschotraumatologie.

Associer les types de recontact du suicidant pour élargir la cible de prévention

Introduction

Faut-il veiller sur une crise suicidaire dès lors qu’un sujet a été rencontré au décours d’une TS ? Nous prônons la simple idée de revenir un peu à distance, sur le compromis de sortie des urgences qui avait été conclu avec le patient suicidant. Nous présentons l’enchaînement des recherches internationales et françaises, quantitatives et qualitatives, qui nous permet aujourd’hui de proposer de tester un nouveau dispositif de soins.

Matériel

Revue d’essais thérapeutiques randomisés comparatifs. L’objectif principal était pour tous la réduction des conduites suicidaires à 6 ou 12 mois, en comparaison d’un groupe contrôle sans intervention spécifique. Un focus particulier sur le PHRC ALGOS et son étude qualitative et sociologique : ÉQUATION.

Résultats

L’efficacité de l’algorithme baptisé ALGOS, jointe aux appropriations par les patients et les partenaires de soin des éléments du processus de veille, nous permettent de proposer un nouveau dispositif de suivi posthospitalier des suicidants : Vigilan S. Ce dispositif associe une « carte ressource prévention » en 0 800 distribuée à tous suicidants quittant le système hospitalier, un suivi téléphonique plus intensifié pour les patients ayant déjà connu une TS auparavant et un rappel téléphonique de tous à 6 mois. Le dispositif est centralisé pour une région donnée et un partenariat très étroit a été tissé avec les Samu/centre 15 qui accueillent les recontacteurs.

Discussion et perspectives

Ce programme se déploie en Nord–Pas-de-Calais depuis le début de cette année et 24 sites sont déjà associés au programme ; en cette fin d’année 2015, 4 autres régions rejoignent le NPC pour un essai populationnel pilote de trois ans, au terme desquelles la DGS associée à la CNAMTS prendront la décision ou non de proposer sa généralisation à tout le territoire français.

Évaluation de la fréquence des troubles du sommeil dans une population de 724 internes de médecine du Nord-Pas-de-Calais en 2015 : étude prospective et transversale

L’insomnie chronique est un problème de santé publique touchant 10 % à 20 % de la population générale selon les études, et survenant à tout âge . Les comportements inadaptés d’hygiène de sommeil constituent les principaux facteurs de risque de trouble du sommeil chez le sujet jeune. Qu’en est-il dans une population d’internes en médecine, soumise à un travail à horaires décalés (gardes et astreintes) ? Nous avons interrogé 724 internes de médecine (spécialités médicales, chirurgie, anesthésie-réanimation, gynécologie médicale et obstétrique, et pédiatrie), du Nord-Pas-de-Calais, lors des répartitions de stage pour l’été 2015. Nous leur avons proposé une échelle de Pittsburgh (PSQI) et un questionnaire concernant leurs habitudes de vie. Sur 724 internes présents, 659 questionnaires remplis ont été recueillis (91 % de participation). Le score au PSQI est pathologique dans 37 % des cas (score > 5). Trois items semblent poser des difficultés spécifiques (troubles de l’endormissement, difficultés de maintien de l’éveil et enthousiasme à la réalisation des activités quotidiennes). La dégradation de ces caractéristiques est probablement en lien avec certains aspects d’hygiène de vie (écrans, excitants) mais également avec la difficulté à gérer les gardes hospitalières. Ces résultats sont du même ordre de grandeur que les données d’une étude américaine réalisée sur le même type de population en 2010 . Ils posent le problème de la gestion du sommeil dans une population jeune, en travail à horaires décalés atypiques, et confrontée à un niveau de responsabilité important. Travailler les comportements par rapport au sommeil, en les adaptant à l’âge des sujets et au travail à horaires décalés, pourrait s’avérer une piste de réflexion ultérieure indispensable.

Validation d’une grille d’évaluation qualitative d’articles de presse écrite sur le suicide, dans le cadre du programme Papageno

Contexte

La couverture médiatique d’un fait suicidaire influence le taux de suicide par le biais d’un effet d’incitation, aussi nommé « effet Werther » (EW) ou d’un potentiel rôle préventif via « l’effet Papageno » (EP) . L’objectif du programme national français Papageno est d’améliorer les propriétés qualitatives du contenu médiatique dont dépendent principalement l’EW et l’EP, via l’application des recommandations de l’Organisation mondiale de la Santé (OMS) pour un traitement journalistique plus responsable du suicide. L’évaluation de l’efficacité du programme est donc un enjeu de prévention qui nécessite un outil d’analyse fidèle à ces recommandations.

Objectifs

Élaborer et valider une grille d’analyse qualitative permettant, pour chaque article de presse traitant du suicide, de mesurer le degré de compliance aux recommandations de l’OMS et de quantifier le risque d’EW et le potentiel EP.

Méthode

La grille d’évaluation PReSS (Print media Reporting on Suicide Scale) combine 10 items descriptifs et 19 items qualitatifs issus de l’opérationnalisation des 11 recommandations de l’OMS. La validation de la fiabilité interjuges a été obtenue par séries de double cotation-correction de 25 articles traitant du suicide. Les critères de satisfaction des items ont été affinés après chaque série jusqu’à obtention d’un coefficient de kappa ≥ 0.7 pour chacun. À titre d’illustration, le traitement médiatique du supposé suicide du pilote d’avion A. Lubitz en mars 2015 a été analysé grâce à la PReSS.

Résultats

Trois séries de cotation-correction ont été nécessaires pour valider la grille. L’analyse de la couverture du suicide présumé d’A. Lubitz montre un compliance faible aux recommandations, un score Papageno bas et un score Werther élevé.

Conclusion

La grille d’évaluation PReSS est un outil fiable et utile pour mesurer la compliance aux recommandations de l’OMS concernant la couverture médiatique du suicide.

Développement d’un dispositif de veille par short message service (SMS) pour la prévention de la récidive suicidaire. Protocole d’étude Suicide Intervention Assisted by Messages (SIAM)

Introduction

Le suicide et les conduites auto-agressives sont fréquents dans la population adulte. De précédentes études ont prouvé que le fait de maintenir le lien avec le sujet suicidant, par lettres ou cartes postales, après la prise en charge en aigu, réduit le risque de récidive. De plus, les études de faisabilité ont montré que l’intervention par SMS est acceptable pour les patients. L‘objectif principal de cette étude est de démontrer l’efficacité du dispositif de veille par SMS sur la réduction de la récidive suicidaire à 6 mois. Nous présenterons dans un premier temps l’étude de faisabilité puis l’étude multicentrique démarrée dans 8 CHU.

Matériel et méthode

Il s’agira d’un essai de supériorité, contrôlé, randomisé, multicentrique, d’une durée de 2 ans, et piloté par le CHRU de Brest. Les sujets seront des adultes ayant survécu à un passage à l’acte suicidaire, inclus après une prise en charge aux urgences ou une courte hospitalisation. Le recrutement s’étalera sur une période de 9 mois. Les SMS seront envoyés à j2, j7, j15, puis mensuellement. Ces messages se soucieront du bien-être du patient, et lui rappelleront les coordonnées d’urgence dont il dispose en cas de besoin. Les patients seront évalués à j0, puis à 6 et 13 mois. Le critère de jugement principal sera le nombre de patients récidivant à 6 mois, dans le groupe recevant les SMS et dans le groupe témoin (qui bénéficie de la prise en charge de référence). Les critères de jugement secondaires seront le nombre de patients récidivant à 13 mois, le nombre de tentatives de suicide à 6 et 13 mois, le nombre de décès par suicide à 6 et 13 mois, dans les deux groupes. Les idées suicidaires seront évaluées dans chaque groupe, à j0, à 6 mois, et à 13 mois. Enfin, les coûts médicaux et la satisfaction seront évalués à 13 mois.

Résultats attendus

La fréquence de récidive attendue à 6 mois dans le groupe témoin est de l’ordre de 18 %. Nous espérons la réduire à 9 % grâce au contact par SMS. Afin d’y parvenir, le nombre de sujets nécessaires a été évalué à 530, soit 265 dans chaque bras.

Discussion

Ce dispositif de veille par SMS s’appuie sur de précédentes interventions, aux résultats significatifs dans le domaine, et est facilement reproductible. Nous proposons d’évaluer son efficacité dans la réduction du risque de récidive suicidaire au sein d’une population d’adultes ayant fait un passage à l’acte.

Autour de serious game et nouvelles technologies : quelles utilisations aujourd’hui et demain ?

Résumé non reçu.

Prévention du suicide : du recontact à la santé connectée

Un geste suicidaire correspond à une volonté de changement vécue comme impossible et qui se solde par une rupture brutale. L’intérêt d’un recontact réside dans la proposition d’un changement tout en retissant ce lien qui nous unit à l’autre, aux autres. La communication de Vincent Jardon a pour objectif de reprendre l’histoire de cette idée du recontact et de la veille auprès d’un patient suicidant, d’en décrire les différentes modalités (cartes ressources, caring letters, cartes postales, appel téléphonique, SMS…) et ce qu’elles apportent (notion de connectedness, fiabilisation des soins). La démonstration de l’efficacité des soins basés sur le recontact, comme l’observation qu’un geste suicidaire suit régulièrement un événement de vie stressant, notamment dans le domaine social, sont deux arguments suggérant l’existence d’une sensibilité accrue aux stress sociaux chez les suicidants. P. Courtet proposera les arguments neuroscientifiques actuels (imagerie, neurospychologie, inflammation) en faveur de cette hypothèse. Il poursuivra sur l’intérêt des nouvelles technologies de la communication (à l’aide de Smartphones) dans l’évaluation in vivo des patients à risque suicidaire. Non seulement, il est démontré que l’évaluation répétée du risque suicidaire dans l’environnement naturel du sujet n’est pas délétère pour les sujets, mais en outre que ce type d’innovation apporte des informations de grand intérêt pour suivre les séquences environnementales conduisant à la génération des idées de suicide. Si le recontact téléphonique ou postal prévient la récidive suicidaire et que les Smartphones sont des outils pertinents d’accompagnement des patients, S. Berrouiguet a raison de faire l’hypothèse qu’un dispositif de veille par SMS aura un intérêt dans la prévention de la récidive suicidaire. Il présentera le protocole de l’étude SIAM et les résultats préliminaires d’une intervention par SMS (ou message texto), adressés depuis une plateforme Internet, destinée à la réduction de la récidive suicidaire.

Le Questionnaire d’évaluation des connaissances sur le suicide (QECS)

L’accès aux soins des personnes à risque constitue un pilier essentiel de la prévention du suicide. Cependant, les idées reçues véhiculées autour des conduites suicidaires y opposent un obstacle significatif. Afin de cibler au mieux les campagnes d’information qui dissiperaient ces mythes, et pour en évaluer l’efficacité, les connaissances sur le suicide devraient pouvoir être quantifiées de façon fiable. À ce jour, seules quelques études anglo-saxonnes dédiées ont été validées. La limite décisive à leur interprétation tient cependant à ce qu’elles ne permettent pas d’approche normative. En effet, l’exactitude de leurs propositions n’est validée par aucun étalon officiel, alors même que certaines relèvent plus de l’expérience clinique que de connaissances issues de la littérature. Notre objectif consiste à palier cette limite en proposant une échelle dont la cotation est adaptée à l’évaluation d’un savoir normé. Le Questionnaire d’Évaluation des Connaissances sur le Suicide (QECS) est un auto-questionnaire qui explore, en 35 items, les principales connaissances relatives à l’épidémiologie et aux mythes communs concernant le suicide. Les réponses y sont recueillies par échelle visuelle analogique. La cotation finale se fait en confrontant ces réponses à celles d’un panel de référence constitué de spécialistes en suicidologie (n = 47). Nous présentons ici les résultats de ce panel, ainsi qu’une illustration des potentialités d’interprétation du QECS, via l’évaluation des connaissances d’un échantillon test d’étudiants en journalisme (n = 111). Les réponses du panel de référence étaient significativement différentes de « ni accord, ni désaccord » pour 27 des 29 items dédiés aux mythes. Pour 25 de ces items, une différence significative était retrouvée entre l’échantillon test et le panel de référence. Ainsi attestée, l’existence d’un avis expertal spécifique a servi d’étalon pour 2 modes de cotation des réponses de l’échantillon test : un score de véracité et un score de concordance aux experts.

Risk factors for treatment resistance in unipolar depression: a systematic review

BACKGROUND

Treatment resistant depression is a complex disorder and an important source of morbidity and mortality. Identification of risk factors of resistance may be useful to improve early recognition as well as treatment selection and prediction of outcome in patients with depression.

METHODS

The aim of this paper was to review the current status of knowledge regarding risk factors of treatment resistance in unipolar depression, in patients who failed to respond to at least two successive and adequate antidepressant treatments.

RESULTS

Systematic literature search yielded 8 publications exploring clinical and biological factors. Specific psychiatric comorbidities, psychosocial factors, clinical characteristics of the depressive episode and biological markers emerge as possible risk factor for treatment resistant depression.

LIMITATIONS

Due to the lack of objective definition and diagnostic criteria for treatment resistant depression, and the paucity of reports on risk factors, our review only summarized a small number of studies.

CONCLUSION

Future investigations of risk factors should help to improve the understanding of the mechanisms underlying resistance in mood disorders and contribute to improve their therapeutic management.

Que nous apprend le parcours de soins des suicidants, dans l’année suivant la tentative de suicide ?

Introduction

Faut-il veiller sur une crise suicidaire dès lors qu’un sujet a été rencontré au décours d’une TS ? Nous prônons la simple idée de revenir un peu à distance, sur le compromis de sortie des Urgences qui avait été conclu avec le patient suicidant. Nous présentons ici la comparaison des parcours de soin dans l’année qui suit le geste, entre un groupe de sujet bénéficiant d’un dispositif de veille baptisé ALGOS et une cohorte témoin de suicidants.

Matériel et méthode

Essai thérapeutique randomisé comparatif en deux groupes parallèles (ClinicalTrials.gov : NCT01123174). L’objectif principal était la réduction des conduites suicidaires à 6 mois, en comparaison d’un groupe témoin sans intervention spécifique. Un recueil exhaustif des consommations de soins directs (hospitalisations, consultations, arrêts de travail, etc.) était réalisé à 6 mois.

Résultats

Vingt-trois centres d’urgence français de tous horizons (CHU, CHG, PSPH) ont inclus 1055 suicidants dans l’essai. À 6 mois, l’analyse en ITT était positive : (96/493) 19,5 % vs. (124/494) 25,1 % adverse outcomes, Khi square = 4,194 ; p = 0,041. Nous observions dans le groupe témoin, une différence significative dans le nombre de consultants en Rhumatologie, dans le nombre de séances chez le Kinésithérapeute (903 vs 419 dans le groupe ALGOS), dans le nombre de jours hospitalisations en MCO (Algos : 157,5 et Témoins : 316) pour un nombre d’hospitalisations quasi identique (Algos : 71 et Témoins : 73), une différence quasi significative du nombre de consultations auprès des assistantes sociales (moyenne Algos : 0,29 et moyenne Témoins : 0,17 ; p = 0,07).

Discussion et perspectives

Ce programme montre pour la première fois l’efficacité d’un dispositif de veille à 6 mois ; ce genre de dispositif se montrerait peu onéreux à mettre en place et ne génère pas d’augmentation des consommations de soin dans le groupe étudié, au contraire.

[Advanced directives in psychiatry: A review of the qualitative literature, a state-of-the-art and viewpoints]

BACKGROUND

Advance Directives are written documents, which are used for people to notify their preference for a future situation when they are unable to give their consent. In psychiatry, psychiatric advance directives (PADs) can be used for patients with chronic psychotic disorders such as schizophrenia, or a bipolar disorder. PADs give the patient an opportunity to state wishes in advance about his/her treatment when he/she is in an acute state of illness. PADs were initially developed as a way for patients to defend themselves against the power of the psychiatrists, but are likely to become a useful tool in psychiatric care. PADs may contain information about medication, non pharmaceutical devices, and the name of a proxy decision maker. The main objective is to reduce the number of compulsory hospitalisations.

OBJECTIVE

This article is a qualitative review which carries out a state-of-the-art on the use of PADs for people with chronic psychotic disorders and defines suggestions to include this intervention in the French psychiatric context.

METHOD

We used the keywords psychiatric advance directives, crisis card, Ulysse directives, joint crisis plan (JCP) in the MEDLINE database to propose a qualitative review. We selected original clinical studies about the use of PADs for people with psychotic disorders.

RESULTS

We included 36 articles. The qualitative analysis identified seven main themes: different types of PADs, effectiveness of PADs, practical use of PADs, patient's views, clinician's views, economical aspects, and legal aspects. The content of the PADs is consistent with psychiatric standard care in nearly all cases, regarding medical instructions, pre-emergency interventions, non-hospital alternatives and non-medical personal care. Patients use their PADs to describe prodromal symptoms of relapse and to suggest a treatment and a hospitalisation in advance. PADs are not used to refuse all treatments. Patients show a strong interest in creating a directive and a high level of satisfaction when using it. They feel they have more control over their mental health problem and are more respected and valued as a person. Thirty-six to fifty-three percent of clinicians had positive opinions regarding PADs. They valued the increase of the patient's autonomy and the prevention of relapse, but were concerned about difficulties for accessing the documents, and about the lack of training of the medical teams. Clinicians also feared the pressure of relatives or partners on treatment decisions. The qualitative analysis revealed the specific benefit of the JCP, a particular type of PADs negotiated with the medical team, on the reduction of the general number of admissions. We can identify practical problems such as the lack of accessibility to PADs in emergency situations, and the clinician's reluctance to use PADs. The only economical evaluation showed a non-significant decrease in total costs.

DISCUSSION

PADs are used in a few countries, although their benefits in terms of patient's perceptions and compulsory admissions are promising. The JCP proposes a specific clinical approach based on therapeutic alliance. Its creation also involves the clinician, family members and a neutral mediator in a negotiated process. The JCP is likely to be the most efficient PAD model in reducing compulsory admissions. The use of the JCP appears to be relevant in the context of the new French legislation, establishing outpatient commitment orders and could be an effective way to improve the relationships with patients.

Is it worth assessing progress as early as week 2 to adapt antidepressive treatment strategy? Results from a study on agomelatine and a global meta-analysis

CONTEXT

A delay of 4-8weeks before modifying the prescribed antidepressant treatment is usually proposed when incomplete treatment response is observed. A number of studies nevertheless proposed that the lack of early improvement (usually 20% decrease of severity at week 2) is predictive of the absence of subsequent treatment response, potentially saving weeks of inadequate treatment, but with no information for non-interventional studies devoted to outpatients.

METHOD

Two thousand nine hundred and thirty-eight outpatients with major depressive disorder were included in a multicentre, non-interventional study, assessing at inclusion, week 2 and week 6, mood (QIDS-C, CGI, PGI and VAS) sleep (LSEQ) and functionality (SDS). All metrics at week 2 were tested for their capacity to predict response (and then remission) at week 6, all patients being treated by agomelatine. A meta-analysis of all studies (n=12) assessing the predictive role of improvement at week 2 was also performed, assessing specific effect size of published studies and the weight of the different parameters they used.

RESULTS

The QIDS-C and the CGI-I were the only instruments with an area under the curve over 0.7, with different cut-offs for treatment response and remission. A decrease of more than five points at the QIDS-C had the highest positive predictive value for treatment response, and a CGI-I over three had the highest negative predictive value, which would favour relying on the clinicians for warning (too high CGI-I), and on instruments for confidence (favourable decrease of the QIDS-C). The meta-analysis of all studies also detected a large effect size of early improvement, stressing how rating week 2 severity could be beneficial in clinical practice.

CONCLUSIONS

Previous reports stressing the interest of an assessment at week 2 were reinforced by the present results, which also defined more accurately what could be the most appropriate cut-offs, and how combining these early results could be more effective.

[Personality and personality disorders in the elderly: diagnostic, course and management]

OBJECTIVE

Little is known about personality and personality disorders in the elderly. This paper summarizes the literature in these fields.

METHODS

Articles were selected using a Medline and Google Scholar search. The keywords were personality, personality disorder, aging and elderly.

RESULTS

Personality is not fixed and can change across the life-time including in the elderly. Personality disorders are frequent with a prevalence estimated between 10 and 20%. These rates are essentially equivalent to that of younger groups. Clinical presentation of these disorders may change over time. Longitudinal observations generally support that the "immature" personality disorders (cluster B), show improvement over time, while the more "mature" (clusters A and C) are characterized by a more chronic course. Many patients with late onset schizophrenia or delusional disorder have a premorbid cluster A personality. Patients with cluster C personality are also stable, and exposed, like all other personality disorders, to depression. Studies suggest that personality disorders may attenuate, re-emerge or appear de novo according to the cluster and the social context. Diagnosing personality disorders in the elderly is a complex undertaking, largely because of the difficulty encountered in distinguishing functional impairments related to personality from those related to physiological and environmental aspects of aging. Tools for assessing personality disorders exist, but there is no ideal assessment instrument for geriatric personality disorders. Psychiatric history and biographical elements have to be collected accurately. Personality disorders may seriously complicate mental and physical health and quality of life. Indeed, a greater risk of depression, suicide, dementia and social isolation is shown in this population. Different types of caring and treatment exist including psychotherapy and pharmacotherapy. Pharmacological strategies should consider augmentation with psychotherapeutic strategies. Interventions should target the predominant presenting problems. Indeed, personality disordered elderly people are a heterogeneous group with frequent axis I comorbidities. Care should be taken on how to administer pharmacological treatment (risk of noncompliance or abuse), pharmacokinetics, pharmacodynamics and finally interaction with age-specific comorbidities. Psychotherapy has shown its effectiveness notably in the management of depression. In institutions, clinical identification of a personality disorder would inform and advise staff regarding the approach to be adopted, and also avoid negative countertransference, emphasizing the pathological aspect of the subject's personality and his/her suffering.

CONCLUSION

Future research should develop adapted and specific diagnosis tools (dimensional and categorical mixed approach), prevention and caring in the elder population. Those studies would be able to determine the link between normal and pathological personality, mortality, depression and dementia.

Categorical and dimensional study of the predictive factors of the development of a psychotrauma in victims of car accidents

OBJECTIVE

This study aimed to evaluate the predictive factors of the emergence of complete PTSD and subsyndromal PTSD (defined as individuals exposed to a traumatic event with at least one psychopathological impact, such as hyperarousal, avoidance or persistent re-experiencing) following a motor vehicle accident (MVA).

METHODS

We recruited 155 adult MVA patients, physically injured and admitted to trauma service, over two years. In the week following the accident, patients were asked to complete questionnaires assessing their social situation (sex, age, marital and employment status, prior MVA or trauma), comorbidity (MINI), distress (PDI) and dissociation (PDEQ) experienced during and immediately after the trauma. An evaluation using the CAPS was conducted six months after the trauma to assess a possible PTSD.

RESULTS

At six months, 25.8% of the participants developed subsyndromal symptoms and 7.74% developed complete PTSD. The three symptoms that best discriminated the groups were dysphoric emotion, perceived life threat and dissociation. Logistic regression results showed that the strongest predictor of PTSD was the perceived life threat. In addition, a dimensional approach to the results revealed significant correlations between (1) peritraumatic distress and persistent re-experiencing or hyperarousal and (2) dissociation score and avoidance strategy. The presence of a prior traumatic event reinforces avoidance strategies.

CONCLUSIONS

Our results stress that peritraumatic factors (especially the perception of a life threat) are good predictors of PTSD development. A dimensional perspective allows better identification of psychological complications following an MVA.

Reduced risk of hospitalisation with risperidone long-acting injectable. Results of the french cohort for the general study of schizophrenia (CGS)

Introduction

Medication non-adherence is a significant risk factor for rehospitalisation in schizophrenia patients. Delayed release formulations like R-LAI may reduce rehospitalisation.

Objectives

To examine the association between R-LAI use and hospitalisation in schizophrenia patients.

Aims

To assess the effect of R-LAI, compared to non-use and use of other antipsychotic drugs, on the risk of hospitalization in real-life settings.

Method

The CGS study recruited schizophrenia patients from 177 public and private wards of psychiatric hospitals across France. Inclusion criteria were schizophrenia (DSM-IV), age 15–65 years, ambulatory/hospitalised for < 93 days at entry. Patients were followed up to 12 months for antipsychotic use and hospitalisation. The recruitment was stratified for long-acting second generation antipsychotic use. Multivariate Poisson regression adjusted for confounding with propensity scores and allowing for autocorrelation was used to estimate relative rates of hospitalisation.

Results

Of 2092 eligible patients, 1859 were included. Their mean age was 38.1 ± 11.1 years, 68.6% were male and 37.8% were hospitalised for < 93 days at entry. A total of 1659 patients (89.2%) were followed up for 12 months, accumulating 933 hospital stays (53.0 per 100 person-years). Compared to other schizophrenia patients, patients on R-LAI were younger, had more often a history of previous hospitalisation for equivalent severity, living conditions and other characteristics. The adjusted relative rate of hospitalisation for R-LAI use against non-use was 0.66 [95% CI 0.46–0.96], and 0.53 [95% CI 0.32–0.88] against long-acting first generation antipsychotics.

Conclusions

Use of R-LAI was associated with lower rates of hospitalization compared to non-use of R-LAI.