Programme de soins psychiatriques : Etude de l’expérience de jeunes patients par une méthode qualitative: Psychiatric care program: A qualitative study of the experience of young patients

OBJECTIVE

Ambulatory care without consent is widely used, but it is controversial, and its effectiveness has not yet been proven. The patient experience remains largely unstudied in France, particularly that of young patients, yet their adherence to care in the early stages of the disease is complex and has an impact on their prognoses. The aim of this study is to investigate the experience of young patients undergoing a program of care (POC) in order to suggest ways of optimizing their care and to enrich the debate on the use of POCs.

METHOD

Semi-structured interviews were conducted with 11 patients between ages 20 and 32, who were either undergoing a POC or had done so in the previous 5 years, followed by a semi-pragmatic phenomenological analysis of the resulting transcripts.

RESULTS

(1) The outpatient experience with restraints is contradictory, ranging from deprivation and intrusion to support and protection. (2) The POC is portrayed as a framework for developing awareness of disorders and acceptance of care. (3) Patients report a lack of information about care with restraints, even to the point of being unaware of its existence. Patient-psychiatrist interactions within the POC are complicated by the restraints, but remain perceived as a care relationship. (4) They report constraints in their daily lives in connection to the POC, which can complicate professional involvement.

CONCLUSION

The results support the importance of nurturing the therapeutic relationship within the POC and involving patients more in their care, starting with better information. They support the use of POCs as a temporary tool to be combined with work on adherence to treatment and support for social and professional reintegration.

SPECIALTY

Psychiatry.

The Influence of Personality Disorder Symptoms on Treatment Outcomes in Bipolar Disorder: A Secondary Analysis of a Randomised Controlled Trial: L'influence des symptômes du trouble de la personnalité sur les résultats du traitement dans le trouble bipolaire : Une analyse secondaire d'un essai randomisé contrôlé

OBJECTIVES

Many people who are diagnosed with bipolar disorder also have comorbid personality disorder. Few studies have explored how personality disorder may influence pharmacological treatment outcomes. The aim of this study was to conduct a secondary analysis of data from a clinical trial of adjunctive nutraceutical treatments for bipolar depression, to determine whether maladaptive personality traits influence treatment outcomes.

METHODS

Scores on the Standardised Assessment of Personality - Abbreviated Scale screener were used to classify participants as having bipolar disorder with (n = 119) and without (n = 29) above threshold personality disorder symptoms (personality disorder). Outcome measures included: The Montgomery Åsberg Depression Rating Scale, Clinical Global Impressions and Improvement Severity Scales, Patient Global Impressions-Improvement scale, Bipolar Depression Rating Scale, Range of Impaired Functioning Tool, Social and Occupational Functioning Assessment Scale and Quality of Life and Enjoyment Scale (Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form). Generalised estimated equations examined the two-way interactions of personality disorder by time or treatment and investigated personality disorder as a non-specified predictor of outcomes.

RESULTS

Over time, the Patient Global Impressions-Improvement scores were significantly higher in those in the personality disorder group. No other significant differences in the two-way interactions of personality disorder by treatment group or personality disorder by time were found. Personality disorder was a significant but non-specific predictor of poorer outcomes on the Bipolar Depression Rating Scale, Range of Impaired Functioning Tool, and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form, regardless of time or treatment group.

CONCLUSIONS

This study highlights the potential impact of maladaptive personality traits on treatment outcomes and suggests that the presence of comorbid personality disorder may confer additional burden and compromise treatment outcomes. This warrants further investigation as does the corroboration of these exploratory findings. This is important because understanding the impact of comorbid personality disorder on bipolar disorder may enable the development of effective psychological and pharmacotherapeutic options for personalised treatments.

Occupational Balance and Emotional Regulation in People With and Without Serious Mental Illness

Background. Serious mental illness affects daily functioning, including occupational balance. Purpose. This study aims to compare occupational balance and emotional regulation between people with serious mental illness and the healthy population and to examine the relationship between occupational balance and emotional regulation. Method. A cross-sectional study was performed. Occupational balance and emotional regulation were measured using the Occupational Balance Questionnaire and the Emotional Regulation Questionnaire, respectively. A multivariate analysis (analysis of covariance) was conducted. Findings. The sample consisted of 112 individuals, divided into two groups: the serious mental illness group (n  =  55); and the healthy group (n  =  57). People with serious mental illness reported lower occupational balance and lower cognitive reappraisal than the healthy population. Furthermore, the higher cognitive reappraisal, the higher the occupational balance, and the higher the expressive suppression, the lower the occupational balance. Conclusion. The results provide preliminary evidence of the relationship between occupational balance and emotional regulation.

[From nursing to changing social representations: the study of health literacy in psychiatry]

The Litterapsy study focuses on the assessment of health literacy in patients with psychiatric disorders, a field that has been little studied in France. It is based on the observations of an advanced practice nurse specializing in psychosocial rehabilitation. Its aim is to provide objective data to better understand how these patients understand medical information and navigate the healthcare system.

In Memory of Anthony Stevens: A Career Retrospective with Emphasis on His Formative Role in the Archetype Debate

This paper celebrates the life and legacy of psychiatrist and Jungian author Anthony Stevens, who passed away at age 90 on July 13, 2023. It outlines Stevens's origins as a research fellow in Greece, where his work on infant attachment led to a lifelong dedication to establishing the biological and evolutionary foundation of psychiatry. It details his instrumental role in the debate about the theory of archetypes and describes the current state of the literature including the responses and reactions to Stevens's biological innatist position. The paper concludes with a career retrospective in which Stevens's major works are introduced and briefly described.

[Restraint during care: The legal aspects]

Restraint in care must be a practice of last resort. To date, it is only regulated in the texts for psychiatric care without consent and only in full hospitalization. Healthcare teams can only use it with great caution, in a manner strictly proportionate to the situation and, if they act outside the legal framework, by taking good professional practices as a reference.

[The narcissistic envelope of the care team in times of crisis in psychiatry]

The narcissistic envelope plays a fundamental role for psychiatric care teams to whom it guarantees sufficient internal security, supporting their investment in the therapeutic relationship. The hospital crisis is undermining these teams. By promoting the denarcissization of the nursing staff, it increases their resistance and questions the future of the care team registered in a collective in psychiatry.

[Questioning restraint practices to develop a caring approach]

In 2021, the Aisne departmental public mental health establishment (EPSMDA) chose to open a seminar on restraint, care and freedom. With the support of the EPSMDA branch of the Chair of Philosophy in Hospitals, developed for this occasion, participants were able to apprehend, thanks to various philosophical, sociological, historical, regulatory, deontological, medical, paramedical and experiential (by the patient himself) approaches, the notions of restraint, container and content that surround the restraint approach with both adults and children. Throughout the year, we welcomed qualified speakers. More generally, the debates dealt with the relationship between the subject of care in psychiatry and the care logic conveyed by professionals in institutions, evoking the transition from a care logic to a care logic.

[Talking about delusion, what delusion?]

When we talk about the clinic of delusional symptoms, we are first and foremost affirming that delusions exist. Professionals working in psychiatry know that delusions can be listened to, that they give meaning to suffering and are part of the history of the subject. Taking the time to reflect on this type of symptom allows us to invest in the clinical field specific to psychiatry, and only makes sense if the clinical approach is based on work referring to the patient's individual history. Maintaining and developing these attitudes to care is essential to the survival of psychiatry as a discipline. Focusing on the clinic of delusion is neither a luxury nor a waste of time.

[Soothing spaces and techniques in psychiatry]

The development of alternatives to seclusion and restraint is a priority for psychiatric care services. Among them, the implementation of soothing spaces is currently experiencing considerable growth.

[Isolation and mechanical restraint in psychiatry]

Since 2016, there has been a succession of legal texts aimed at framing the use of seclusion and mechanical restraint in psychiatric services. These legal evolutions are not without consequence on the practice of caregivers. We propose here a practical summary of this issue.

[Isolation and restraint in psychiatry: practice and feedback from professional experiences]

A psychiatric nurse since 2013, who became a clinical psychologist in 2022, I have had the opportunity, on numerous occasions, to use isolation and therapeutic restraint as part of my nursing practice, mainly in a closed psychiatric admissions service. These therapeutic tools, specific to psychiatry, are used in a very specific theoretical and legislative framework. Their use always leads to reflection, both individually and as a team. Indeed, their use must remain the last therapeutic bulwark to be used because it can be experienced with difficulty or even in a traumatic way by the patient, which can damage the relationship of trust with the carers. Thus, it is important that this practice be supervised and discussed with the patient and the team in order to be as appropriate as possible.

[Birth of an IPA collective within a hospital]

Since 2020, the Charles-Perrens Hospital Center in Bordeaux has been supporting the implementation of advanced practice nursing. The formation of a group of five advanced practice nurses (APNs) has enabled the deployment of numerous missions consistent with the APN model. With a view to developing the nursing discipline and enriching the healthcare offer, they are developing direct clinical missions or missions addressed to professionals and the healthcare system. The collective represents a major lever for implementation, and allows this new professional identity to be positioned within the hospital institution.

[Advanced nursing practice in a medical-psychological center]

The introduction of an advanced practice nurse in psychiatry and mental health (APN) at the University Hospital of Nîmes has made it possible to improve the quality and safety of care while controlling costs and ensuring the satisfaction of patients, partners and care teams. A favorable institutional policy, the involvement of the management, psychiatrists and the IPA PSM facilitated the acceptance of this new profession by the care teams and other professionals, despite the existence of statutory and logistical obstacles.

[Three examples of IPA implementation in medical-psychological centers]

The Paul-Guiraud Hospital Group has three advanced practice nurses (APNs) specializing in psychiatry and mental health who work in different medical-psychological centers. Supported by the institution, each APN project has been thought out by a multi-professional team within the structures, according to their specific needs.

[A sport-health centre open to mental health]

Physical activity is a determinant of the overall health and well-being of patients with mental disorders. The story of a clinical experience in a physical activity and sports center, recognized as a health and sports center, allows us to highlight the specific issues of adapted physical activity in psychiatry, oriented towards recovery and social integration. The opening of sport-health centres in mental health is an inclusive step forward that contributes to the improvement of care practices in psychiatry.

[The transitional mobile team, psychiatric care upon release from prison]

The "transitional mobile team" has been developed to optimize the management of the transition from prison to the community for people with psychiatric disorders in France. The objectives are to limit the risk of relapse and death during this high-risk period and to ensure the links between psychiatry in prison and community psychiatry.

[The care partnership pact in adult psychiatry]

Programs to reduce the use of coercive measures emphasize the importance of patient involvement in their care and the use of formalized tools. An adult psychiatric care admission unit offers a specific tool to the hospitalized patient: the "Preventive Emotion Management Questionnaire", as soon as the patient is admitted to the unit. Thus, in case of a crisis period, caregivers will know what the patient's wishes are, which will facilitate the implementation of a care partnership, guided by two nursing theories.

[Psychiatric care in specially equipped hospital units]

The specially equipped hospital units (UHSA) receive detainees in the region (men, women, minors) requiring full psychiatric hospitalization, either in free care or in care by decision of the State representative. They are located on the site of hospitals, but a penitentiary enclosure allows for the control of the entry and exit of patients, as well as the security of the perimeter. To date, nine UHSAs are in operation in France.

[Therapeutic alliance between sectorial psychiatry inpatients and nurses and aides: A prospective, observational and cross-sectional study]

BACKGROUND

Therapeutic alliance represents a rarely studied object when it relates to nurses and care provided by a nursing team in acute care hospitalization.

OBJECTIVE

The objective was to study how factors might influence the therapeutic alliance built between nurses and aides and adult inpatients in an acute care unit of sectorial general psychiatry.

METHOD

This is a prospective, observational and cross-sectional study using a therapeutic alliance measurement scale. Therapeutic alliance (TA) score was measured with a STAR-P scale in a sample of 240 patients.

RESULTS

The median score found is 33.4 (±7.8) out of a maximum theoretical score of 48. The global score of TA in patients aged 60 years old or more is significantly higher than the score of patients between 18 and 29 years old (p=0.021). The lack of external follow-up in the three months after hospital release is not associated with TA global score (p=0.73). If inpatients, no matter what their diseases or types of care are, under legal obligation or not, consider their TA is rather good after their hospital stay. Only sociodemographic factors like age, housing conditions (insecure or sustainable), having a job or not, living alone or with a partner affect TA and follow-up.

CONCLUSION

Results evoke concepts of anomie and attachment, that seem to play an important role in the lack of follow-up after hospital stay, and indicate the mandatory global approach to care and an involvement of health professionals as well as social beings, where empathy must find its place.

[Psychiatry of the elderly: a sometimes complex clinical picture]

Psychiatry of the elderly is a discipline that focuses on the subject as a whole. The interaction of psychiatric, neurological and somatic pathologies impacts the elderly subject on a functional, psychological and social level. Multidisciplinary care is therefore essential to build a complete therapeutic project and to accompany the patient in the plurality of his problems.

[Social care for patients hospitalized in units for difficult patients]

The units for difficult patients are secure psychiatric wards that receive people suffering from mental illnesses with a risk of dangerous behaviour. Within the framework of the global care of these patients, the intervention of social service assistants plays an essential role. The objective is to induce the psychosocial benefits necessary for the stabilization and evolution of these patients.

[Choosing to be a psychiatric nurse]

Being a nurse in psychiatry is not an accident. The particularity of the care and people being cared for and the autonomy of the nurse in his or her role as clinician can guide the choice to practice this profession in this environment. Similarly, the particularities of the technical care provided in psychiatry and the special place of the care teams are also arguments to explain this decision.

[Stigmatization of psychiatric nurses]

Within the framework of its establishment project, a public mental health establishment located in Essonne wished to develop paramedical research. The theme of the stigmatization of nurses working in psychiatry was chosen. Using a qualitative methodology, interviews were conducted with two groups of professionals and one group of student nurses, the aim being to find out whether they felt stigmatized by their peers and/or by society in general. The results obtained are interesting.

[The psychiatric hospital in search of an extra soul]

The evocation of the meaning of the patients' suffering and their quest for appeasement refocuses the reflection on the missions of the psychiatric hospital around reception and accompaniment. It reminds us above all of the role of the carers in psychiatry, between availability, listening and benevolence. The maintenance of the link between the caregiver and the patient, in an atmosphere of trust, is essential to the care and quality of the accompaniment. We must not forget this.

[The meeting, a lever towards the exercise of nursing care in psychiatry]

Nursing training is provided in nursing training institutes by a multidisciplinary teaching team. During this course, the nursing student will forge his or her professional identity. However, psychiatry is a field that is not very popular with students. Social representations, apprehension and lack of knowledge of the discipline, and the crisis that the sector is going through all work against this choice. Especially since young nurses are ill-equipped to develop a sufficiently good posture, in line with the expectations of the health care team. Nevertheless, some of those who have chosen to work in psychiatry emphasize the notion of encounters as a determining factor in their professional orientation. This encounter is based on three stages: an encounter with oneself, with specific knowledge and with the clinic.

[Professional commitment and work in psychiatry]

The practice of care in a psychiatric service, whether outpatient or inpatient, appears more than ever to be a personal commitment. How can we conceive it despite the difficulties of the profession, which make new professionals hesitate to join it? There is now open talk of a "crisis in psychiatry", of professionals leaving the profession. However, many observers and caregivers manage to give meaning to this demanding profession, at the crossroads between disciplines and institutions. The activity is constantly evolving, shaped as much by the advent of multiple theoretical frameworks as by societal movements. The number of people using this discipline, which is now also called "mental health" care, is constantly increasing, while at the same time all the players are struggling to recruit professionals. However, patients who have become users can testify to the quality of the caregivers.

[Consultado, an outpatient facility for adolescents]

Adolescence is a pivotal period in the construction of identity. The individuation process at stake creates a fragile context. However, the quality of this process is what determines the development of the young adult. In this perspective, this period of life is often described as a time of rupture, of great reorganisation. When an acute psychiatric crisis occurs at the heart of this complex movement, the Consultado system intervenes. This meeting between the care provider, the young person and his or her family constitutes a time that is both singular and central, set in a short time frame.

[Social care for patients hospitalised in units for difficult patients]

The units for difficult patients are secure psychiatric wards that receive mentally ill people who could have committed or have committed dangerous acts. As part of the overall care of these patients, the treatment of their social problems by social workers plays an essential role. These interventions provide the psychosocial benefits necessary for the stabilisation and evolution of these subjects.

[Touch in the care relationship]

Touching someone is a multisensory encounter with the other, it is listening, hearing, seeing, smelling, feeling, perceiving, etc. This contact allows for the interpersonal circulation of a host of information in a close relationship. The caregiver touches the patient's body with his or her eyes before beginning to grasp it with his or her hands. In order to adjust his or her approach to care, he or she must be attentive to the messages that the patient sends. But touching a patient's body also means that the caregiver is touched by the emotions produced by the confrontation of the person's body with his or her own body.

[Professional identity and care practice in adolescent psychiatry]

In psychiatric wards, nurses are an essential professional group in institutional and hospital life. In full hospitalization units for adolescents with psychological disorders, their professional identity is constructed in a care approach, at the crossroads of care and education. Motivated by individuation and by a feeling of collective and institutional belonging in their care practices, this identity construction seems to be beneficial for the patients since it is reinvested in the therapeutic relationship between caregiver and patient.

[Influence of the work environment on burn-out and depression in nurses]

Burn out is defined as a state of psychological exhaustion in the face of an unfavourable work environment. In the health sector, this includes, among other things, an excessive care burden, the lack of autonomy or control over work, the vicious circle of absenteeism, the lack of support, moral and sexual harassment, discrimination or the Covid-19 health crisis. Burn-out also increases the risk of depression among care workers.

[Organisation and methods of intervention of the medical-psychological emergency units]

In the particular case of exceptional health situations involving multiple victims or not, the early psychiatric care of patients affected, directly or not, relies on the medical-psychological emergency cells (Cump). The organisation of these units is based on ministerial instructions. The indications for recourse to the Cump as well as the method of triggering it are based on recommendations established by French learned societies.

[Pharmacological and multimodal care of the adult patient with psychiatric presentation in the emergency department]

The pharmacological management of patients with psychiatric presentations, on prescription, and by nurses in emergency medicine structures is based on knowledge of a limited number of molecules and their methods of administration. This is accompanied by a relational approach and techniques to ensure the safety of the teams in the case of an agitated or very resistant patient.

[The elderly with a psychiatric prognosis in the emergency room]

In the emergency department, the diagnosis of an acute psychiatric condition in an elderly patient should only be made after rigorous clinical and paraclinical examinations to rule out any somatic pathology. In addition, the management and treatment of acute agitation must be adapted.

[Physical restraint of the adult patient with uncontrollable agitation]

In the context of psychiatric emergencies, it is important to distinguish between so-called controllable agitation and uncontrollable agitation. In this context, physical restraint of the adult patient is sometimes necessary, but remain an exceptional measure. Restraints must be applied rapidly and in a protocolised manner. It should be used sparingly in the elderly patient. Physical restraint is a medical prescription that must be accompanied by chemical restraint.

[Medico-legal framework for emergency care of a patient with psychiatric conditions]

The care and referral of patients with psychiatric conditions is a perilous process. It combines the need for care with respect for individual freedom. Knowledge of the different legal frameworks is thus necessary for psychiatric care at the request of a third party, care without request of a third party within the framework of a procedure for imminent danger, and finally for the injunction of psychiatric care on the decision of a State representative. These are necessary prerequisites for practising in an emergency structure.

[Plea for a collegial practice of emergency psychiatric care]

The care of patients, especially in the field of agitation or psychiatry, requires close coordination between different actors. Interdisciplinarity makes it possible to analyse and harmonise the links between various disciplines with the common aim of solving complex problems. This interdisciplinarity must now become a fundamental in the teaching of health sciences and a prerequisite for the functioning of hospital services, in particular in the formalisation of acute care pathways.

[Emergency medical assessment of the patient with psychiatric conditions]

The evaluation by the emergency doctor of the patient presenting with a psychiatric symptom before being taken care of by the psychiatric team is described by the term medical clearance. There is little work on the performance of complementary examinations on these patients. A retrospective multicentre study conducted at the Metz-Thionville regional hospital (57) shows that at least one complementary examination was carried out in 61% of hospitalised patients, compared with 28% of non-hospitalised patients. For 2.4% of patients, the final diagnosis was organic.

[Managing mass psychiatric chaos]

During an event with a high traumatic potential, the patient, as well as the first intervener in the care process, will resonate with his or her own intimate life experience and that of the other person. This happens in the reality of experiences, but also in the constructed projections. These stress-related phenomena must be widely known and taught, in order to increase the capacity to respond and adjust to these individual and collective crisis situations. This guarantees the physical and psychological health of the people involved.

[Psychiatry to support the Covid-19 vaccination campaign]

Health professionals have been mobilised to contribute to the emergency vaccination campaign deployed since the end of 2020 to combat the Covid-19 pandemic. In a mental health institution of the Grand-Est region, a vaccination centre has been implemented in emergency to contribute to the collective public health effort. Feedback from a hospital health executive.

[From involuntary restraint to the subject "containing himself"]

An alternative approach to restraint in psychiatry? The literature on the use of restraint in psychiatry reveals that it is mainly used against patients' will. An alternative way of restraining a patient in anticipation of a crisis situation is proposed through the calming effect of holding (psychoanalytical concept) and sensory integration (neurosciences). Offering patients a method of "voluntary restraint" could partly restore their autonomy.

[Reception of a patient suspected of having a psychiatric condition in an emergency department]

Many emergency patients have pre-existing psychiatric conditions. They may also present a symptomatology likely to evoke this type of psychiatric pathology. The way in which these patients are received and managed is of prime importance, as it determines the subsequent treatment. It is therefore essential that the emergency services organise a specific pathway for these patients.

[Managing suicidal crisis in a suicidology unit]

The reception service for suicidal patients is part of the national public health strategy of suicide prevention. The mission of this specialized unit is to accompany the person in order to defuse the suicidal crisis and, more broadly, to propose an adapted therapeutic strategy around the suicidal act.

[Nursing clinical judgement in situations of restraint]

Coercive measures such as seclusion and restraint, which are sometimes used in psychiatry, remain current practices. According to literature, these interventions are particularly complex for the nurses implementing them. In situations of seclusion and restraint, these professionals focus in particular on the nurse-patient relationship, the patient's safety and the respect of their humanity. Training is possible to help nurses manage these situations and improve their approach to the clinical judgement.

[The setting up of advanced practice nursing with patients with schizophrenia]

The first advanced practice nurses in psychiatry and mental health are being deployed across the country. Such is the case at Paris XV psychiatric university hospital, which is working to gradually integrate an advanced practice nurse into medico-psychological centres to work with patients with schizophrenia. The role also comprises time devoted to research and teaching.

[Caregiver burden: From recognition to care]

The burden of caregivers of patients with chronic diseases has been the subject of research for several years, but few studies have focused on the suffering of family members from the time of their first hospitalization in psychiatry. The identification of the determinants of this burden would allow us to propose early management aimed at improving the well-being of the patients' family and friends and maximizing intra-family resources.

[Covid-19 infectious disease is also a psychogeriatric disease]

Severe forms of Covid-19 infectious disease often affect the frail elderly. They can induce inaugural psychiatric manifestations or aggravate the underlying psychiatric pathologies. Some of these pathologies persist after the acute episode and require specific management. Doctors and caregivers involved in the care of infected patients are themselves exposed to psychological and even psychiatric difficulties and are looking for collaborative help complementing actions in the somatic care sectors.

[Preventing radicalisation with the necessary involvement of all]

As a recent public policy, the prevention of radicalisation has been built in response to an evolving phenomenon. The implementation of tools for reporting and monitoring people undergoing radicalisation will begin in 2014. Although there is no standard profile of radicalised people, the target group for these systems is mainly young people, adults or minors. In terms of prevention of radicalisation, care covers a broad spectrum of interventions and professionals.

[Entrustable Professional Activities in Graduate Medical Education in Psychiatry: A Promising Concept]

Entrustable Professional Activities in Graduate Medical Education in Psychiatry: A Promising Concept Abstract. Entrustable Professional Activities (EPAs) are competency-based learning goals derived from observable clinical activities. In undergraduate medical education, they have now been adopted throughout Switzerland as part of the so-called PROFILES catalog (Principal Relevant Objectives and Framework for Integrated Learning and Education in Switzerland). The nine core EPAs to be mastered in undergraduate medical education can serve as a basis for introducing EPAs in graduate medical education as well. We will discuss this approach in the context of graduate medical education in psychiatry and psychotherapy from the perspective of different training contexts and a pilot example. In this position paper, we describe a promising opportunity to improve graduate medical training through the implementation of EPAs, both in terms of the quality of training and thus of patient care, as well as in terms of the attractiveness of the specialty for future residents.