[Health professionals facing the coronavirus disease 2019 (COVID-19) pandemic: What are the mental health risks?]

Objectifs

La pandémie de la maladie à coronavirus (COVID-19) a provoqué une crise sanitaire majeure et mis en quarantaine la moitié de la population planétaire. En France, elle a provoqué une réorganisation en urgence de l’offre de soins mobilisant les soignants dans un climat d’incertitude. L’objectif du présent article est de faire le point sur les risques associés à l’exposition des soignants au COVID-19 pour leur santé mentale.

Méthodes

Les auteurs ont conduit une revue de la littérature internationale tenant compte des données des précédentes épidémies (SARS-CoV-1, H1N1) et des données plus récentes concernant le COVID-19.

Résultats

Les caractéristiques de cette pandémie (rapidité de diffusion, connaissances incertaines, sévérité, décès de soignants) ont installé un climat anxiogène. Des facteurs organisationnels peuvent être source de stress : déficit d’équipement de protection individuel, réaffectation de postes, manque de communication, manque de matériels de soins, bouleversement de la vie quotidienne familiale et sociale. D’autres facteurs de risque sont identifiés comme l’absence de soutien, la crainte de contaminer un proche, l’isolement ou la stigmatisation sociale, le haut niveau de stress au travail ou les patterns d’attachement insécure. Les soignants ont ainsi un risque augmenté d’anxiété, de dépression, d’épuisement, d’addiction et de trouble de stress post-traumatique.

Conclusions

Cette crise sanitaire devrait nous aider à mieux comprendre la vulnérabilité des soignants à la souffrance psychologique afin de renforcer les stratégies de prévention primaire et la formation aux enjeux psychologiques des soins, de la relation, et de la gestion des situations de crises sanitaires.

The use of repetitive transcranial magnetic stimulation for modulating craving and addictive behaviours: a critical literature review of efficacy, technical and methodological considerations

OBJECTIVES

Repetitive transcranial magnetic stimulation (rTMS) is a potential therapeutic intervention for the treatment of addiction. This critical review aims to summarise the recent developments with respect to the efficacy of rTMS for all types of addiction and related disorders (including eating disorders), and concentrates on the associated methodological and technical issues.

METHODS

The bibliographic search consisted of a computerised screening of the Medline and ScienceDirect databases up to December 2013. Criteria for inclusion were the target problem was an addiction, a related disorder, or craving; the intervention was performed using rTMS; and the study was a clinical trial.

RESULTS

Of the potential 638 articles, 18 met the criteria for inclusion. Most of these (11 of the 18) supported the efficacy of rTMS, especially in the short term. In most cases, the main assessment criterion was the measurement of craving using a Visual Analogue Scale.

DISCUSSION

The results are discussed with respect to the study limitations and, in particular, the many methodological and technical discrepancies that were identified. Key recommendations are provided.

Subjective craving and event-related brain response to olfactory and visual chocolate cues in binge-eating and healthy individuals

High-sugar/high-fat foods are related to binge-eating behaviour and especially people with low inhibitory control may encounter elevated difficulties to resist their intake. Incentive sensitization to food-related cues might lead to increased motivated attention towards these stimuli and to cue-induced craving. To investigate the combined influence of olfactory and visual stimuli on craving, inhibitory control and motivated attention, 20 healthy controls and 19 individuals with binge-eating viewed chocolate and neutral pictures, primed by chocolate or neutral odours. Subjective craving and electroencephalogram activity were recorded during the task. N2 and Late Positive Potential (LPP) amplitudes were analysed. Patients reported higher craving than controls. Subjective craving, N2 and LPP amplitudes were higher for chocolate versus neutral pictures. Patients showed a higher relative increase in N2 amplitudes to chocolate versus neutral pictures than controls. Chocolate images induced significant increases in craving, motivated attention and measures of cognitive control. Chocolate odour might potentiate the craving response to visual stimuli, especially in patients with binge-eating.

Practical considerations for the evaluation and management of Attention Deficit Hyperactivity Disorder (ADHD) in adults

Attention deficit with or without hyperactivity disorder (ADHD) is one of the most frequent neuropsychiatric disorders, and affects 2-4% of adults. In contrast with many European countries, the identification and management of adult ADHD remains underdeveloped in France, and a subject of controversy. This review provides a practical update on current knowledge about ADHD in adults for French-speaking professionals who have to detect or manage adult patients with ADHD. ADHD is classified as a neurodevelopmental disorder in the recent update of the international diagnostic classification. While symptoms and impairment due to ADHD are frequently severe during childhood, they often evolve as children grow older, with frequent persistent disabilities in adulthood. In adulthood, the clinical presentation, as in childhood, involves the symptom triad of inattention, hyperactivity and impulsivity. However, differences are noted: hyperactivity is more often internalized, symptoms of inattention may be masked by anxiety symptoms or obsessive-like compensation strategies. ADHD is often diagnosed during childhood, but it is not rare for the diagnosis to be made later. Failure to recognise symptoms resulting in misdiagnosis, or alternatively well-developed compensation factors could be two underlying reasons for the long delay until diagnosis. Other symptoms, such as emotional deregulation or executive function-related symptoms are also usually observed in adults. In addition, in adults, ADHD is often associated with other psychiatric disorders (in 80% of cases); this makes the diagnosis even more difficult. These disorders encompass a broad spectrum, from mood disorders (unipolar or bipolar), to anxiety disorders, and other neurodevelopmental disorders and personality disorders, especially borderline and antisocial personality disorder. Substance-use disorders are very common, either as a consequence of impulsivity and emotional dysregulation or as an attempt at self-treatment. Sleep disorders, especially restless leg syndrome and hypersomnolence, could share common pathophysiological mechanisms with ADHD. ADHD and comorbidity-related symptoms are responsible for serious functional impairment, in various domains, leading to academic, social, vocational, and familial consequences. The impact on other psychiatric disorders as an aggravating factor should also be considered. The considerable disability and the poorer quality of life among adults with ADHD warrant optimal evaluation and management. The diagnostic procedure for ADHD among adults should be systematic. Once the positive diagnosis is made, the evaluation enables characterisation of the levels of severity and impairment at individual level. A full examination should also assess medical conditions associated with ADHD, to provide personalized care. In recent years, a growing number of assessment tools have been translated and validated in French providing a wide range of structured interviews and standardized self-report questionnaires for the evaluation of core and associated ADHD symptoms, comorbidities and functional impairment. The treatment of ADHD in adults is multimodal, and aims to relieve the symptoms, limit the burden of the disease, and manage comorbidities. The most relevant and validated psychological approaches are psycho-education, cognitive-behavioural therapy and "third wave therapies" with a specific focus on emotional regulation. Cognitive remediation and neurofeedback are promising strategies still under evaluation. Medications, especially psychostimulants, are effective for alleviating ADHD symptoms with a large effect size. Their safety and tolerance are satisfactory, although their long-term clinical benefit is still under discussion. In France, methylphenidate is the only stimulant available for the treatment of ADHD. Unfortunately, there is no authorization for its use among adults except in continuation after adolescence. Hence the prescription, which is subject to the regulations on narcotics, is off-label in France. This article aims to provide practical considerations for the management of ADHD and associated disorders in adults, in this particular French context.

Analytical method for the biomonitoring of bisphenols and parabens by liquid chromatography coupled to tandem mass spectrometry in human hair

Bisphenols and parabens are endocrine disruptors families widely used in daily life. They are known to be linked to numerous pathologies such as reproductive disorders, obesity, breast cancer, hypertension and asthma. Biomonitoring is an essential tool for assessing population exposure to environmental pollutants. Blood and urine are the main matrices used in human biomonitoring. However, they are not suitable to evaluate long-term exposure to endocrine disruptors with a short elimination half-life such as parabens or phenols. Hair appears to be an interesting alternative matrix allowing a wide window of exposure due to an accumulation of xenobiotics during hair growth. This study presents the development and validation of a high-performance liquid chromatography coupled to tandem mass spectrometry for the simultaneous determination of bisphenol A, its chlorinated derivatives, bisphenol F, bisphenol S and parabens in human hair. An optimised sample preparation based on acidic hydrolysis followed by liquid-liquid extraction was performed, before an analysis by ultra-high performance liquid chromatography coupled to tandem mass spectrometry in multiple reaction monitoring mode. To validate the method, recognized bioanalytical guidelines were used and calibration and quality control samples were prepared in human hair samples. Linearities were over 0.996 in the whole range of concentrations. Trueness and precision were demonstrated for each target analyte with intra-day and inter-day bias values ranging from 86 % to 118 % and relative standard deviation values ranging from 0 % to 19 %. At the same time, limits of quantification were set at 0.25 ng/g for bisphenol A and parabens, 0.05 ng/g for bisphenols F and S and 0.00625 ng/g for the chlorinated derivatives of bisphenol A. This reliable method was applied to hair samples taken from hospital professionals and allowed the quantification of these endocrine disruptors in this population. Chlorinated derivatives of bisphenol A were quantified here in hair for the first time.

Adherence to treatment guidelines in clinical practice for using electroconvulsive therapy in major depressive episode

BACKGROUND

ECT is the most effective treatment of major depressive episode (MDE) but remains a neglected treatment. The French Society for Biological Psychiatry and Neuropsychopharmacology aimed to determine whether prescribing practice of ECT followed guidelines recommendations.

METHODS

This multicenter, retrospective study included adult patients with major depressive disorder (MDD) or bipolar disorder (BD), who have been treated with ECT for MDE. Duration of MDE and number of lines of treatment received before ECT were collected. The reasons for using ECT, specifically first-line indications (suicidality, urgency, presence of catatonic and psychotic features, previous ECT response, patient preference) were recorded. Statistical comparisons between groups used standard statistical tests.

RESULTS

Seven hundred and forty-five individuals were included. The mean duration of MDE before ECT was 10.1 months and the mean number of lines of treatment before ECT was 3.4. It was significantly longer for MDD single episode than recurrent MDD and BD. The presence of first-line indications for using ECT was significantly associated to shorter duration of MDE (9.1 vs 13.1 months, p<0.001) and lower number of lines of treatment before ECT (3.3 vs 4.1, p<0.001).

LIMITATIONS

This is a retrospective study and not all facilities practicing ECT participated that could limit the extrapolation of the results.

CONCLUSION

Compared to guidelines, ECT was not used as first-line strategy in clinical practice. The presence of first-line indications seemed to reduce the delay before ECT initiation. The improvements of knowledge and access of ECT are needed to decrease the gap between guidelines and clinical practice.

[Dementia: Where are the Lewy bodies?]

Dementia with Lewy bodies (DLB) is the second cause of degenerative dementia in autopsy studies. In clinical pratice however, the prevalence of DLB is much lower with important intercenter variations. Among the reasons for this low sensitivity of DLB diagnosis are (1) the imprecision and subjectivity of the diagnostic criteria; (2) the underestimation of non-motor symptoms (REM-sleep behavior disorder, dysautonomia, anosmia); mostly (3) the nearly constant association of Lewy bodies with Alzheimer's disease pathology, which dominates the clinical phenotype. With the avenue of targeted therapies against the protein agregates, new clinical scales able to apprehend the coexistence of Lewy pathology in Alzheimer's disease are expected.

[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.

Evolution of sexual functioning of men through treated and untreated depression

OBJECTIVES

Depression as well as a treatment by antidepressant are factors that may interfere with sexuality. Due to this complex relationship between depression, antidepressant and sexuality, it is difficult to incontestably establish the exclusive accountability of a treatment or of a psychiatric disorder on sexual dysfunctions. The main purpose of the SADD (for Sexuality, Anti-Depressant and Depression) study is to evaluate sexual dysfunctions in depressed men treated with antidepressant or not.

METHODS

Participants of this transversal, observational study were men aged over 18 years old, suffering from unipolar major depressive disorder and treated by a psychiatrist, with or without antidepressant. Assessment of sexual functioning through three times: euthymia (before depression), untreated depression and treated depression if applicable was performed based on the ASEX scale.

RESULTS

Seventy patients were included. Eight percent of euthymic patients presented a sexual dysfunction (average score on the ASEX=12.4) whereas 56% of untreated patients presented a sexual dysfunction (average total score on the ASEX=17.7) and 62% (34/55) of patients treated with antidepressant (average total score on ASEX=18.5) (P<0.001). Sexual functioning of men receiving treatment is not significantly different to that among men not receiving any antidepressant, even if patients treated with antidepressant reported that they had a better mood than those untreated.

CONCLUSIONS

Our results reveal a high prevalence of sexual dysfunction within the framework of major depressive disorder and its treatment and underlines the complex relationship between major depressive disorder, antidepressant and sexuality.

tDCS et addictions comportementales : le coup de foudre !

Contexte

Les addictions comportementales (AC), ou addictions sans drogues, ont en commun la perte de contrôle sur le comportement et la poursuite de ce comportement malgré les dommages. Les principales AC sont : le jeu pathologique, l’addiction sexuelle, l’exercice physique excessif, les achats compulsifs et certains troubles du comportement alimentaire. Associées à des comorbidités psychiatriques et addictives, à des conséquences sociales, leur prise en charge repose essentiellement sur des psychothérapies et des mesures sociales. L’utilisation des techniques de stimulation cérébrale est encore relativement récente, notamment dans le champ des addictions. La tDCS a principalement été testée dans les addictions avec substances, mais très peu dans les AC. Cette revue de la littérature a pour objectif de faire une mise au point méthodologique et clinique sur les premiers travaux couvrant cette question.

Matériels et méthodes

Une recherche bibliographique a été réalisée sur Pubmed et ScienceDirect, jusqu’au 30 juillet 2014. Les critères d’inclusion étaient : articles de revue, articles didactiques, essais thérapeutiques, études physiopathologiques.

Résultats et discussion

Quatorze revues et études ont été retenues. Elles portent sur les troubles du comportement alimentaire, l’obésité, et les processus décisionnels et de prise de risque. Les études cliniques ont montré l’intérêt de la tDCS bilatérale dans la diminution de la prise de risque, et du craving alimentaire. La tDCS présente des avantages prometteurs dans le traitement des AC. Non invasive, bien tolérée, avec un dispositif portable, peu coûteuse comparée à la TMS, elle pourrait être dispensée dans un cadre ambulatoire.

Les déterminants de la qualité de vie subjective des patients diabétiques : un regard biopsychosocial

La qualité de vie des patients diabétiques est déterminée par un grand nombre de facteurs de type biologique, social et psychologique, qui interagissent ensemble. Le modèle biopsychosocial (BPS), élaboré par Engel dans les années 1980, est basé sur cette notion holistique et interactive. Plus récemment, cette conception a été opérationnalisée sous la forme d’un questionnaire hétéro-évaluatif qui comporte 20 items (outil INTERMED). Même si la notion de conception holistique du bien-être de l’individu diabétique est reconnue dans la pratique clinique, notamment hospitalière, peu de travaux s’intéressant, de manière expérimentale, au bénéfice de ce concept sont disponibles dans la littérature. L’étude présentée a inclus 28 patients diabétiques, hospitalisés en service d’endocrinologie. Chaque participant a donné son consentement écrit, s’est entretenu avec une investigatrice, et a rempli une échelle mesurant la qualité de vie (SF-36). 43 % d’entre eux présentent un haut niveau de complexité BPS, ce qui indique un besoin de prise en charge multidisciplinaire. À travers des analyses de corrélation, il a été démontré que chaque composante de la complexité est associée de manière négative, et statistiquement significative, à la qualité de vie perçue. De plus, la complexité globale permet de mieux expliquer la qualité de vie que la simple prise en compte de n’importe quel facteur local. En pratique, ces résultats soulignent la nécessité de prendre en charge les éléments psychosociaux auprès des patients afin d’assurer au mieux le vécu subjectif de leur état de santé. Des services, tels que la psychiatrie de liaison, deviennent ainsi essentiels dans l’offre de soin holistique et multidisciplinaire.

[Recommendations for a gradual and controlled resumption of electroconvulsive therapy in France during the period of lifting of the containment and of the COVID-19 pandemic linked to SARS-CoV-2]

La pandémie du COVID-19 a des conséquences majeures sur l’organisation des soins. En France et dans le monde, les centres pratiquant l’électroconvulsivothérapie (ECT) ont vu leur activité diminuer, voire s’arrêter, pour de diverses raisons. Dans ce contexte, le maintien ou la reprise de cette activité thérapeutique essentielle pour de nombreux patients souffrant de troubles psychiatriques nécessite des adaptations matérielles, humaines et logistiques qu’il convient d’encadrer. L’objectif de ce travail collectif et national est de proposer des recommandations simples et applicables immédiatement par tout établissement de santé, public ou privé, pratiquant les ECT. Elles sont issues d’un retour d’expériences pluriprofessionnelles et interétablissements. Déclinées en trois étapes, ces recommandations sont accompagnées d’une fiche pratique qui décrit, de façon précise, les conditions nécessaires et préalables à toute reprise d’activité ECT.

[Treatments for depression in consultation-liaison psychiatry: From theory to practice]

Treatments for depression include an adapted lifestyle, physical activity, psychotherapies, antidepressant and mood stabilizing drugs, neuromodulation, chronotherapy, spa treatments. Drug treatments used for major depressive episode are antidepressants and mood stabilizers. For a mild episode, psychotherapy is indicated. It should be combined with an antidepressant (serotonin reuptake inhibitor) for moderate and severe episodes. Suicide risk assessment is essential throughout the depressive episode. It is recommended to monitor at the start of antidepressant treatment for suicidal behavior, a change in mood suggesting an underlying bipolar disorder. The effectiveness of the treatment is evaluated after 4 to 8 weeks. The total duration of antidepressant treatment for an EDC is between 6 months and 1 year after remission, in order to prevent relapses. The use of liaison psychiatry, a real healthcare system within the general hospital, is strongly recommended for better screening and treatment of depression, thus reducing the length of hospital stays, improving the prognosis of depression. The aim of this article is to provide clinicians with a summary of validated data on the efficacy/tolerance of treatment for depression, and to suggest practical action to be taken on the main daily clinical situations: treating comorbid conditions, taking into account interactions drugs, manage the serotonin syndrome, lead to withdrawal from antidepressants, manage treatment in the elderly.

Assessment of Endocrine Disruptor Exposure in Hospital Professionals Using Hair and Urine Analyses: An Awareness Campaign

BACKGROUND

In 2021, French public authorities initiated the fourth National Environmental Health Plan to prevent environment-related health risks. This plan primarily focuses on the sensitization of health professionals and health care institutions. Endocrine disruptors (EDs) are environmental factors associated with several adverse health effects, such as reproductive disorders, obesity, and cancer. This study aimed to conduct an awareness campaign among professionals at a general hospital center on the risks related to EDs.

METHODS

Hospital professionals were directly involved in this study, and urine and hair samples were collected to determine bisphenol and paraben exposure levels. Analyses were performed using validated liquid chromatography-tandem mass spectrometry methods, enabling the simultaneous determination of bisphenols and parabens. A questionnaire on lifestyle habits was distributed to assess its relationship with the exposure profiles. Nineteen professionals were recruited for the study.

RESULTS

Bisphenol A was detected in 95% of the urine samples, and the chlorinated derivatives of bisphenol A were between 16% and 63%. parabens showed detection frequencies between 37% and 100%, and methylparaben was quantified at an average concentration of 0.45 ± 0.46 ng/mL. In hair samples, bisphenols A, F, and S were detected at 95%-100%, chlorinated derivatives of bisphenol A were detected at 37%-68%, and parabens were detected at 100%.

CONCLUSIONS

This awareness campaign may encourage health care institutions to adopt a policy of reducing endocrine disruptor exposure among their patients and professionals, who could be educated regarding the risks associated with EDs. Conducting a multicenter study to refine the results herein and establish a dynamic to prevent endocrine disruptor and environmental risks in health care systems would be valuable.

Preparation and physicochemical stability of 50 mg/mL hydroxychloroquine oral suspension in SyrSpendⓇ SF PH4 (dry)

In the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, hydroxychloroquine has been proposed as a potential agent to treat patients with COVID-19 (coronavirus disease 2019) caused by SARS-CoV-2 infection. Older adults are more susceptible to COVID-19 and some patients may require admission to the intensive care unit, where oral drug administration of solid forms may be compromised in many COVID-19 patients. However, a liquid formulation of hydroxychloroquine is not commercially available. This study describes how to prepare a 50 mg/mL hydroxychloroquine oral suspension using hydroxychloroquine sulfate powder and SyrSpend^Ⓡ SF PH4 (dry) suspending vehicle. Moreover, a fully validated stability-indicating method has been developed to demonstrate the physicochemical stability of the compounded hydroxychloroquine oral suspension over 60 days under refrigeration (5 ± 3 °C). Finally, use of the proposed oral suspension provides a reliable solution to perform safe and accurate administration of hydroxychloroquine to patients with SARS-CoV-2 infection.

Place relative et complémentarité de l’ECT et de la rTMS dans le traitement de la dépression sévère ou résistante

Contexte

La stimulation magnétique transcrânienne (rTMS) est un traitement efficace de la dépression résistante. Sa place relative par rapport aux ECT dans la stratégie thérapeutique est questionnée ainsi que leur possible complémentarité.

Matériels et méthodes

Nous avons procédé à une synthèse de la littérature sur Pubmed fin juin 2014 avec la combinaison des mots clés suivants : ECT, mECT, rTMS, versus, adjuvant, add-on, comparative, efficacy, maintenance treatment, relapse, longitudinal follow-up, depression.

Résultats et discussion

La rTMS peut être aussi efficace que l’ECT à coût équivalent sous certaines conditions (durée > 4 semaines, plus de 1200 pulses par séance, moins d’échecs médicamenteux antérieurs, et surtout absence de symptômes psychotiques). Les mécanismes d’action sont en partie communs : neurogenèse, sécrétion de facteurs neurotrophiques, transmission monoaminergique, gabaergique et glutamatergique, régulation de l’axe hypothalamo-hypophysaire et régulation de l’activité cérébrale frontal et limbique. L’action rapide de la rTMS sur le risque suicidaire reste à démontrer mais elle présente probablement un meilleur profil de tolérance cognitive en cure initiale, voire un effet procognitif. Dans les deux cas le taux de rechute est estimé entre 40 et 50 % à 3 mois en l’absence de prophylaxie adéquate. Le traitement d’entretien par rTMS consiste le plus souvent en 2 séances sur une journée de façon hebdomadaire sans consensus actuellement sur cette question. Bien que les ECT de maintenance soient bien tolérées, certains patients fragiles du fait de co-morbidités, ou réticents à certains traitements psychotropes, ou craignant les anesthésies, pourraient bénéficier de rTMS en relais des ECT. Plusieurs séries de cas plaident en ce sens.

Conclusion

Des essais prospectifs longitudinaux avec présence de groupes contrôles sont souhaitables, contrôlant sur la durée les traitements et les aspects cognitifs de façon objective et comparative. La rythmicité, les sous-groupes cliniques éligibles, et les traitements associés restent à préciser.

TORPP - Turtles, One Health Research & Plastic Pollution: A multidisciplinary consortium to evaluate the environmental and health impact of Micro/NanoPlastics (MNPs) pollution

Although the World Health Organization characterizes a One Health concern as one in which there is the capability to incorporate numerous disciplines to tackle health challenges threatening humans, animals and ecosystems, scientific efforts frequently remain compartmentalized. Here we report an original consortium, TORPP, spanning 16 disciplines, focused on Micro/NanoPlastics (MNPs) pollution as a One Health concern. Whereas the MNP topic has been largely studied in marine ecology, research effort remains scarce in human medicine. Equally, while marine ecology is highly skilled in MNP sampling and characterization, human medicine has developed pathophysiological concepts and tools that can be used more broadly to evaluate the health impact of MNPs. TORPP consortium propose that these strengths and knowledges must be transferred across fields of study to advance our understanding of MNP toxicity to organisms, by uniting integrative approaches (ecological, experimental and clinical) under a common conceptual and analytical framework.