Incidence and predictors of metabolic syndrome onset in individuals with bipolar disorders: A longitudinal study from the FACE-BD cohort

INTRODUCTION

Metabolic syndrome (MetS) is a cluster of components including abdominal obesity, hyperglycemia, hypertension, and dyslipidemia. MetS is highly prevalent in individuals with bipolar disorders (BD) with an estimated global rate of 32.6%. Longitudinal data on incident MetS in BD are scarce and based on small sample size. The objectives of this study were to estimate the incidence of MetS in a large longitudinal cohort of 1521 individuals with BD and to identify clinical and biological predictors of incident MetS.

METHODS

Participants were recruited from the FondaMental Advanced Center of Expertise for Bipolar Disorder (FACE-BD) cohort and followed-up for 3 years. MetS was defined according to the International Diabetes Federation criteria. Individuals without MetS at baseline but with MetS during follow-up were considered as having incident MetS. A logistic regression model was performed to estimate the adjusted odds ratio and its corresponding 95% confidence interval (CI) for an association between each factor and incident MetS during follow-up. We applied inverse probability-of-censoring weighting method to minimize selection bias due to loss during follow-up.

RESULTS

Among individuals without MetS at baseline (n = 1521), 19.3% developed MetS during follow-up. Multivariable analyses showed that incident MetS during follow-up was significantly associated with male sex (OR = 2.2, 95% CI = 1.7-3.0, p < 0.0001), older age (OR = 2.14, 95% CI = 1.40-3.25, p = 0.0004), presence of a mood recurrence during follow-up (OR = 1.91, 95% CI = 1.22-3.00, p = 0.0049), prolonged exposure to second-generation antipsychotics (OR = 1.56, 95% CI = 0.99, 2.45, p = 0.0534), smoking status at baseline (OR = 1.30, 95% CI = 1.00-1.68), lifetime alcohol use disorders (OR = 1.33, 95% CI = 0.98-1.79), and baseline sleep disturbances (OR = 1.04, 95% CI = 1.00-1.08), independently of the associations observed for baseline MetS components.

CONCLUSION

We observed a high incidence of MetS during a 3 years follow-up (19.3%) in individuals with BD. Identification of predictive factors should help the development of early interventions to prevent or treat early MetS.

Psychometric properties of two implementation measures: Normalization MeAsure Development questionnaire (NoMAD) and organizational readiness for implementing change (ORIC)

Background

Effective interventions need to be implemented successfully to achieve impact. Two theory-based measures exist for measuring the effectiveness of implementation strategies and monitor implementation progress. The Normalization MeAsure Development questionnaire (NoMAD) explores the four core concepts (Coherence, Cognitive Participation, Collective Action, Reflexive Monitoring) of the Normalization Process Theory. The Organizational Readiness for Implementing Change (ORIC) is based on the theory of Organizational Readiness for Change, measuring organization members' psychological and behavioral preparedness for implementing a change. We examined the measurement properties of the NoMAD and ORIC in a multi-national implementation effectiveness study.

Method

Twelve mental health organizations in nine countries implemented Internet-based cognitive behavioral therapy (iCBT) for common mental disorders. Staff involved in iCBT service delivery (n = 318) participated in the study. Both measures were translated into eight languages using a standardized forward-backward translation procedure. Correlations between measures and subscales were estimated to examine convergent validity. The theoretical factor structures of the scales were tested using confirmatory factor analysis (CFA). Test-retest reliability was based on the correlation between scores at two time points 3 months apart. Internal consistency was assessed using Cronbach's alpha. Floor and ceiling effects were quantified using the proportion of zero and maximum scores.

Results

NoMAD and ORIC measure related but distinct latent constructs. The CFA showed that the use of a total score for each measure is appropriate. The theoretical subscales of the NoMAD had adequate internal consistency. The total scale had high internal consistency. The total ORIC scale and subscales demonstrated high internal consistency. Test-retest reliability was suboptimal for both measures and floor and ceiling effects were absent.

Conclusions

This study confirmed the psychometric properties of the NoMAD and ORIC in multi-national mental health care settings. While measuring on different but related aspects of implementation processes, the NoMAD and ORIC prove to be valid and reliable across different language settings.

A conceptual framework to develop a patient-reported experience measure of the quality of mental health care: a qualitative study of the PREMIUM project in France

Background: The objective of this study was to develop a conceptual framework to define a domain map describing the experience of patients with severe mental illnesses (SMIs) on the quality of mental health care. Methods: This study used an exploratory qualitative approach to examine the subjective experience of adult patients (18-65 years old) with SMIs, including schizophrenia (SZ), bipolar disorder (BD) and major depressive disorder (MDD). Participants were selected using a purposeful sampling method. Semistructured interviews were conducted with 37 psychiatric inpatients and outpatients recruited from the largest public hospital in southeastern France. Transcripts were subjected to an inductive analysis by using two complementary approaches (thematic analysis and computerized text analysis) to identify themes and subthemes. Results: Our analysis generated a conceptual model composed of 7 main themes, ranked from most important to least important as follows: interpersonal relationships, care environment, drug therapy, access and care coordination, respect and dignity, information and psychological care. The interpersonal relationships theme was divided into 3 subthemes: patient-staff relationships, relations with other patients and involvement of family and friends. All themes were spontaneously raised by respondents. Conclusion: This work provides a conceptual framework that will inform the subsequent development of a patient-reported experience measure to monitor and improve the performance of the mental health care system in France. The findings showed that patients with SMIs place an emphasis on the interpersonal component, which is one of the important predictors of therapeutic alliance. Trial registration: NCT02491866.

[Psychopharmacotherapeutic guidelines : a challenge during health crisis]

The construction of pharmacological guidelines is a complex endeavor, and this is all the truer amidst a health crisis such as the current SARS-CoV-2 pandemic. In psychiatric settings, guidelines have to consider the handling of other drugs (i.e., psychotropic medications), that have been suggested as potentially prophylactic for COVID-19. These dialectics are discussed here, and the methodological foundations used for the elaboration of guidelines are put forward.

Evolution and characteristics of the use of valproate in women of childbearing age with bipolar disorder: Results from the FACE-BD cohort

BACKGROUND

Valproate is associated with teratogenic and neurodevelopmental effects. Several agencies have restricted the conditions of its prescription in bipolar disorders (BD). We aimed to assess the evolution of valproate prescription and the clinical profile of BD women of childbearing age receiving valproate.

METHODS

Based on a large national cohort, we included all BD women 16-50 years old. Sociodemographic, clinical and pharmacological data were recorded. Logistic regression analyses were used to describe variables associated with valproate prescription.

RESULTS

Of the 1018 included women 16-50 years old, 26.9% were treated with valproate with a mean daily dosage of 968 mg. The prevalence of BD women using valproate was 32.6% before May 2015 and 17.3% after May 2015 (p<0.001), the date of French regulatory publication of restriction of valproate prescription. The multivariate analysis revealed that the inclusion period after May 2015 (OR=0.54, CI 95% 0.37-0.78, p=0.001), the age lower than 40 years (OR=0.65, CI 95% 0.43-0.98, p=0.040) and the number of lifetime mood episodes (OR=0.98, CI 95% 0.95-0.99, p=0.040) were the variables negatively associated with the use of valproate.

LIMITATIONS

Study could be underpowered to determine a clinical profile associated with valproate prescription.

CONCLUSIONS

The regulatory change in BD women of childbearing age had a significant impact on valproate prescription, even if the prescription rate remains high. Important efforts are needed to help clinicians and patients to improve quality of care in BD women of childbearing age.

Euthymia is not always euthymia: Clinical status of bipolar patients after 6 months of clinical remission

Introduction

Most studies selected euthymic patients with bipolar disorder in inter-episodic phase according to clinical remission criteria at least between 1 and 6 months. However, possible differences can exist in the course of clinical symptoms in bipolar patients related to the duration of clinical remission.

Objectives

The main aim of this study was to evaluate the clinical status of bipolar patients after 6 months of clinical remission.

Methods

We performed a cross-sectional study of bipolar outpatients in clinical remission for at least 6 months. Bipolar Depression Rating Scale (BDRS), Young Mania Rating scale, Pittsburgh Sleep Quality Index (PSQI) scale, Visual Analogic Scales (VAS) evaluated cognitive impairment were used to assess residual symptomatology of patients. Multivariate analysis (MANCOVA) was conducted for analysing possible differences between 3 groups of patients according to their duration of clinical remission (< 6 months–1 year, < 1 year–3 years, < 3 years–5 years).

Results

A total of 525 patients were included into the study. The multivariate analysis indicated a significant effect of the duration of clinical remission on the different residual symptoms (Pillai's trace: F 4.48, P < 0.001). The duration of clinical remission was associated with the significant improvement of the BDRS total score (P = 0.013), the PSQI total score (P < 0.001) and the cognitive VAS total score (P < 0.001)

Conclusion

These results support a possible improvement of residual symptoms according to the duration of clinical remission in bipolar patients. Any definition of euthymia should specify the duration criteria.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

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.

The implications of hypersomnia in the context of major depression: Results from a large, international, observational study

According to the DSM-5, "reduction in the need for sleep" is the only sleep-related criteria for mixed features in depressive episodes. We aimed at studying the prevalence, clinical correlates and the role of hypersomnia in a sample of acutely depressed patients. Secondarily, we factors significantly increasing the odds of hypersomnia were studied. We conducted a post-hoc analysis of the BRIDGE-II-Mix study. Variables were compared between patients with hypersomnia (SLEEP+) and with insomnia (SLEEP-) with standard bivariate tests. A stepwise backward logistic regression model was performed with SLEEP+ as dependent variable. A total of 2514 subjects were dichotomized into SLEEP+ (n = 423, 16.8%) and SLEEP- (n = 2091, 83.2%). SLEEP+ had significant higher rates of obese BMI (p < 0.001), BD diagnosis (p = 0.027), severe BD (p < 0.001), lifetime suicide attempts (p < 0.001), lower age at first depression (p = 0.004) than SLEEP-. Also, SLEEP+ had significantly poorer response to antidepressants (AD) such as (hypo)manic switches, AD resistance, affective lability, or irritability (all 0<0.005). Moreover, SLEEP+ had significantly higher rates of mixed-state specifiers than SLEEP- (all 0 < 0.006). A significant contribution to hypersomnia in our regression model was driven by metabolic-related features, such as "current bulimia" (OR = 4.21) and "overweight/obese BMI (OR = 1.42)". Globally, hypersomnia is associated with poor outcome in acute depression. Hypersomnia is strongly associated with mixed features and bipolarity. Metabolic aspects could influence the expression of hypersomnia, worsening the overall clinical outcome. Along with commonly used screening tools, detection of hypersomnia has potential, costless discriminative validity in the differential diagnosis unipolar and bipolar depression.

Mixed states in bipolar and major depressive disorders: systematic review and quality appraisal of guidelines

OBJECTIVE

This systematic review provided a critical synthesis and a comprehensive overview of guidelines on the treatment of mixed states.

METHOD

The MEDLINE/PubMed and EMBASE databases were systematically searched from inception to March 21st, 2018. International guidelines covering the treatment of mixed episodes, manic/hypomanic, or depressive episodes with mixed features were considered for inclusion. A methodological quality assessment was conducted with the Appraisal of Guidelines for Research and Evaluation-AGREE II.

RESULTS

The final selection yielded six articles. Despite their heterogeneity, all guidelines agreed in interrupting an antidepressant monotherapy or adding mood-stabilizing medications. Olanzapine seemed to have the best evidence for acute mixed hypo/manic/depressive states and maintenance treatment. Aripiprazole and paliperidone were possible alternatives for acute hypo/manic mixed states. Lurasidone and ziprasidone were useful in acute mixed depression. Valproate was recommended for the prevention of new mixed episodes while lithium and quetiapine in preventing affective episodes of all polarities. Clozapine and electroconvulsive therapy were effective in refractory mixed episodes. The AGREE II overall assessment rate ranged between 42% and 92%, indicating different quality level of included guidelines.

CONCLUSION

The unmet needs for the mixed symptoms treatment were associated with diagnostic issues and limitations of previous research, particularly for maintenance treatment.

Efficacy of shared decision-making on treatment adherence of patients with bipolar disorder: a cluster randomized trial (ShareD-BD)

BACKGROUND

Shared decision-making (SDM) is a model of interaction between doctors and patients in which both actors contribute to the medical decision-making process. SDM has raised great interest in mental healthcare over the last decade, as it is considered a fundamental part of patient-centered care. However, there is no research evaluating the efficacy of SDM compared to usual care (CAU), as it relates to quality of care and more specifically treatment adherence, in bipolar disorder (BD).

METHODS/DESIGN

This is a 12-month multi-centre, cluster-randomized controlled trial comparing the efficacy of SDM to CAU. Adult BD patients (n = 300) will be eligible after stabilization for at least 4 weeks following an acute mood episode. The intervention will consist of applying the standardized SDM process as developed by the Ottawa Hospital Research Institute in order to choose the maintenance treatment of BD. A multidisciplinary team developed a decision aid "choose my long-term treatment with my doctor" for BD patients to clarify possible therapeutic options. Primary outcome will assess the patient's level of adherence (based on hetero-evaluation) of ongoing treatment at 12 months. Secondary outcomes will assess the difference between the 2 groups of patients in terms of adherence to maintenance drug therapy based on other measures (self-assessment scale and plasma levels of mood stabilizers). Additionally, other dimensions will be assessed: decisional conflict, satisfaction with care and involvement in decision making, beliefs about treatment, therapeutic relationship, knowledge about information for medical decision and clinical outcomes (depression, mania, functioning and quality of life). The primary endpoint will be analysed without adjustment by comparison of adherence scores between the two groups using Student t-tests or Mann-Whitney tests according to the variable distribution. A set of secondary analyses will be adjusted for covariates of clinical interest using generalized linear mixed regression models.

DISCUSSION

This will be the first study evaluating the effect of an SDM intervention on patient adherence in BD. This is also an innovative protocol because it proposes the development of an evidence-based tool that should help patients and clinicians to initiate discussions regarding the use of BD treatment.

TRIAL REGISTRATION

The study has been registered with ClinicalTrials.gov as NCT03245593 .

Aggressiveness in depression: a neglected symptom possibly associated with bipolarity and mixed features

OBJECTIVE

To evaluate aggressiveness during a major depressive episode (MDE) and its relationship with bipolar disorder (BD) in a post hoc analysis of the BRIDGE-II-MIX study.

METHOD

A total of 2811 individuals were enrolled in this multicenter cross-sectional study. MDE patients with (MDE-A, n = 399) and without aggressiveness (MDE-N, n = 2412) were compared through chi-square test or Student's t-test. A stepwise backward logistic regression model was performed.

RESULTS

MDE-A group was more frequently associated with BD (P < 0.001), while aggressiveness was negatively correlated with unipolar depression (P < 0.001). At the logistic regression, aggressiveness was associated with the age at first depressive episode (P < 0.001); the severity of mania (P = 0.03); the diagnosis of BD (P = 0.001); comorbid borderline personality disorder (BPD) (P < 0.001) but not substance abuse (P = 0.63); no current psychiatric treatment (P < 0.001); psychotic symptoms (P = 0.007); the marked social/occupational impairment (P = 0.002). The variable most significantly associated with aggressiveness was the presence of DSM-5 mixed features (P < 0.001, OR = 3.815). After the exclusion of BPD, the variable of lifetime suicide attempts became significant (P = 0.013, OR = 1.405).

CONCLUSION

Aggressiveness seems to be significantly associated with bipolar spectrum disorders, independently from BPD and substance abuse. Aggressiveness should be considered as a diagnostic criterion for the mixed features specifier and a target of tailored treatment strategy.

The aggressor at the mirror: Psychiatric correlates of deliberate self-harm in male prison inmates

BACKGROUND

Deliberate self-harm (DSH) causes important concern in prison inmates as it worsens morbidity and increases the risk for suicide. The aim of the present study is to investigate the prevalence and correlates of DSH in a large sample of male prisoners.

METHODS

A cross-sectional study evaluated male prisoners aged 18+ years. Current and lifetime psychiatric diagnoses were assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders - DSM-IV Axis I and Axis II Disorders and with the Addiction Severity Index-Expanded Version. DSH was assessed with The Deliberate Self-Harm Inventory. Multivariable logistic regression models were used to identify independent correlates of lifetime DSH.

RESULTS

Ninety-three of 526 inmates (17.7%) reported at least 1 lifetime DSH behavior, and 58/93 (62.4%) of those reported a DSH act while in prison. After multivariable adjustment (sensitivity 41.9%, specificity 96.1%, area under the curve=0.854, 95% confidence interval CI=0.811-0.897, P<0.001), DSH was significantly associated with lifetime psychotic disorders (adjusted Odds Ratio aOR=6.227, 95% CI=2.183-17.762, P=0.001), borderline personality disorder (aOR=6.004, 95% CI=3.305-10.907, P<0.001), affective disorders (aOR=2.856, 95% CI=1.350-6.039, P=0.006) and misuse of multiple substances (aOR=2.024, 95% CI=1.111-3.687, P=0.021).

CONCLUSIONS

Borderline personality disorder and misuse of multiple substances are established risk factors of DSH, but psychotic and affective disorders were also associated with DSH in male prison inmates. This points to possible DSH-related clinical sub-groups, that bear specific treatment needs.

Determinants of Functioning in Euthymic Patients with Bipolar Disorder: A Structural Equation Modelling Approach

Background

Euthymic patients with bipolar disorder (BD) experience residual symptoms. Interestingly, residual symptoms appear to impact the natural course of BD and represent potential predictors of recurrence and functional impairment.

Objectives

The study aimed to analyse the relationship between residual depressive symptoms, sleep disturbances and cognitive impairment as determinants of psychosocial functioning in a large sample of euthymic BD patients.

Methods

We performed a cross-sectional study of 468 BD outpatients in clinical remission for at least 6 months. Bipolar Depression Rating Scale (BDRS), Pittsburgh Sleep Quality Index (PSQI) scale, Visual Analogic Scales (VAS) evaluated cognitive impairment and functioning assessment short test were used to assess residual symptomatology and functioning of patients. We evaluated functioning with. Structural equation modelling (SEM) was used to describe the relationships among the residual depressive symptoms, sleep disturbances, perceived cognitive performance and functioning.

Results

SEM showed good fit. This model revealed that residual depressive symptoms (path coefficient = 0.37) and perceived cognitive performance (path coefficient = 0.27) were the most important features significantly related to psychosocial functioning. Sleep disturbances were indirectly associated with functioning via residual depressive symptoms and perceived cognitive performance (path coefficient = 0.23).

Conclusions

This study contributes to a better understanding of the determinants of psychosocial functioning during the interepisodic periods of BD patients. These findings should have implications for the improvement of functioning of BD patients in a personalized approach to treatment.

Disclosure of interest

COI: Dr. Samalin reports personal fees and nonfinancial support from Astra-Zeneca, Bristol Myers Squibb, Janssen, Lundbeck, and Otsuka.

The authors L. Boyer, A. Murru, I. Pacchiarotti, M. Reinares, C.M. Bonnin, C. Torrent, V. Norma, P. Corinna, I. de Chazeron, M. Boucekine, P.A. Geoffroy, F. Bellivier, P.M. Llorca, E. Vieta have have not supplied their declaration of competing interest.

Course of residual symptoms according to the duration of euthymia in remitted bipolar patients

OBJECTIVE

Although many studies showed the negative impact of residual symptoms on the course of bipolar disorder (BD), there is a need to examine potential differences in residual symptoms according to the duration of euthymia in remitted BD patients.

METHOD

This was a large cross-sectional study of 525 euthymic BD out-patients. A multivariate analysis of covariance was conducted to compare depressive and manic residual symptoms, sleep disturbances and cognitive complaints among three patient groups on the basis of duration of euthymia (A. 6 months to <1 year; B. 1 year to <3 years; C. 3 years to ≤5 years).

RESULTS

A significant difference between the three groups was found in residual symptoms [Pillai's Trace: F(8942) = 4.659, P < 0.001]. Tukey post hoc analysis indicated that patients from Group C presented lower residual depressive symptoms, higher sleep quality and better perceived cognitive performance compared with Group A. Group B also presented better sleep and cognitive outcomes than Group A. In addition, Group C showed the lowest incidence of functional impairment.

CONCLUSION

This study suggests that the intensity of residual symptoms and functional impairment in remitted BD patients is negatively related to the duration of euthymia.

Serious game : un nouvel outil pédagogique dans la prise en charge des patients souffrant de schizophrénie

Résumé non reçu.

[French Society for Biological Psychiatry and Neuropsychopharmacology task force. Formal consensus for the treatment of bipolar disorder: an update (2014)]

As part of a process to improve the quality of care, the French Society for Biological Psychiatry and Neuropsychopharmacology developed in 2010 formal consensus guidelines for the treatment of bipolar disorder. The evolution of therapeutic options available in France for the treatment of bipolar disorder has justified the update of this guideline. The purpose of this work was to provide an updated and ergonomic document to promote its use by clinicians. This update focuses on two of the six thematic previously published (acute treatment and long-term treatment). Aspects of the treatment of bipolar patients sparking debate and questions of clinicians (use of antidepressant, place of the bitherapy, interest of long-acting antipsychotics…) were also covered. Finally, we proposed graded recommendations taking into account specifically the risk-benefit balance of each molecule.

[Aripiprazole long-acting for the maintenance treatment of schizophrenia.]

Antipsychotics are the cornerstone for the maintenance treatment of schizophrenia patients. Their long-acting formulations are helpful for preventing relapses through improvement of adherence to medication and a better pharmacokinetic coverage. However, their use is often reserved for refractory or non-observant clinical forms because of limitations among both clinicians and patients. The development of a new formulation of long-acting injectable aripiprazole administered every 4 weeks is a new option. Two randomized controlled trials vs. placebo and vs. oral aripiprazole respectively show a superiority and non-inferiority in terms of relapse prevention. Meanwhile, a mirror-image study demonstrates fewer hospitalizations. The safety profile is comparable to the oral formulation, particularly in terms of metabolic and neurological side-effects. As mentioned in various professional recommendations, long-acting injectable antipsychotics, so long-acting injectable aripiprazole, are one of the major strategies of the maintenance treatment for patients with schizophrenia.

Analyse coût-efficacité du palmitate de palipéridone par rapport aux autres antipsychotiques indiqués dans le traitement de la schizophrénie en France

Objectif

Évaluer l’efficience du palmitate de palipéridone (PP) par rapport aux antipsychotiques les plus communément utilisés en France.

Méthodes

Un modèle médico-économique a été développé afin de simuler la progression d’une cohorte de patients atteints de schizophrénie à travers quatre états de santé (« Stable-traité », « Stable-non-traité », « En-rechute », « Décédé »). PP a été comparé à rispéridone injectable à libération prolongée (ILP), aripiprazole ILP, olanzapine ILP, halopéridol décanoate et olanzapine orale (OO). Les coûts, les années de vie pondérées par la qualité de vie (« Quality-adjusted-life-year » ; QALY) et le nombre de rechutes ont été estimés sur cinq ans selon une perspective tous payeurs. Supposés stabilisés suite à une décompensation clinique, les patients initiaient un antipsychotique et passaient en phase de prévention de la rechute en cas de succès après trois mois. Ils/elles pouvaient arrêter leur traitement après une rechute, un manque de tolérance ou par choix, et passer sur la ligne de traitement suivante jusqu’à la troisième ligne (c.-à.-d. clozapine). Afin de prendre en compte l’observance, les probabilités de rechute en phase de prévention ont été calculées à partir de taux d’hospitalisation sur des données françaises en vie réelle. Les données de tolérance et d’utilité ont été dérivées d’études internationales, et les coûts de sources françaises. La robustesse des résultats a été testée via des analyses de sensibilité.

Résultats

À 5 ans, PP est le moins coûteux des ILP et est associé à un surcoût de 249 € par rapport à OO. Rispéridone ILP et PP sont associés aux plus grands nombres de QALY. PP domine tous les autres ILP en termes de rechute évitée hormis olanzapine ILP.

Conclusion

PP est le moins coûteux des antipsychotiques ILP en France. OO est l’antipsychotique le moins coûteux, mais est associée à un nombre plus faible de QALY gagnées et de rechutes évitées comparé aux antipsychotiques ILP.

Ralentissement psychomoteur et schizophrénie

Le ralentissement psychomoteur dans la schizophrénie comprend un ensemble de symptômes dont les premières descriptions ont été rapportées par Bleuler et Kraepelin dans les années 1900. Néanmoins, peu d’études visant à comprendre la nature et le rôle du ralentissement psychomoteur ont été réalisées dans cette maladie.

Si le ralentissement psychomoteur fait partie des critères diagnostiques du trouble dépressif caractérisé, il n’est pas actuellement considéré comme un élément central au diagnostic de schizophrénie. La catatonie est longtemps restée comme un sous-type de schizophrénie mais l’évolution du DSM dans sa 5e version la considère comme une spécification pouvant être associée à d’autres troubles mentaux (trouble dépressif caractérisé, trouble bipolaire, trouble psychotique bref…). Pourtant le ralentissement psychomoteur est observé dès le début de la maladie et a un impact sur les capacités cognitives et le fonctionnement des patients schizophrènes. Le ralentissement de la performance sur les différentes mesures psychomotrices est associé, indépendamment du traitement, à la présence de symptômes négatifs et, dans une moindre mesure, à la présence de symptômes positifs et dépressifs [1].

Les études comparant les patients souffrant d’un trouble dépressif caractérisé avec des patients schizophrènes ont retrouvé un ralentissement global chez les patients déprimés alors qu’il était plus marqué au niveau cognitif pour les patients schizophrènes [2].

D’autres paramètres extrinsèques peuvent cependant influencer les symptômes psychomoteurs comme l’âge des patients ou les traitements antipsychotiques de première génération. La spécificité et l’impact pronostique du ralentissement psychomoteur chez les patients souffrant de schizophrénie nécessitent pour certains auteurs [3] de considérer les perturbations psychomotrices comme un critère diagnostique de schizophrénie.

[Efficacy of aripiprazole for the treatment of schizophrenia: what dose is required?]

OBJECTIVE

Problem of the choice of antipsychotic dose is a key issue in clinical practice. It determines the efficacy and safety of treatment. Aripiprazole is recommended at a dose of between 10 and 15 mg/day in the treatment of schizophrenia, with a dose range considered to be effective, between 10 and 30 mg/day. This wide therapeutic range prompted us to investigate the existence of a possible dose-effect relationship for aripiprazole in the treatment of schizophrenia.

METHOD

We conducted a literature review from PubMed and EMBASE database, with the keywords: aripiprazole, schizophrenia. We limited it to studies published in English and French, with the main objective to assess the efficacy of aripiprazole in patients with schizophrenia. We selected only randomized clinical trials, double-blind, controlled against placebo or against an active comparator. Studies in which aripiprazole was studied added to another antipsychotic were not retained.

RESULTS

Twenty-two randomized, double-blind, controlled studies were selected. Three studies assessed the efficacy of aripiprazole on agitation symptoms in patients with schizophrenia and for which a dose of aripiprazole between 1 and 15mg showed significant efficacy compared to placebo. Seven clinical trials focused on the effect of aripiprazole short term (less than 12weeks). For the primary endpoint (PANSS scores), aripiprazole was superior to placebo or equivalent to active comparators (risperidone, olanzapine or haloperidol). These short-term studies revealed a range of effective doses from 10 mg/day to 20 mg/day. Five studies, lasting between 16 and 52 weeks, with a primary endpoint being the time to discontinuation for any cause for two studies, the time before relapse in one study, and the improvement in PANSS scores for the two other studies. On these different endpoints, aripiprazole was effective at average doses between 15 and 28.1 mg/day. The safety of aripiprazole was particularly favourable in these trials. Finally, we listed seven post-hoc analyses. In support of these long-term analyses on different endpoints, aripiprazole showed significant efficacy at higher doses (20 and 30 mg/day) than those used in the agitation treatment.

CONCLUSIONS

No study was designed to compare aripiprazole doses in schizophrenia. Nevertheless, efficacy on agitation and hostility components had been observed for doses of 10mg/day, or lower; whereas the antipsychotic effect in acute or maintenance phase appeared optimal for doses ranging from 10 to 25 mg/day. Only one study retained a minimum effective dose of 10mg/day on the PANSS scores. This literature review reveals an effective dose range between 10 and 25 mg/day for aripiprazole in schizophrenia. Less than 10 mg/day did not show significant efficacy on symptoms of schizophrenia, apart from a specific short-term effect on agitation, at very low doses (starting at 1mg). Optimization of treatment, at doses above 25 mg/day, cannot be the subject of evidence-based recommendations.

Recommandations professionnelles en psychiatrie : quelles méthodologies, quels enjeux ?

Depuis une trentaine d’années, dans le but d’aider le clinicien à décider des soins appropriés à des circonstances cliniques spécifiques, des recommandations professionnelles ont été développées de façon méthodique. Elles visent à améliorer la qualité des soins en limitant la variabilité inexpliquée des soins et en intégrant les progrès issus de la recherche clinique. Il existe à l’heure actuelle de nombreuses recommandations professionnelles dans tous les troubles psychiatriques qui sont élaborées par des agences ou sociétés savantes nationales et internationales. D’un point de vue méthodologique, nous retrouvons deux grands types de recommandations professionnelles : celles fondées sur une gradation du niveau de preuve disponibles ou « Evidence-Based Guidelines » et celles fondées sur des avis formalisés ou des consensus d’experts ou « Consensus-Based Guidelines ». Chacune de ses méthodologies présente ses avantages et ses limites. Le développement exponentiel de ces recommandations rend difficile le choix du clinicien quant à quelle recommandation professionnelle utiliser en pratique clinique. Une meilleure compréhension de ces aspects méthodologiques pourrait permettre de faciliter ce choix et favoriser l’adhésion des psychiatres à leur utilisation.

[The contributions of the evidence-based medicine or how to optimize the management of major depressive disorder]

In the early 1980s, Evidence-Based Medicine (EBM) has been developed in the Department of Clinical Epidemiology at McMaster Medical School in Canada to meet the ever-increasing need to integrate publications in clinical practice. In this approach, we cannot ever consider that the evidence will replace clinical experience. The quality of scientific data is prioritized taking into account the methodological characteristics of studies. It takes time to learn and practice the method, which is often difficult in daily practice. The concept of "management recommendations" covers multiple realities. It can rely on the results of clinical trials (randomized, controlled or not…), the trends from the meta-analysis that attempt to "simplify" the field of literature or the Clinical Practice Guidelines. Meta-analysis should be used with caution. They do not preclude the need to use the data "sources", but they help the comparability of results and synthesis work. However it should be aware that this is a work of interpretation. The controversy over the action of antidepressants compared to placebo in depression according to the severity of the episode shows that a result depends on the included studies, the statistical technique used, but also how the results are reported. The international literature produced many recommendations in the management of depression. It is useful to refer to it as the meta-analysis because they provide an overall view of the current state of knowledge. We can regret the lack of recent French recommendations that could articulate the specifics of the French practice and data from the literature. The use of guidelines in clinical practice remains low in all fields of medicine. However improving the consideration of the recommendations is an important issue because it is associated with improved patient care. It remains to develop a collective strategy to implement them. The Evidence-Based Medicine is a major change in the everyday clinical practice. It may be insufficiently known and understood, seems too complex, time-consuming and therefore inapplicable. We have to mobilize our efforts to improve our practices.

[Methodological approach to inter "guideline" variability in the management of bipolar disorders]

INTRODUCTION

In recent decades, an increasing number of pharmacologic agents have become available in bipolar disorder treatment. These therapeutic advances provide a new challenge for clinicians in the choice of medication for patients with bipolar disorder. In this context, tools have been developed for making medical decisions in the management of bipolar disorder: guidelines.

METHODS

Guidelines for bipolar disorder were compared on the basis of their construction methodology (evidence-based treatment guidelines or consensus-based treatment guidelines), results and recommendations for clinical practice.

RESULTS

There are differences between guidelines for treating bipolar disorder. For the American Psychiatric Association (APA), the severity of the manic episode is a primary endpoint of the decision-making tree for the choice of therapy. On the other hand, the National Institute for Health and Clinical Excellence (NICE) ruled that the choice of the initial treatment, in the case of manic episode, should be based first on the current patient's treatment (history of anti-manic therapy) while the World Federation of Societies of Biological Psychiatry (WFSBP) emphasizes the clinical classification of the type of mania. The sequencing of medication in the guidelines may vary according to the construction methodology, the date of elaboration, the geocultural context and experts' position. Recent guidelines consider the last randomized controlled trials (RCT) as those of aripiprazole in the treatment of mania, recommending it in first line as anti-manic agent. The recent updated WFSBP guidelines changed in its construction methodology taking into account the negative studies or those showing non-superiority compared to placebo. Thus, a recent study of non-superiority of lithium monotherapy compared to placebo in the treatment of bipolar depression downgraded lithium from level of evidence B to D. During recent years, a large number of RCT have demonstrated superior efficacy (particularly in mania treatment) of lithium or valproate combined with second-generation antipsychotic compared with lithium or valproate monotherapy. Consequently, according to geocultural context or experts' position, some guidelines recommended medication combinations in first line (Canadian Network for Mood and Anxiety Treatment) and other guidelines considered monotherapy in first line (except for particular cases) to promote tolerance and good therapeutic alliance (WFSBP). Malhi et al. recommended a sequencing of medication based on the benefit risk ratio for the management of each phase of bipolar disorder. These differences between guidelines may cause difficulties for clinicians in choosing clinical practice guidelines.

CONCLUSION

While there are a large number of guidelines for bipolar disorder, the recommendations may vary depending on multiple factors. It seems interesting to conduct a comparative study of guidelines for bipolar disorder on the basis of a validated scale (AGREE) or completed by other items such as date of elaboration and number of proposed recommendations. However, the methodological understanding of guidelines remains the central element for practitioners in their choice of guidelines. Thus, the initial objective of guidelines "to develop statements to assist clinician and patient decisions about the most appropriate health care for specific clinical situations" could be implemented in clinical practice.

Factors involved in the level of functioning of patients with schizophrenia according to latent variable modeling

PURPOSE

This study aimed at using latent variable modelling to explore the significantly contributing variables to functioning in schizophrenia patients.

METHODS

The study cohort comprised 296 schizophrenia patients evaluated once for demographic characteristics, functioning (FROGS, SWN-K, QLS) and symptomatology (Positive and Negative Syndrome Scale [PANSS]). First exploratory multivariate analyses were conducted and then a model with functioning as a latent variable was proposed and tested with the data.

RESULTS

Symptomatology as negative, cognitive and excitation factor are significant predictors of functioning assessed through FROGS (P<0.0001), SWN-K and QLS (P<0.001). The model was constructed with functioning defined as a latent variable, indicators are subscores on FROGS, SWN-K, QLS and exogenous variable included symptomatology, Duration of Untreated Psychosis (DUP) and educational level.

CONCLUSION

Using the five clinical dimensions of the PANSS, (Positive, Negative, Cognitive, Anxiety/Depression and Excitation) the negative and cognitive dimensions are highly correlated via the latent variable to the three dimensions of functioning evaluated by the FROGS: "daily life", "social functioning" and "treatment" and the QLS subscores (interpersonnal, common object, instrumental role). Educationnal level is positively linked to functioning but not DUP. The model emphasizes the need for treatment strategies that have an effect on cognitive-factors, to improve functioning in schizophrenia.

Patient perspectives on use of long-acting antipsychotics in bipolar disorder: focus on risperidone injection

In the last few years, oral second-generation antipsychotics have demonstrated mood-stabilizing properties and are now widely used in the treatment of bipolar disorder. Unfortunately, treatment of this chronic and complex illness is hampered with poor adherence on the part of patients. Long-acting injectable formulations of second-generation antipsychotics could combine the effect of oral second-generation antipsychotics in patients with bipolar disorder and the benefits of depot formulation with the assurance of steady medication delivery and thereby improve adherence. In this context, the efficacy and tolerance of risperidone long-acting injection (RLAI) for maintenance treatment in patients with bipolar disorder is assessed. The relevant studies found RLAI to be effective in preventive treatment of manic but not depressive recurrences in bipolar patients, with good tolerance. RLAI appeared to be particularly suitable for patients with known poor adherence to treatment or severe bipolar disorder (such as patients who relapse frequently). Lastly, if RLAI, unlike the first-generation antipsychotics, does not induce depressive symptoms, the different studies do not enable us to consider its use in monotherapy in the preventive treatment of patients with depressive polarity. Long-acting second-generation antipsychotics in bipolar patients are therefore associated with long-term benefits, but their use in clinical practice needs to be improved.