Search

Introduction: The prevalence of psychiatric disorders among prisoners remains a major public health issue worldwide. In France, despite the increasing number of persons who are incarcerated (+30% between 1992 and 2002 with a 120% prison overcrowding), and a historical concern about the mental health of persons in detention and its management, no systematic review has been published on this subject. The aim of this article is to present the results of a systematic review of the literature on the prevalence of psychiatric disorders in French prisons., Method: The reporting of this systematic review conforms to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) checklist. We searched the PubMed and Web of Science databases. We used combinations of keywords relating to prison (prison*, jail*, inmate*), to psychiatry ("mental health", psychiatr*), and to France (France, French). This work was completed with a search through the digital libraries of the École des Hautes Études en Santé Publique (EHESP) and of the Système Universitaire de Documentation (Sudoc) to obtain data from academic works and the gray literature. References cited in studies included in this review were also examined. All references published up to September 2022, written in English or French, presenting the results of original quantitative studies on the prevalence of psychiatric disorders in correctional settings were included. Two researchers independently extracted data from included references according to a pre-established protocol., Results: Among 501 records identified, a total of 35 papers based on 24 epidemiological studies met the eligibility criteria for inclusion in this review: 16 were cross-sectional, 7 retrospective and 1 both cross-sectional and retrospective. All papers were published between 1999 and 2022. We found one European study, 5 international studies, 18 regional or local studies. Of these, 21 studies had all-male or mixed gender samples (but when the sample was mixed gender, it was always at least 92% male). Almost half of the studies (n=11) involved a small sample of fewer than 500 persons. Half of the studies involved a sample of recently incarcerated persons: 6 involved a random sample of persons in detention, and 1 involved a sample of people incarcerated for more than 5 years. The last 5 studies focused on persons aged over 50 years and incarcerated for more than one year (n=1), incarcerated for sexual offences (n=2), placed in disciplinary cells (n=1) or in a special wing for radicalized or suspected radicalized individuals (n=1). Nine studies used standardized and validated diagnostic tools. According to the 4 studies involving representative samples and using standardized and validated diagnostic tools, the prevalence of the following psychiatric disorders was: 29.4-44.4% for anxiety disorders, 5-14.2% for PTSD, 28-31.2% for mood disorders, 6.9-17% for psychotic disorders, 32% for personality disorders and 11% for ADHD., Conclusion: This systematic review of the literature highlights the high prevalence of psychiatric disorders in French prisons. The data collected are in line with international studies. The great methodological heterogeneity of the papers included in this review calls for further rigorous research to better understand the rates of mental disorders in French prisons and to explore their determinants., (Copyright © 2024 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Objectives: Homelessness is associated with several issues (psychiatric and neurological disorders, neurodevelopmental difficulties, malnutrition…) which are also risk factors for cognitive disorders. However, little is known about the relationship between the cognition of homeless people and these eventual explicative etiologies. The aim of this work is to complete the results of Depp et al. about cognition in homelessness by proposing a systematic review of the neuropsychological disorders of homeless people associated with an analysis of the etiologies likely to explain these disorders., Methods: We followed the PRISMA recommendations to build up this work. We analyzed the abstracts of 385 papers found on databases PSYCINFO and PubMed. Twenty-two studies have been selected for respecting our criteria (at least one valid neuropsychological test ; general group of homeless people and not a sub-group of this population ; study published in English). The prevalence quality has been evaluated through the criteria of Loney et al. Cognitive scores and etiological factors have been compared between studies., Results: The 22 studies represent only nine countries. More than half of them are considered as having a poor prevalence quality. In total, 4,256 participants have been evaluated. Their mean age was around 40 years, and 85 % of the participants were men. The results show a prevalence of cognitive disorders (MMSE) in 8.77 % of the sample. The mean IQ was 87.47 and the premorbid IQ 94.59. We also notice possible disorders affecting the episodic memory and the executive functions. Mean scores for short-term memory, speech and visuo-spatial functions are relatively low. None of the studies evaluated the praxia, the gnosia or the social cognition. The heterogeneity of studies and the lack of data did not allow us to give general conclusions about the etiology of these disorders. However, we see that around 40 % of the time subjects had histories of brain injuries and 89 % of childhood trauma. Intellectual disability is found in 49 % of the sample of a single study. Also, 70 % of the homeless population have been diagnosed with substance-related disorders and 65 % with psychiatric disorders. It appears that the only factors correlated with cognitive disorders would be the history of brain injuries and childhood traumas., Conclusions: We confirm that homeless people often suffer from cognitive difficulties, and some of these difficulties (memory, executive functioning) are severe. Yet the etiology of these disorders remain relatively unknown: even if we observe a high prevalence of psychiatric, substance-related, neurodevelopmental and neurological issues by the homeless population, only a few of them (brain injury history and childhood trauma) seem to be correlated with cognition in homelessness. The potential explicative factors have been too rarely explored to bring a powerful explanation of cognitive disorders in homeless people. Further research needs to be done in order to give a more precise neuropsychological profile of the homeless population and to better understand what the disorders are rooted in. Last but not least, all this research and knowledge should be applied more to the care of homeless people by providing neuropsychological assessment and rehabilitation and by training the team to detect cognitive disorders and to support the person with a cognitive disability., (Copyright © 2019 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Background: In France, on the first of January 2018, 772 underage persons were in jail or about 1.1 % of the incarcerated population. The prevalence of psychiatric disorders among those inmates is high. As a result psychiatric care (and particularly full-time hospitalization) is essential for this population. The unités hospitalières spécialement aménagées (UHSA) are full-time inpatient hospitalization units for inmates in France. Adults but also underage inmates can be admitted to UHSA for voluntary or involuntary hospitalization. However, no study about the characteristics of young patients admitted to UHSA is currently available. The aim of this study is to describe the population of children and adolescent patients hospitalized in these facilities and to evaluate the care provided., Method: We conducted a retrospective study, including all the patients under 18 years of age, who have been hospitalized in UHSA since its creation in 2010 until 31 December 2016. Anonymized data concerning socio-demographic profile, clinical symptoms and care provided have been collected from the medical records of each patient., Results: Overall 80 underage patients were included, for 120 hospitalisations in UHSA. Those patients are mainly male (80%) with a mean age of 16.7 years. They are mostly hospitalized with their consent (59%) for stays of about 50 days and frequently after self-harm behaviours. The main diagnoses are anxiety disorders (26%) and psychotic disorders (25%). At the end, 86% of the patients are prescribed a psychotropic drug treatment and 40% of those medical drugs are prescribed outside the guidelines. Finally, several specific problems were identified. Especially, contact with families and educators or access to education programs are very challenging., Conclusion: This study highlights the current difficulties encountered in the management of inmate underage patients in full-time psychiatric hospitalization. In this paper, we propose areas for improvement through (1) specific arrangements to receive young patients (specific service's management in order to reinforce the observation of those young people, to facilitate contact with their families, to improve the access to education programs, etc.); (2) specific arrangements in the treatment offered to young patients in UHSA (specific training course for nurses, specific therapeutic programs, etc.); (3) the development of networks working with psychiatric services inside and outside the prison, educators, families and prison services, in order to promote the continuity of cares., (Copyright © 2018 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Objectives: Recovery is a process through which people experiencing mental illness learn to live with their disorder and reach social insertion and citizenship. This positive approach focuses on a person's competencies and strengths rather than on the symptoms. Within this philosophy, peer support has been unevenly developing in mental health services worldwide with roots in the South-American social programs for homeless people and in the American recovery circles in the field of addiction. Therapeutic efficiency of peer support has been proven by several studies including a control group, as being at least as good as traditional services and even better in some specific areas such as reduction of need for emergency services and ability to reach "difficult" patients. The integration of former psychiatric services users in mental health services can take several forms, from the participation to scientific research studies to the direct involvement in a professional team at mental health facilities. In this context, our research aims to sum up the situation in France in comparison with other countries., Methods: We conducted a worldwide literature review in English and in French on peer support experiences and policies in mental health services, using medical and psychological databases (PsycInfo, PsycArticles, SantéPsy, Cairn, Medline, Wiley Interscience and PubPsych) on a recent period: 2005-2016. In total, 32 relevant scientific papers have been included in our research. In some cases, we have also used official reports, blogs, Internet sites, and mass media articles when they were relevant., Results: Our results show that this movement has been long to develop in France, with controversies having been raised since the beginning on the role that peers should play and confusion with existing social integration programs in the associative sector. Drawing inspiration from the Canadian model, a recent "peer mentor" initiative has been analyzed after 2 years of existence: many benefits for services users such as the optional aspect of this care process, a more authentic therapeutic relationship, a less normative frame, an active partnership, and a more optimistic philosophy aiming to make "small steps" towards improvement have been reported. Health professionals and peer mentors themselves have found benefits during the process. However, several limits such as difficulties to find a place with regards to the psychiatric team and difficulties to take advantage of the peer specificity, resulting in a significant attrition of the number of peer mentors, could be observed. A few other important initiatives focused on social insertion and using the help of professional peer support have been developed in recent years, but they seem to have encountered the same issues about positioning themselves both in terms of day-to-day integration in the professional environment and in the job title given by institutions which rarely corresponds to their experience and specificity. In addition, it remains difficult to obtain reliable information, as only a few papers have been published on this matter. Also, while some evaluation studies are currently being carried out, independent quantitative studies of the few running programs seem to lack in this field., Conclusions: In our presentation, taking into account the difficulties that were raised in French programs and the lessons of practical experiences at work in other countries, we propose recommendations for larger and more effective implementations of peer support programs in France. As this new kind of care is emerging and seems promising in terms of benefits for not only the users but also the peer supporters and the teams of health professionals, we also insist on the need for a systematic scientific and objective evaluation of the programs., (Copyright © 2018 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Objective: Since the publication of the DSM-5 (APA, 2013), the dimensional conception of the personality disorders is co-existing with the classical categorical paradigm. Tools have been proposed for the evaluations of five big pathological factors to be explored further according to the APA (negative affectivity, detachment, antagonism, disinhibition, psychoticism). Despite numerous works using these questionnaires (30 works in 3 years according to Al-Adjani et al., 2015), none of them have yet been translated into French. Also, the main objective of the paper is to present a French translation of the Personality Inventory for DSM -5 by Kruegger et al. (2013) in its brief form of 25 items (PID-5 BF)., Method: To reach this goal, we have employed the classic translation-retranslation method (Vallerand, 1989) and tested the consistence and the validity of this French version among a non-clinical sample (n=216) of young adults (age=31.4, SD=4.8), in joining some other questionnaires in their short forms to study the external validity of the PID-5 about the psychological distress (SCL-10, Nguyen, 1983), the categorical diagnosis of personality disorders (SAPAS, Moran et al., 2003) and the classical Big Five dimensions of the personality (BDI 10, Ramamstedt and John, 2007). The internal consistency of this translation has been studied through the classical outcomes on factor analysis for the dimensional repartitions of the items in 5 scales and Cronbach's alpha for the consistency of each found dimensions. The external validity has been explored by studying Pearson's correlations between the outcomes on each dimension of the PID-5 BF and both the clinical dimensions of SCL-10, personality dimensions of the BFI-10 or personality disorders (SAPAS)., Results: Factor analysis led to the same repartition of the 25 items as the original versions. Each of the dimensions is consistent enough (α>.65) to be taken into account as clinically significant. The items of the French version of the PID-5 BF follow the expected repartitions in 5 dimensions, which are consistent enough. Although their mean scores are significantly not different from the outcomes found by Krueger with the PID-5 200 items among another non-clinical population (n=264), one cannot say that is enough to ensure the external validity of our translation, for it uses neither the same tools nor sample. A comparison with a French translation of the PID-5 would be more significant. However, the external validity of the French version seems to be significant enough. Global score on the PID-5 is correlated both to the Global Severity Index of the SCL-10, which reflects global psychological distress, and SAPAS's score, which evaluates the suspicion of personality disorder. The clinical validity of the PID-5 is confirmed by the relationships between negative affectivity and anxiety or depression or antagonism and hostility, although the clinical scale of the SCL-10, with one item by dimension, is less sensitive than the complete original version in 90 items (DeRogatis, 1974). PID-5 score and domains are also correlated with the Big Five personality dimension and global score of personality disorders which led us to think that it is coherent with the evaluation of personality suffering (r=.34) and dimensions. The links between negative affectivity and neurosism (r=.48) or between desinhibition and extraversion (r=.32) or the negative correlation between psychoticism and conscientiousness (r=-0.16) are consistent with the expectations related both to the descriptions of the domains by the DSM and outcomes on the comparisons between PID-5 200 item scales and NEO-PI or BFI 45 items., Discussion: This translation offers enough consistency and validity to be used in future studies. This could lead us to either continue studying a more representative general population or testing its validity in focusing on a clinical sample where personality disorders are prevalent, such as homeless men or substance users. As soon as a French version of the PID-5 200 items is published, one can compare the outcomes on PID-5 BF and PID-5 to lead to estimations of personality disorders and pathological domains among French populations and explore personality disorders throughout a dimensional paradigm instead of syndromic perspective. One can also see whether the items that have been kept for each dimension are as saturated in the French version as in the original one. Among general populations, comparisons with clinical distress, syndromic personality disorders or dimensional aspect of personality could be done with complete versions of PID-5, Symptom Check-list, Personality Disorders Questionnaires or Big Five Inventory; therefore, the brief forms of any questionnaire could be used among any people whose psychological distress or side effects impaired their attention and concentration., (Copyright © 2016 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Theoretical Background: The borderline personality disorder is a complex psychiatric disorder that represents a high number of patients in a psychiatric adult service. Even if some therapies have shown to be effective in the therapeutic care of the borderline personality disorder they only target certain symptoms (e.g. anxiety, sadness, self-mutilation). The aim of this paper is to introduce a therapeutic model little known in France: the mentalization based therapy (MBT) developed in 2004 by Bateman and Fonagy. This therapeutic model apprehends the borderline personality disorder in all its complexity and is based on two main concepts: Bowlby's attachment theory and the concept of mentalization. The MBT is based on the hypothesis that a deficit of mentalization leads to the development of borderline disorder. The capacity of mentalization, also known as reflexive function, is acquired in infancy through interpersonal relationships, in particular those of attachment, and is the ability to understand the mental state (emotions, needs, thoughts, etc.) of oneself and others which underlies explicit behaviour. This reflexive capacity is of a better quality when the person has a secure attachment style. Indeed, borderline patients have, mainly, a deficit of mentalization capacity associated with an insecure attachment style. Thus, the main objective of the Bateman and Fonagy approach is to develop and reinforce the mentalization capacity through a therapeutic relationship as a secure base, a group therapy and the concept of insight., Therapy Structure and Techniques: Classically, MBT is structured over a period of 18 months divided into 3 distinct phases distributed in two therapeutic axes: group and individual therapy. The initial phase aims to engage the patient in the therapy by evaluating attachment style, mentalization's ability, interpersonal functioning; providing psychoeducation about borderline disorder and establishing a therapeutic contract. To evaluate attachment style, the authors strongly recommend the use of the Relationship Scales Questionnaire. During the second phase, which includes individual and group therapy, the aim is to stimulate the capacity of mentalization through different techniques according to the patient's attachment style. These include therapeutic relationship, empathy, affect clarification and elaboration, positive and negative reinforcement. The final phase serves to review the patient's improvement and to prepare him progressively for the end of the therapy which can be experienced as an abandonment., Clinical Trials of Mbt and Developments: Effectiveness of MBT in treating borderline disorder has been shown in several studies with short and long term benefits. It can be adapted for other personality disorders and specific populations such as adolescents., Conclusion: This article introduces the key concepts and aims of mentalization based treatment. The therapy is briefly described in its different phases and the various techniques are discussed. Clinical trials have shown that MBT is effective in treating borderline disorder in adolescent and adult populations. Despite the effectiveness of this therapy, it is difficult to set up and requires substantial resources. Interpersonal therapy based on attachment provides a therapeutic model focused on problematic areas which can offer an alternative therapy and reduce the fields of investigations., (Copyright © 2016 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Getting and keeping a job are not only one of the criteria of recovery from schizophrenia, but are also one of its main means. Indeed, recovery is partly defined by the ability to work. Despite the lack of data in France about employment of people with schizophrenia, it is widely acknowledged that the employment rate of people with schizophrenia remains quite low, and frequently it is only an employment in sheltered workshops, not on the regular work market. International research data show that it is possible to improve significantly this employment rate, with an appropriate support, that is precisely defined by the current researches, and that is quickly spreading in most developed countries. The aim of this paper is to present, on the basis of a broad current literature review, the key predictive factors of the return to work for people with schizophrenia, and the strategies to optimize vocational services. It will appear that there are several ways to improve practices and interventions in France to support work integration. To begin with individual factors of work integration, dependant on each person, the clinical state and the cognitive skills (in a broad sense, including social cognition and metacognition) are to be taken into account, and optimized by means of the association of a finely tuned pharmacological treatment and psychosocial interventions such as cognitive remediation adjusted to the person's specific needs. The other main kind of factors is environmental factors, particularly the kind of vocational support, which turns out to have a major impact not only on job acquisition, but importantly also on job tenure. The most effective vocational services are based on the "Place and train" model, and even more precisely on the Individual Placement and Support (IPS) model, that allows to the majority of people with a severe mental illness (more than 50%) to obtain a competitive employment after 6 to 18 months of individualized support. This approach is now widely recommended as "an evidence-based practice" of rehabilitation. It is important to promote in France the development of this kind of practice, already implemented as an experiment by few militant and involved associations. This development remains in France slow and delayed (compared to the practices in the other European countries) because of the lack of public funding. It implies an evolution of the social and medico-social practices, taking into account current research data, and assessing the outcomes of their practices in order to improve them. The employment specialist (sometimes called also the "job coach") turns out to play a key role, emphasized by current research, implying, among many other tasks, to coordinate the net of people supporting the work integration, including the clinical team, the employer and the colleagues of the workplace., (Copyright © 2015 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Background: Substance use has increased worldwide. Based on these data, we may think that substance use has also increased during pregnancy, but epidemiological data are scarce in this population. The potential consequences of tobacco, cocaine or cannabis use during pregnancy are a major public health concern. The combined use of different substances during pregnancy may have serious consequences on the pregnancy and on child development., Methods: In this paper, we will describe the potential consequences for the newborn, child and adolescent after being exposed to tobacco, cannabis and cocaine in utero. For this purpose, we will review all retrospective and prospective studies (in English and French) referenced in PubMed reporting on the somatic or psychiatric consequences of alcohol, tobacco and drug consumption by pregnant women on newborn and children. Consumption during pregnancy was assessed in these studies using simple questionnaires, biomarkers analysis or both., Results: Generally speaking, these pregnancies are at high risk for both the mother and the foetus: for example, an increased risk of miscarriage or of reduced length of gestation, an increased risk of uterine apoplexy and placenta praevia, more premature births and/or hypotrophy were reported. The occurrence of a newborn's withdrawal syndrome may be misdiagnosed. Many consequences on child development may be observed such as growth disorders, learning or motor disorders, language disorders, cognitive disorders (attention, memory, executive functions), attention deficit disorders with impulsivity or with hyperactivity (ADHD), and memory disorders. The prevalence of depressive or anxiety disorders may also be increased in these children. The risk of addictive disorders or schizophrenia in children exposed in utero to illicit drugs or tobacco is still unknown. The combined use of different substances increases, consequently it is difficult to disentangle the consequences on child development of each of the drugs used during pregnancy owing to potential interactions between these drugs. The consequences on child development will also depend on the dose and on the time of drug use during pregnancy., Discussion: The National Institute of Drug Abuse reported that 75% of the infants exposed in utero to one or more substances will present medical problems during childhood, as compared to only 27% of the non-exposed infants. However, the medical consequences are still a matter of controversies. Methodological biases, such as the use of different rating scales among studies, and the heterogeneity of the populations included are main limitations. Further studies are needed using larger cohorts and longer follow-up periods., (Copyright © 2014 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

From a historical perspective, this article describes the use of antipsychotic long-acting injections (LAI) in the treatment of schizophrenia, a disorder that was defined in the final years of the 19th century. An efficient treatment for schizophrenia was discovered only in 1952 with the introduction of chlorpromazine, a phenothiazine derivative. Fairly soon, antipsychotics became available as LAI. The first compounds were fluphenazine enanthate (1966) and decanoate (1968) whose development is attributed to G.R. Daniel, a medical director at Squibb & Sons. Other first-generation antipsychotics long-acting injections (FGA-LAIs) were introduced in a rapid succession in the 1960s and 1970s. FGA-LAIs made a key contribution to the development of community psychiatry. As neuroleptics emptied psychiatric hospitals, it was important to ensure that patients could be taken care of in outpatient facilities. FGA-LAIs prevented covert non-compliance. Compliance was further reinforced by the social and psychological support of patients. The introduction of second-generation antipsychotics (SGA) led to a loss of interest in FGA-LAIs. This is evidenced by a drop in the number of papers published on this topic. The interest in LAI was revived with the introduction of the first SGA-LAI in 2003. Four different preparations have been approved in the decade between 2003 and 2013. SGA-LAIs differ from FGA-LAIs in the technology that is used to produce the depot effect, and also in the treatment objectives. The rationale for using SGA-LAIs is not only to prevent relapses due to treatment interruption, but also to achieve more constant plasma levels in order to reduce side effects due to excessive plasma levels and loss of efficacy due to insufficient plasma levels. Also, treatment objectives are no longer limited to controlling acute symptoms. Treatment objectives now include the alleviation of negative symptoms and cognitive deficits that are key prognostic factors., (Copyright © 2014 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Background: Among illegal psycho-active drugs, cannabis is the most consumed by French adolescents. Multidimensional family therapy (MDFT) is a family-based outpatient therapy which has been developed for adolescents with drug and behavioral problems. MDFT has shown its effectiveness in adolescents with substance abuse disorders (notably cannabis abuse) not only in the United States but also in Europe (International Cannabis Need of Treatment project). MDFT is a multidisciplinary approach and an evidence-based treatment, at the crossroads of developmental psychology, ecological theories and family therapy. Its psychotherapeutic techniques find its roots in a variety of approaches which include systemic family therapy and cognitive therapy., Objective: The aims of this paper are: to describe all the backgrounds of MDFT by highlighting its characteristics; to explain how structural and strategy therapies have influenced this approach; to explore the links between MDFT, brief strategic family therapy and multi systemic family therapy; and to underline the specificities of this family therapy method., Discussion: The multidimensional family therapy was created on the bases of 1) the integration of multiple therapeutic techniques stemming from various family therapy theories; and 2) studies which have shown family therapy efficiency. Several trials have shown a better efficiency of MDFT compared to group treatment, cognitive-behavioral therapy and home-based treatment. Studies have also highlighted that MDFT led to superior treatment outcomes, especially among young people with severe drug use and psychiatric co-morbidities. In the field of systemic family therapies, MDFT was influenced by: 1) the structural family therapy (S. Minuchin), 2) the strategic family theory (J. Haley), and 3) the intergenerational family therapy (Bowen and Boszormenyi-Nagy). MDFT has specific aspects: MDFT therapists think in a multidimensional perspective (because an adolescent's drug abuse is a multidimensional disorder), they work with the system and the subsystem, focusing on the emotional expression and the parental and adolescent enactment (a principle of change and intervention). MDFT includes four modules (adolescent, parent, family interaction, and extra-familial systems) in three steps (1) build the foundation, (2) prompt action and change by working the themes, and (3) seal the changes and exit). The supervision philosophy and methodology is also based on the principle of multidimensionality. Indeed, many different supervision methods are used in a coordinated way to produce the required adherence and clinical skill (written case conceptualizations, videotape presentation and live supervision)., Conclusion: Family vulnerability and chronicity factors are a major challenge of modern research. MDFT questions the reciprocal adjustments that have to be made by the subject and his/her familial environment. It also helps to clarify the therapeutic interventions in order to enhance better adolescent development. For this purpose, MDFT offers a specific therapeutic frame, for it is a family therapy focused on adolescents with cannabis abuse problems. Its action and questioning on parental practices and adolescents lead to better psycho-educational support. It focuses the therapeutic process on emotions and family capacity for change., (Copyright © 2013 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Background: Bipolar disorder is a complex disease which requires multiple healthcare resources and complex medical care programs including pharmacological and non pharmacological treatment. If mood stabilizers remain the corner stone for bipolar disorder treatment, the development of atypical antipsychotics and their use as mood stabilizers has significantly modified therapeutic care. At the present time, psychiatrists have a large variety of psychotropic drugs for bipolar disorder: mood stabilizers, atypical antipsychotics, antidepressants, anxiolytics… However, despite the publication of guidelines on pharmacological treatment, with a high degree of consensus, everyday clinical practices remain heterogeneous. Moreover, there are few longitudinal studies to describe therapeutic management of bipolar disorder, whatever the phase of the disease is. Indeed, most of the studies are carried out on a specific phase of the disease or treatment. And there is no study comparing French and European practices., Objectives: In this paper, we aim to present the comparison of the management of pharmacological treatments of bipolar disorder between France and Europe, using the data of the observational Wide AmbispectiVE study of the clinical management and burden of bipolar disorder (WAVE-bd study)., Methods: The WAVE-bd study is a multinational, multicentre and non-interventional cohort study of patients diagnosed with BD type I or type II, according to DSM IV-TR criteria, in any phase of the disorder, who have experienced at least one mood event during the 12 months before enrolment. In total, 2507 patients have been included across 8 countries of Europe (480 in France). Data collection was retrospective (from 3 to 12 months), but also prospective (from 9 to 15 months) for a total study length of 12 to 27 months. Main outcome measures were the healthcare resource use and pharmacological treatments., Results: Our results show differences in the therapeutic management of bipolar disorder between France and other European countries. Regarding healthcare resource use, our results show that French patients consult more frequently a psychiatrist or a psychologist and less frequently a general practitioner or the emergency ward in comparison with patients from other European countries. In the whole European population, including France, atypical antipsychotics are widely used. Only 25% of the patients receive lithium and more than 50% of the patients receive antidepressants, while their use in bipolar disorder remains controversial. Most of the patients receive polymedication. Considering all phases of the disease pooled, less lithium and less atypical antipsychotics are prescribed to French patients, whereas they receive more antidepressants and more benzodiazepines than patients from other European countries. On the over hand, prescription of anticonvulsants and electroconvulsive therapy are equal. Moreover, data analyses by polarity of the episodes globally confirm these trends. There are a few exceptions: mixed states, in which lithium is twice more prescribed in France in comparison to other countries; depressive states, in which antidepressants are even more prescribed in other countries than in France; and less prescription of anticonvulsants in manic, mixed and euthymic phases in France., Conclusion: The WAVE-bd study is the first observational study conducted on a large sample of bipolar I and II patients that compares therapeutic management between France and other European countries. The differences observed in therapeutic care across the different phases of the disease show that treatments differ depending on the countries studied, but also according to the preventive or curative phases, polarity of the bipolar disorder, comorbidities, impact of guidelines, and care organization. Although French patients have been treated by less lithium and less atypical antipsychotics than other European patients, they receive more antidepressants and more benzodiazepines. Finally, patients generally receive polymedication and the diversity in prescriptions shows how bipolar disorder is a complex disorder., (Copyright © 2014 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Objectives: The fear of childbirth, a central aspect of tokophobia, recently started to capture the attention of the scientific community as a potential determinant of obstetric and post-natal complications. However, studies on this subject are still few and this can be partly explained by the lack of validated instruments, especially in French. This paper presents the results from two studies designed to develop and evaluate the psychometric properties of a French version of the Traumatic Event Scale (TES), adapted to assess fear of childbirth (Söderquist et al., 2004 [21])., Method: The first study presents details regarding the development of this scale and checks the quality of the resulting items as well as their internal consistency, convergent validity and factorial validity. This study relied on a sample of 65 mothers with at least one child under the age of 36 months. In the second study, the psychometric properties of the instrument developed in Study 1 were tested more systematically on a sample of 204 women who were at the time experiencing their first pregnancy., Results and Conclusion: The results from the first study show adequate psychometric properties, strong correlations with measurements assessing worry, and support a five factor model. Results from this second study replicated the results from the first one on the basis of confirmatory factor analyses. Findings presented in these studies confirm that this instrument presents very good psychometric properties as a measurement of the fear of childbirth in pregnant women., (Copyright © 2011 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Context and Objective: In France, consumption of gambling games increased by 148% between 1960 and 2005. In 2004, gamblers lost approximately 0.9% of household income, compared to 0.4% in 1960. This represents approximately 134 Euros per year and per head. In spite of this important increase, the level remains lower than the European average (1%). However, gambling practices may continue to escalate in France in the next few years, particularly with the recent announce of the legalisation of online games and sports betting. With the spread of legalised gambling, pathological gambling rates may increase in France in the next years, in response to more widely available and more attractive gambling opportunities. In this context, there is a need for better understanding of the risk factors that are implicated in the development and maintenance of pathological gambling., Methods: This paper briefly describes the major risk factors for pathological gambling by examining the recent published literature available during the first quarter of 2008. This documentary basis was collected by Inserm for the collective expert report procedure on Gambling (contexts and addictions). Seventy-two articles focusing on risk factors for pathological gambling were considered in this review. Only 47 of them were taken into account for analysis. The selection of these 47 publications was based on the guide on literature analysis established by the French National Agency for Accreditation and Assessment in Health (ANAES, 2000). Some publications from more recent literature have also been added, mostly about Internet gambling., Results: We identify three major types of risk factors implicated in gambling problems: some of them are related to the subject (individual factors), others are related to the object of the addiction, here the gambling activity by itself (structural factors), and the last are related to environment (contextual or situational factors). Thus, the development and maintenance of pathological gambling seems to be conditioned by the interaction of a person and a gambling activity, in a particular context. This conceptual model is based on the well-known theory of Olivenstein on toxicomania, which was proposed in the seventies. The structural factors that appeared to be highly related to pathological gambling development and maintenance are payment modality, entertaining dimension, temporality, reward level, educational messages, gambling ambiance, gambling medium and part of hazard. Among contextual factors, availability and accessibility of gambling opportunities are well known. However, social and economic factors (e.g. culture, ethnicity, religion, education) are also important. Lastly, among individual factors, psychosocial factors are gender, age, familial and personal antecedents and psychiatric comorbidities. Neurobiological factors are not discussed here., Conclusions: This paper briefly summarises risk factors for development and maintenance of pathological gambling. It highlights that these factors are very similar to those that are implicated in substance use disorders, except for the gambling activity and context. Prevention regarding behavioural addictions should, in the future, take advantage of the findings on substance use disorder, since behavioural addictions are less known. Conversely, it seems obvious that findings on pathological gambling, and more widely behavioural addictions, could highlight all types of addiction. It appears that this fact is especially valid with regards to the evolution and stability of addictive status, which must be taken into account for treatment proposals., (Copyright © 2011 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Early maladaptive schemas developed during childhood are relatively stable. Once activated, these early maladaptive schemas could influence reality perceptions and create cognitive distortions. Previous studies showed that early maladaptive schemas are linked to depression: early maladaptive schemas could be a risk factor for depression (Young, 2001) and a vulnerability marker for depression (Dozoïs, 2007)., Objectives: The main objective of the present study was to explore the influence of early maladaptive schemas on depression severity among a French adult population., Method: One hundred and sixty-two participants (mean age 29 years; SD=13.86) were enrolled, 66 men (mean age 29 years; SD=13.65) and 106 women (mean age 30; SD=14.07). Participants were invited to complete the Young Schema Questionnaire, short version (YSQ-S1-Young 1994) and the Beck depression Inventory, 2nd version (BDI-II-Beck 1994). Fifty-six participants were randomly selected to complete a paper version of the scales, and 95 participants completed an online electronic version., Results: Fifty-two percent of the participants were not depressed, 15% slightly depressed, 17% moderately depressed and 16% met criteria of severe depression. All 15 schemas scores were positively correlated to depression scores. Comparing schema scores and depression severity it can be noted that for severely depressed participants all schema scores were significantly higher, and six of 15 schemas were significantly higher in the case of moderate depression. In addition, three schemas (imperfection, vulnerability, fusional relation) are significantly and positively linked to depression scores, whereas one schema (everything is owed to me) appears to be a significantly negative predictor of associated depression., Conclusion: This study confirms results of previous research concerning the link between early maladaptive schemas and depression. What is more, the results show that the importance of these schemas increases with depression severity. The most important variation was found on schemas concerning interpersonal relationships like "abandonment" or "social insulation and social exclusion" as well as schemas related to personal competence as for example "failure" or "dependence and incompetence". Further research will be necessary to explore the role of depression as an activator or/and by reinforcing early maladaptive schemas., (Copyright © 2011 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

The aim of this paper is to examine the short questionnaire of the Eysenck Personality Questionnaire Revised (the Eysenck Personality Questionnaire Revised-Abbreviated [EPQR-A]) among a student population. University students were invited, in groups, to fill in the forms proposed. Three sites were compared, representing a sample of 346 participants (Chambéry=118 subjects [44 males and 74 females]; Lille=110 subjects [50 males and 60 females] and Toulouse=118 subjects [60 males and 58 females]). The three groups of students have comparable scores on the EPQR-A wherever they live (Chambéry, Lille or Toulouse). Moreover, neither the age nor the gender allowed the detection of differences between subjects. Our sample of students is situated in the range of a "normal" group of students. Regarding the internal consistency coefficients, the French version we used of the neuroticism and the extraversion scales of the EPQR-A obtained a satisfactory result. The internal consistency coefficient of psychoticism was rather low (<70). This unsatisfactory level of internal reliability for the psychoticism is also found in the English version [7]. The four-factor model of the EPQR-A is judged to be an adequate explanation of the data. In the end, self-esteem correlated positively with extraversion and negatively with neuroticism. On the other hand, there is no link between psychoticism and self-esteem., (Copyright © 2010 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: The Brief Psychiatric Rating Scale was initially developed as a rapid method to assess symptom change in psychiatric inpatients of various diagnoses. The original version was expanded to an 18-item version and thereafter to a 24-item version to increase sensitivity to a broader range of psychotic and affective symptoms. The latest version of the expanded 24- item BPRS provides probe questions and detailed anchor points for the ratings for each item., Literature Findings: Studies have shown the expanded and anchored 24-item BPRS to be a sensitive and effective measure of psychiatric symptoms with good interrater reliability that can be maintained over time. To our knowledge, there are eight published papers including factor analyses of the BPRS-E(A). While many similarities are evident between these studies, inconsistencies are apparent that may have been due to sample size, characteristics and / or methodological differences in the factor analysis computation. Among these studies, six provided a four-factor solution. There was no French version of this scale available., Methods: After its translation into French and back translation, we investigated the validity of the French BPRS-E(A) version. We carried out a component analysis on the data of 111 participants of various diagnoses, mostly hospitalised for a first psychotic episode, yielding to a three-factor solution (positive symptoms--disorganisation; depression-anxiety and negative symptoms)., Results: A good internal consistency and interrater reliability were found. These results confirm the psychometric value of the BPRS-E(A) in its French version. We compared those findings to earlier reports; similarities and differences are discussed., (Copyright © 2009 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Information and prevention campaigns are privileged tools for public health institutions in their risk reduction policies concerning heath disorders and their consequences. Mental health in general, and depression in particular, have been the focus of several public campaigns in different countries for 20 years., Aim of the Study: The aim of this paper is to analyse depression campaign messages, to highlight their underlying logics and to show some of their effects, in particular in relation to contextual conflicts between professionals that possibly emerge because of these campaigns., Material: Previous depression campaign materials were analysed, and the recent French campaign launched in November 2007 was the subject of specific attention., Results: Common messages of the campaigns are centred on the prevention of emergence, recurrence, worsening and individual, social and economic consequences of depressive disorders. Depression is always presented as "a disease"; a position which differs from international classifications describing depression as "a disorder", a much less affirmative statement. This choice, which has important "performance" values is based upon several factors including the difficulty to "popularise" psychological technology, a consensus resulting from a political struggle between professionals, a reaction to the current norms of autonomy implying a new set of rights and responsibilities from and towards the people who are "sick", and the importance given to the reduction of stigmatisation from which the "mentally ill" suffer. From all of these aspects appears a logic of "dementalisation" corresponding to a "deficit" model, in which depression is presented as something external to the individual, and where treatment is supposed to "fix" the deficit., Discussion: The French campaign shares many of those fundamental characteristics: prevalence, seriousness of the disease's consequences, low level of services use, preference for biological monoaminergic theories, and environmental risk factors to explain the disease (an aetiology which is more bioenvironmental than really biopsychosocial), presentation of the main chemotherapeutics and psychological treatments, referring first to a general practitioner, importance of reducing stigmatisation, and presentation of depression as a disease. However, the French campaign differs from other campaigns in its use of an organising concept for the symptoms (slowing down) and a more precise description of the frontiers between normal and pathological functioning. Furthermore, beyond the usual biological and environmental elements, greater importance is given to the psychological mechanisms and to phenomena that are not only in the "real world", such as symbolic losses. Nevertheless, it does not explicitly recommend any psychotherapy "brand"., Conclusion: This "specificity" reflects the compromise found between the different French professional positions and the opposing paradigms that govern them. The campaign led by the French Institut national de prévention et d'éducation à la Santé (Inpes) on depression is a first step of prevention and heath promotion of mental health in France. The analyses presented in this paper highlight the present orientations in this domain, its underlying tensions and the importance of respecting and preserving the multiple aspects of this domain, which are many different ways to explore the complex object that is mental health. This paper also replaces those campaigns in the complexity of their logic and their context, in an attempt to provide elements for a dispassionate reflection for all of the actors concerned by these questions., (Copyright (c) 2009 L’Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Background: Estimates suggest that there are more than 700,000 adult caregivers of persons with dementia in this country, a large number of whom experience some form of sleep disturbance during the course of their caregiving career. Health care professionals are in the best position to detect and address this significant public health problem., Objectives: Prospective study of sleep with the main caregivers providing home-care for demented patients., Methods: This study was performed on elderly persons living at home. Two populations were concerned. The control group concerned 86 old persons living in the area of Limoges (France) and was contacted to join by the senior clubs of this city. The other group concerned caregivers to persons with dementia, living with them at home, and the assessments were done during the patient assessment. Each group had a cognitive evaluation by a Folstein's test and answered a questionnaire to describe their possible sleep difficulties., Results: Sixty-eight caregivers face sleep disturbance versus 25 non-caregiver controls. Caregiver sleep-problems are often linked to sleep disturbances in the care-recipient. Night-time awakenings by persons with dementia are a common precipitating cause of sleep/wake disturbances in vulnerable caregivers. Caregivers awake 2.3 times during the night versus 1.2 for control persons. Caregivers awake earlier (around 6:20) than non-caregivers (around 7:05) and their sleep time is shorter by one hour. Caregivers are more often depressed (28 in 98 versus 13 in 86) and have more often high blood pressure (56 in 98 versus 24 in 86). They received more medications and used more often self-medication., Discussion: Three major contributors to caregiver sleep-disturbance are pointed in this paper: the apparition of caregiver disrupted sleep routines, caregiver burden and depression and the caregiver's physical health status. Successful treatment of a caregiver's sleep disturbance requires careful consideration of each of these contributors. Non-pharmacological options are generally recommended as a first line of treatment for managing sleep disturbances in older adults, including caregivers of persons with dementia., (2009 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Mental Health is a Public Health issue, however, access to relevant treatment often does not meet the population needs. Patients, their relatives, as well as Mental Health professionals are still victims of a high stigmatization process. Whatever the countries and the cultural settings, public beliefs and attitudes towards mental illness (insanity) and mentally ills (insane people) play a major role in the ranking of priorities given to Mental Health national prevention and care policies. This paper presents the methodology of the research-action entitled "Mental Health in General Population: images and realities (MHGP)" carried out by the World Health Organisation Collaborative Centre (Lille, France) and the Direction of research, studies, assessment and statistics (Drees) of the French Ministry of Health, in a sample of 36 000 French subjects over 18 years old, between 1999 and 2003., Objectives: The MHGP Survey is an international multisite study aimed at: Describing, in the general population, the representations attached to insanity, mental illness and depression, and the related care; Assessing the prevalence of major psychiatric disorders in the general population; Rising awareness about Mental Health issues among various social groups: social workers, local elected, care professionals, by including them in the research-action procedure; Promoting the development of Community Psychiatry, following WHO main Guidelines., Methods: About 900 individuals were recruited in 47 centres in metropolitan France between 1999 and 2003 according to the following criteria: i) informed consent to take part in the study, ii) age over 18 yrs, iii) not residing in a care institution and not homeless. Subjects were selected by quota sampling stratified by age, gender, educational and occupational level with the general population of the general population of the centre as sampling frame. The quotas were defined on the basis of the 1999 national population census. The data was collected by 1700 nursing students using a 50-item structured questionnaire administered in face-to-face interviews; mean length 40 minutes. The interviewers received a special 3-day training course. The assessment included a specially developed questionnaire enabling description of representations of insane, mentally ill and depressed individuals; the Mini International Neuro-psychiatric Interview (Sheehan and Lecrubier); a specific questionnaire on care consumption in case of positive MINI diagnosis and a sociodemographic questionnaire. In each centre, a team of supervisors (psychiatric staff) coordinated the interviews and the data collection; the local elected and the social and care networks were given information about the research and the results. The results of the local study were systematically presented to the general population, the local elected and the social and care professionals. Prevalence rates of mental disorders are very similar to those observed in other studies. Results on social representations and public beliefs in general population can compare with the international data available. MHGP research-action remains the first study of this scale on the topic of Mental Health in France, combining representations and prevalences description. It allowed the development of anti-stigma actions at a national and local level., (Copyright 2010 L’Encéphale. Published by Elsevier Masson SAS.. All rights reserved.)

Introduction: Social disparities in health is becoming a topic of major importance. Recent studies presents data on social differences in morbidity on various diseases. This paper shows how mental health disorders prevalences are strongly linked to sociological variables. It is based on the data of the research-action entitled "Mental Health in General Population: images and realities (MHGP)" carried out by the World Health Organisation Collaborative Centre (Lille, France) and the Direction of research, studies, assessment and statistics (Drees) of the French Ministry of Health, in a sample of 36 000 French subjects over 18 years old, between 1999 and 2003., Objectives: The MHGP Survey is an international multisite study aimed at assessing the prevalence of major psychiatric disorders in the general population, as well as describing the representations attached to insanity, mental illness and depression, and the related care. It allows the analysis of the impact of professional situation on prevalence data in a large sample., Methods: The MHGP Survey was carried out in 47 French public sites between 1999 and 2003. A face-to-face questionnaire was used to interview a representative sample of French metropolitan subjects, aged 18 and over, non-institutionalized and homeless. These subjects were recruited using quota sampling for age, gender, socio-professional and education levels, according to data from the 1999 national French population census. Representations of insane, mentally ill and depressive persons were explored by a specific questionnaire with open and semi-open questions. Psychiatric diagnoses were identified using the Mini International Neuropsychiatric Interview (MINI); including: mood disorders, anxiety disorders, alcohol and drug disorders, psychotic disorders and suicidal risk. A national database was then constituted by pooling data from all sites, weighted for age, gender, level of education, socio-professional level and work status to be representative of the French general population. Prevalence rates of mental disorders are very similar to those observed in other studies. Social disparities were analysed mainly using the work status categories, comparing employed people and unemployed people (unemployed, retired, students, housewife)., Results: Results show that mental disorders and suicidal risk are not fairly distributed between the various social categories. Half of unemployed people suffers from at least one mental disorder, whereas less than a third of employed people. For example, the prevalence of mood disorders is more than twice higher in unemployed (23.6%) than in employed (11.7%). Suicidal risk is specially high in unemployed people (22%) and students (15%). As in other pathologies and in causes of death, presence of mental disorder or suicidal risk negatively correlates with social status. Prevalence of mental disorders is higher in unemployed people and unskilled workers than in executives, managers and intellectual professions. Social disparities in mental health do not distinguish with those in health in general. Therefore, the issue of search for the causes of disparities is similar to that for any disparity in health., (Copyright 2010 L’Encéphale. Published by Elsevier Masson SAS.. All rights reserved.)

Image of Madness was always strongly linked with the notion of "dangerousness", provoking fear and social exclusion, despite the evolution of psychiatric practices and organisation, and the emphasis on user's rights respect. Mediatization and politicization of this issue through news item combining crime and mental illness, reinforce and spread out this perception. This paper presents a review of the litterature on social perceptions associating "dangerousness", "Insanity" and "mental illness", available data about the link between "dangerous states" and "psychiatric disorders", as well as the notion of "dangerousness" and the assessment of "dangerous state" of people suffering or not from psychiatric disorders. MAPPING OF SOCIAL REPRESENTATIONS: The French Survey "Mental Health in General Population: Images and Realities (MHGP)" was carried out between 1999 and 2003, on a representative sample of 36.000 individuals over 18 years old. It aims at describing the social representations of the population about "insanity/insane" and "mental illness/mentally ill". The results show that about 75% of the people interviewed link "insanity" or "mental illness" with "criminal or violent acts". Young people and those with a high level of education more frequently categorize violent and dangerous behaviours in the field of Mental illness rather than in that of madness. CORRELATION BETWEEN DANGEROUS STATE AND PSYCHIATRIC DISORDERS: in the scientific literature, all experts reject the hypothesis of a direct link between violence and mental disorder. Besides, 2 tendencies appear in their conclusions: on one hand, some studies establish a significative link between violence and severe mental illness, compared with the general population. On the other hand, results show that 87 to 97% of des aggressors are not mentally ills. Therefore, the absence of scientific consensus feeds the confusion and reinforce the link of causality between psychiatric disorders and violence. OFFICIAL FIGURES BY THE MINISTRY OF JUSTICE: according to the French Ministry of Justice, there is a lack of significative data in general population, that would allow the accurate evaluation of the proportion of authors of crimes and offences presenting a "dangerous state", either of criminological order or related to a psychiatric disorder. FROM "DANGEROUSNESS" TO "DANGEROUS STATE": the vagueness of the notion of "dangerousness" aggravates the confusion and reinforce the negative social representations attached to subjects labelled as "mentally ills". A way to alleviate this stigmatisation would be to stop using the word "dangerous", and rather use those of "dangerous states". Assessment of dangerous states is complex and needs to take into account several heterogeneous factors (circumstances of acting, social and family environment...). Besides, it is not a linear process for a given individual. Those risk factors of "dangerous state" lead to the construction of evaluation or prediction scales, which limits lay in the biaises of over or under predictive value. The overestimation of dangerousness is harmful, not only to individuals wrongly considered as "dangerous", but also to the society which, driven by safety concerns, agrees on the implementation of inaccurate measures. A FEW TRACKS FOR REMEDIATION: the representations linking "mental illness" and "dangerousness" are the major vectors of stigma, and deeply anchored in the collective popular imagination. They are shared by all population categories, with no distinction of age, gender, professional status or level of education. To overcome those prejudices, one has to carefully study their basis, their criteria, document them with statistical data, look for consistency and scientific rigour, in the terminology as well as in the methodology. Moreover, one has to encourage exchanges about this topic, between users, relatives, carers, local elected, politicians, media and health professional., (Copyright 2010 L’Encéphale. Published by Elsevier Masson SAS.. All rights reserved.)

Introduction: Deliberate self-injury is defined as the intentional, direct injuring of body tissue without suicidal intent. There are different types of deliberate self-mutilating behaviour: self cutting, phlebotomy, bites, burns, or ulcerations. Sometimes, especially among psychotic inpatients, eye, tongue, ear or genital self-mutilations have been reported. In fact, self-mutilation behaviour raises nosological and psychopathological questions. A consensus on a precise definition is still pending. Many authors consider self-mutilating behaviour as a distinct clinical syndrome, whereas others hold it to be a specific symptom of borderline personality disorder. Self-mutilating behaviour has been observed in 10 to 15% of healthy children, especially between the age of 9 and 18 months. These self mutilations are considered as pathological after the age of 3. Such behaviour is common among adolescents, with a higher proportion of females, and among psychiatric inpatients. Patients use different locations and methods for self-mutilation. Deliberate self harm syndrome is often associated with addictive behaviour, suicide attempt, and personality disorder., Clinical Material: We report on an observational study including 30 inpatients and we compared the data with the existing literature. As a matter of fact, until now, most of the papers deal with case reports or with very specific patterns of self-mutilation (eye, tongue or genital self-mutilations). Otherwise, papers report the relationships between self-mutilation and somatic or personality disorders (Lesh Nyhan syndrome, borderline personality disorder, dermatitis artefacta, self-mutilation in children following brachial plexus related to birth injury, mental retardation...). Our study included all self harmed patients who had been admitted to our psychiatric hospital (whatever the location and type of self-mutilation). Patients suffering from brain injury or mental retardation were excluded., Results: In our sample, there was a higher percentage of women (29 women and 1 man) and the mean age was 18 (12 to 37). More than half of the patients were aged under 18. Single parent families were reported in 30% of cases. Thirty percent of patients had been physically or sexually abused during childhood. Sixty percent had a comorbid psychiatric disorder, 63% had been hospitalised previously (half of them twice or more). Seventy-three percent of patients had previously attempted suicide (notably deliberate self-poisoning and cutting) that was not considered as self-mutilating behaviour by the patients themselves. Each patient had self harmed themselves at least twice and most often different methods and locations were used (deliberate self harm of forearms 90%, thighs 26.7%, legs 16.7%, chest 10%, belly 10%, hands 6.9%, face 6.9%, arms 6.7%, and feet 3.3%). Addictive disorders, such as substance abuse (tobacco 46.7%; alcohol 23.3%; illicit drugs 16.7% mostly cannabis or cocaine) and eating disorders (33.3% and among them 50% of cases were restrictive anorexia nervosa) were often associated with a deliberate self harm syndrome. Three psychiatric diagnoses were often observed in our cohort: depressive disorder 36.7%; personality disorder 20%; psychosis 10% and depressive disorder associated with personality disorder 33.3%. In our sample, psychotic patients differed on several clinical aspects: the atypical location (abdomen, nails) and method (needles) of self-mutilating behaviour. None of them had been abused during childhood and none was suffering from addictive disorders.

Introduction: This paper presents a survey conducted on a population of multi-handicapped patients and autistic adults hospitalised long term in the Paul Guiraud mental health Hospital in Villejuif France., Objective: The aim of the survey is to deepen the knowledge of the treatments for this specific population., Methods: A preliminary medical investigation was conducted on the population in order to target different groups of patients. Once patients had listed and defined their medical needs, prescriptions were analysed to assess whether clinical characteristics had an impact. Thus, the analysis of treatments was carried out for the 57 patients (14% of the hospital population) and compared to other investigations conducted on the population commonly hospitalised in Psychiatry. The evaluation of the treatments was obtained through a questionnaire which enabled us to target the therapeutical goals and to obtain additional clinical information. The drugs with a high rate of prescription were compared between the autistic group and the multi-handicapped group. The important comorbidity and the multi-symptomatology of autism often involves the polymedication of these patients (8+/-0.8 drugs per patient)., Results: Fifty per cent of the treatments are referred to as somatic treatments. The average length of stay (22.3 years) and the high average age are aggravating factors for polymedication. The average number of psychotropic molecules also appears higher than in the populations studied in the literature. The heterogeneity of clinical forms of autism and polyhandicap encourages prescribers to multidrug therapy. The prescriptions usually remain stable (17.5% of psychiatric treatment is adapted and only 7% of somatic treatment). Epilepsy and constipation are the main treated somatic disorders. In psychiatry, the oral route is the privileged route of administration (81% of treatments) with, more specifically, the use of drinkable solutions for the psychiatric treatment. Neuroleptic drugs are the basic treatment of these patients (82% of prescriptions). The aim of the prescription of neuroleptics is essentially to obtain behavioural or antipsychotic sedation. Cyamemazin is the most prescribed drug (46% of neuroleptic prescriptions), mainly for its anxiolytic effects. Co-prescription is frequent (55.3%) and corresponds to 53% of co-prescriptions of an association of phenothiazine and butyrophenone. Doses are high, which implies the prescription of treatments against the neuroleptics side-effects (86% of patients have such a prescription). The rate of prescriptions of the other psychotropic drugs (hypnotics, anxiolytics, etc.) is approximately equivalent between our population and the "classical" hospitalised psychiatric population, except for antidepressants (7% of prescriptions) because the differential diagnosis is difficult in these patients. Nearly 60% of patients have prescriptions of hypnotic drugs. However, this figure is tempered by prescriptions of drugs "if necessary" in two-thirds of the cases. Finally, only 30% of patients have systematic hypnotic prescriptions., Conclusion: Although autistics are clinically different from multi-handicapped patients, no statistically significant difference was demonstrated in their prescriptions, which implies a similar pharmacological management. It is difficult to clearly distinguish these two populations only according to the type of drugs used and the doses prescribed.

Introduction: Anhedonia is defined as a diminished capacity to experience pleasant emotion and is commonly included among the negative symptoms of schizophrenia. However, if patients report experiencing a lower level of pleasure than controls, they report experiencing as much pleasure as controls with online measurements of emotion., Objective: The Temporal Experience of Pleasure Scale (TEPS) measures pleasure experienced in the moment and in anticipation of future activities. The TEPS is an 18-item self-report measurement of anticipatory (10 items) and consummatory (eight items) pleasure. The goal of this paper is to assess the psychometric characteristics of the French translation of this scale., Methods: A control sample was composed of 60 women and 22 men, with a mean age of 38.1 years (S.D.: 10.8). Thirty-six were without qualification and 46 with qualified professional diploma. A sample of 21 patients meeting DSM IV-TR criteria for schizophrenia was recruited among the community psychiatry service of the department of psychiatry in Lausanne. They were five women and 16 men; mean age was of 34.1 years (S.D.: 7.5). Ten obtained a professional qualification and 11 were without qualification. None worked in competitive employment. Their mean dose of chlorpromazine equivalent was 431 mg (S.D.: 259). All patients were on atypical antipsychotics. The control sample fulfilled the TEPS and the Physical Anhedonia Scale (PAS). The patient sample fulfilled the TEPS and was independently rated on the Calgary Depression Scale and the Scale for Assessment of Negative Symptoms. For comparison with controls, patients were matched on age, sex and professional qualification. This required the supplementary recruitment of two control subjects., Results: Results with the control sample indicate that the TEPS presents an acceptable internal validity with Crombach alphas of 0.84 for the total scale, 0.74 for the anticipatory pleasure scale and 0.79 for the consummatory pleasure scale. The confirmatory factor analysis indicated that the model is well adapted to our data (chi(2)/dl=1.333; df=134; p<0.0006; root mean square residual, RMSEA=0.064). External validity measured with the PAS showed R=-0.27 (p<0.05) for the consummatory scale and R=-0.26 for the total score. Comparisons between patients and matched controls indicated that patients were significantly lower than control on anticipatory pleasure (t=2.7, df(40), 2-tailed p=0.01; cohen's d=0.83) and on total score of the TEPS (t=2.8, df (40), 2-tailed p=0.01; cohen's d=0.87). The two samples did not differ on consummatory pleasure. The anticipatory pleasure factor and the total TEPS showed significant negative correlation with the SANS anhedonia, respectively R=-0.78 (p<0.01) for the anticipatory factor and R=-0.61 (p<0.01) for the total TEPS. There was also a negative correlation between the anticipatory factor and the SANS avolition of R=-0.50 (p<0.05). These correlations were maintained, with partial correlations controlling for depression and chlorpromazine equivalents., Conclusion: The results of this validation show that the French version of the TEPS has psychometric characteristics similar to the original version. These results highlight the discrepancy between results of direct or indirect report of experienced pleasure in patients with schizophrenia. Patients may have difficulties in anticipating the pleasure of future enjoyable activities, but not in experiencing pleasure once in an enjoyable activity. Medication and depression do not seems to modify our results, but this should be better controlled in a longitudinal study. The anticipatory versus consummatory pleasure distinction appears to be useful for the development of new psychosocial interventions, tailored to improve desire in patients suffering from schizophrenia. Major limitations of the study are the small size of patient sample and the under representation of men in the control sample.

Introduction: In France, World War II lasted from 1939 to 1945. Under-nourishment was a national problem, and was more severe in mental hospitals. The mortality of psychiatric inpatients in France during World War II has long been a controversial issue in the country., Literature Findings: Some authors wrote of the "soft extermination" of 40 000 mental patients, although this has been proven false. The historical study published in 2007 by Isabelle von Bueltzingsloewen provides in-depth description and analysis of starvation due to food restrictions in French mental hospitals. Although the French official statistic services published detailed data, no demographic study has been published so far. Such studies have been conducted in Norway and in Finland. "The influence of a period of under-nourishment upon mortality in mental hospitals can rarely be seen with a clarity equal to that in this work. The strict rationing was the same for everybody, but, extra muros, there was private initiative and ingenuity to help in alleviating the distress. Naturally, patients in institution had no ability to act on their own. The immense increase during the period of war from 1941 to 1945 appeared both as an increase in the exact death-risk and as an increase in the disproportion with normal mortality. The men reacted more strongly than women; which is readily comprehensible on physiological grounds, as the rations were virtually the same for all." Excess mortality continued after the war. Even though under-nourishment had ceased, death rates from tuberculosis remained high the following year. Both papers state that the poor hygiene and bad living conditions existing in mental hospitals before the war worsened the effects of food restrictions. DEMOGRAPHIC DATA: French data were published by the General Statistics of France (SGF) that became the National Institute of Statistics and Economic Studies (Insee) in 1946. A series of datasets were published each year according to sex, diagnosis and type of psychiatric institution. In 1943, the outdated diagnostic classification was replaced by a more modern one, with reference to ICD. The same year, the age groups also changed (instead of 35-44, it became 30-39). Publication of data by type of institution was discontinued in 1943; from 1945 to 1948, the only available data concerned patients in hospital on 31st December, by age, sex and diagnosis. General population data were published by the National Institute of Demographic Studies (INED). The data referring to civilian population during the war are provided by the Human Mortality Database. This study covers number of people in hospital, mortality rates by sex, age, diagnosis and type of institution, and standardised mortality ratios. These refer to the civilian population which is more relevant since mental patients would not have been allowed to join the armed forces, even if they had not been in hospital. Finally, mortality trends in mental hospitals are compared with those in "hospices for old, disabled or incurable people", in order to ascertain whether all vulnerable populations in institutions suffered to the same extent. The results show that the number of inpatients in 1945 was about half the total recorded in 1940, due to fewer admissions and to a large increase in the number of deaths. However, the number of discharges increased in 1940, even though the number of admissions had begun to slow down: many patients were sent to places offering better food and hygiene. The number of deaths began to rise as from 1939. Mortality rates were high in 1940 and especially in 1941, when almost one man in three and more than one woman in five died. Global rates did not change in 1942. In December that year, a government order stated that mental patients should receive more food. Mortality rates went down in 1943 and 1944, but rates did not return to the prewar values until 1946. In 1939, mortality rates are high but only among patients of 70 years of age or more. In 1940, they were highest above 55; in 1941, rates between ages 15 and 54 were double those of the preceding year. Thus, even though excess mortality affected all ages, its strongest effects were felt from the older patients to the younger ones from 1939 to 1941. Trends according to diagnosis are difficult to interpret because of the change of classification in 1943. The patients suffered greatest hardship in public hospitals, which had no budget of their own and were run by the departments and lowest in private hospitals contributing to the public service, most of which were congregational and received religious funding. In 1941, standardised mortality ratios were more than three times higher than they were before the war., Conclusion: Comparison with people living in hospices shows that during the war mortality rates were 50% higher in these institutions, while they almost tripled in mental hospitals. The number of people who died of starvation and infectious diseases in mental hospitals from 1939 to 1945 can be estimated at about 45,500. However, mental patients were made specially vulnerable by circumstances that existed before the war in mental hospitals, in terms of food, hygiene and staffing, as suggested by an official document quoted in the paper.

Background: Cognitive impairments are a core feature in schizophrenia. They impact several cognitive abilities but most importantly attention, memory and executive functions, consequently leading to great difficulties in everyday life. Most schizophrenia patients need assurance and require assistance and help from care workers, family members and friends. Family members taking care of a patient have additional daily work burden, and suffer psychological anguish and anxiety. Therefore, improving cognitive functions in schizophrenia patients is essential for the well-being of patients and their relatives. Reducing these deficits may decrease the economic burden to the health care system through lower numbers of hospital admissions and shorter hospitalisation periods, for example. Cognitive rehabilitation was developed to address the limited benefits of conventional treatments on cognitive deficits through the use of assistive technology as a means of enhancing memory and executive skills in schizophrenia patients., Objective: To provide clinicians with comprehensive knowledge on cognitive trainings, programs of remediation, and cognitive assistive technologies., Method: Literature review. A search in the electronic databases (PubMed, EMBASE, Index Medicus) for recent articles in the last 10 years related to cognitive remediation published in any language using the words: cognitive and remediation or rehabilitation and schizophrenia, and a search for chapters in psychiatry and rehabilitation textbooks., Results: We found 392 articles and 112 review paper mainly in English. First, we identified cognitive remediation programs that were beneficial to schizophrenia patients. Programs available in French (IPT, RECOS, and RehaCom) and others (CET, NET, CRT, NEAR, APT and CAT) were identified. In addition, since memory and executive function impairments could be present in people without schizophrenia, we reviewed inventories of cognitive assistive technologies proven to enhance cognitive skills in other populations. Finally, we present a review of recent studies testing innovative devices developed to assist schizophrenia patients., Discussion: First, we found several cognitive programs proven to be effective with schizophrenia patients, but only three were validated in French. It could be useful to adapt other programs for French-speaking populations. Unfortunately, we found that very few of the existing cognitive assistive technologies are proposed to be used with schizophrenia patients. In fact, most of the available cognitive orthoses were tested primarily in people with neurological injuries (for example, various memory impairments caused by traumas), and in elderly illnesses (like Alzheimer disease). Devices for patients with mental deficits (e.g., mental retardation) were developed later, and only very recently explored for use in schizophrenia. As a result of an international collaboration between France and Canada, currently a tool called MOBUS is being tested. This technology aims at improving the autonomy of schizophrenia patients, by helping them plan and remember their daily activities. Furthermore, it encourages patient-caregiver communication, and permits monitoring patients' subjective reports of their symptoms. The use of cognitive assistive technologies is not meant to isolate patients by replacing the human element of relatives and caregivers by a machine. On the contrary, they offer a sense of security and they improve interpersonal relationships by permitting enhanced autonomy and greater self-confidence. Finally, a literature review of cognitive remediation in schizophrenia emphasizes the importance of a structured application of the technique in order for it to succeed. First, it is crucial to detect the impairments that will be targeted in each patient presenting a specific pattern of impairments. For this purpose, validated and customised neuropsychological tests are required. Then, cognitive remediation programs must be customised to each patient's needs in order to motivate the patient to participate. Finally, long-term effects must be assessed in order to verify whether reinforcement is needed. Following these steps, most of the studies show an improvement in the well-being of patients with schizophrenia. These recommendations are also suitable for the cognitive remediation programs, as for treatments with cognitive assistive devices. An important hurdle facing the advance of cognitive assistive technology programs is that different research groups work individually without a coordinated effort to improve and validate the existing programs., Conclusion: Schizophrenia treatments must take into account not only patients' symptoms, but also the associated cognitive deficits which constitute an important factor in their social problems. It has been shown that several cognitive remediation programs are efficient in schizophrenia. New technologies complement the benefits of such programs, and support pharmacological treatments and psychotherapies.

Introduction: The commercial introduction of atypical antipsychotics, called second-generation antipsychotics (SGAs), a few years ago, has led to a world-wide reappraisal of the established treatment strategies for people with psychotic or bipolar disorders. They permitted improvements in the pharmacologic management of psychiatric diseases. As compared to conventional neuroleptics or first-generation antipsychotics (FGAs), they promised better efficacy especially on negative symptoms and cognitive impairments of psychiatric diseases and, at the same time, better tolerance on neurological side effects. Now, they have shown other side effects and they have a higher acquisition cost than FGAs., Objectives and Methods: The aim of this paper is to describe and analyse the prescribing practices of antipsychotic drugs in French psychiatric hospitals for adult inpatients and to compare them with other surveys and guidelines. In June 2004, we conducted a one-day, cross-sectional, observational and naturalistic study in 13 hospitals, members of the PIC network., Results: Two thousand one hundred and ninety-two prescriptions with antipsychotic treatment were collected. One thousand one hundred and fifty-four prescriptions (52.6%) included a SGA, but the FGAs were the most prescribed (65.8%; n=2259), principally cyamemazine (24.7%). There was one antipsychotic in 50.7% of prescriptions, two antipsychotics in 42.2%, but the second neuroleptic used was a sedative (82.6%), principally cyamemazine. Multiple antipsychotics were present in 1081 prescriptions (49.3%), with an average number of 1.57 antipsychotics. A mood stabiliser, an antidepressant, an anxiolytic and a hypnotic were coprescribed in respectively 37, 30.5, 65.1 and 41.6%. There were 2.48 psychotropic drugs associated with the principal antipsychotic; in total, with correctors of side-effects of the antipsychotics, there were 3.38 drugs per prescription. The SGAs aimed more often for psychotic (F20-F29) patients (61.9% versus 43.3% with FGAs), who were males (61.4% versus 68%), younger (42.6 years versus 44.1 years; p<0.02), with higher average daily doses, more associated with other neuroleptics (p<0.0004) and less associated with anticholinergic antiparkinsonian agents (p<10(-4)) than FGAs. Compared to other surveys, these results showed that the SGAs have become the first-line treatment for psychiatric disorders. The highest average daily doses corresponded to treatments of psychotic patients and, hence, the values might largely exceed the authorized maximum doses. Furthermore, in more than half of the cases, an FGA, generally a sedative, was associated with an SGA that did not comply with the principle of monotherapy established by the national and international guidelines; that also annulled the expected benefit of the SGAs on the awakening, cognition and the neurological tolerability of the treatment. The coprescriptions of the other psychotropic drugs to neuroleptics also remained the rule in psychiatry, showing all the complexity of pharmacological psychiatric medications. Prescriptions also included treatments for side effects of antipsychotics; even on the prescriptions including the SGAs, there was the coprescription of anticholinergic antiparkinsonian drugs, the deleterious character of which one knows on cognition. This resulted in a difficulty of understanding the prescription for the patient, associated with reduced compliance and increased risks of pharmacological side effects. The heterogeneity of the situations of crisis in psychiatric hospitals could make the strict application of guidelines' recommendations difficult. Nevertheless, the educational interventions in psychopharmacology for patients and the training campaigns for psychiatrists and nurses are necessary to improve the therapeutic management of the patient and ensure him/her optimal quality of life., Conclusion: This kind of survey, far too rare, was very important because it showed the routine clinical settings in which these new drugs were really used. The results showed that SGAs appeared to take the place of the FGAs used in the treatment of psychoses, particularly schizophrenia, but also in the treatment of mood disorders and they reflected actual clinical practices. Other surveys must be conducted to see whether our study confirms the general trend concerning the use of these drugs and, therefore, to reassess these prescribing practices.

Background: An increasing interest in the study of cognition in Schizophrenia has developed within the last few years although cognitive problems have been described in this disorder since the beginning of the 20th century. Presently, various data tend to assert that cognitive disorders are the core disturbance in schizophrenia and that their severity is predictive of the course of the disease. Indeed, studies have shown that the disturbances measured in cognitive tests are neither the consequences of positive or negative symptoms, nor related to motivation or global intellectual deficit, nor to anti-psychotic medication. It is also presently known that the severity of cognitive symptoms is a better indicator of social and functional outcome than the severity of the negative or positive symptoms. The patients who have the most severe cognitive deficits during the first episode of the disease are most likely to present a chronic and severe form later on. The aspects of cognition that are specifically impaired in schizophrenia are verbal memory, working memory, motor function, attention, executive functions, and verbal fluency. Cognitive disturbances are thus very important in several fields of research in schizophrenia such as: understanding the psychopathology, epidemiology (indicators of vulnerability), genetics (endophenotypes), neuro-imaging (including functional neuro-imaging), and psychopharmacology (they can be used as a parameter of evaluation in therapeutic trials with new molecules, or cognitive psychotherapy). LIMITS OF COGNITION ASSESSMENTS: However, there are some methodological limits to these cognitive evaluations. First, schizophrenia is a heterogeneous disease and there are no specificities of the different subgroups in terms of cognition. Secondly, the time chosen to evaluate the abilities of the patient is also a limiting factor. But most of all, the batteries of tests used in different studies are not standardized. BRIEF ASSESSMENT OF COGNITION IN SCHIZOPHRENIA: It is therefore of great interest to create an available and easily used battery of validated tests. This would enable one to measure the different cognitive deficits and to repeat the tests, and assess evolution through longitudinal follow up of the patients. The BACS is a new instrument developed by Keefe et al. in the Department of Psychiatry and Behavioural Sciences at the University of Duke Medical Centre. It evaluates the cognitive dimensions specifically altered in schizophrenia and correlated with the evolution of the disease. This test is simple to use, requiring only paper, pencils and a stopwatch. It can be administered by different carers. The duration of the test session is approximately 35min. This battery of tests was validated on a sample of 150 patients compared with a sample of 50 controls, matched for age, parent education and ethnic groups. This aim of this study is to create a French adaptation of the BACS (translation and back translation approved by the Department of Psychiatry and Behavioural Sciences at the University of Duke Medical Centre) and then to test its easiness of administration and its sensitivity, performing correlation analysis between the French Version of the BACS (version A) and a standard battery. Its adaptation and validation in French would at first be useful for the French-speaking areas and then would add some new data for the pertinence of using the BACS., Methods: 35 French stabilized schizophrenic patients were recruited from the inpatient and outpatient facilities at the Clermont-de-L'Oise Mental Health Hospital (Picardie area, France) in Dr Boitard's Psychiatric Department (FJ 5.) Patients were required to meet DSM-IV criteria for schizophrenia or schizoaffective illness. The patients were tested on two separate days by two independent clinicians with less than two weeks between the two assessments. During the first test session, subjects received the French A version of the BACS and during the second session, they were administered the standard battery of cognitive tests including: the Rey Auditory-Verbal learning test, the Wechsler Adult Intelligence Scale, third edition, subtests (Digit inverse sequencing, Digit Symbol-Coding), the Trail-Making A, Verbal Fluency (Controlled Oral Word Association Test, Category Instances), and the Wisconsin Card Sort Test (128 card version). The factor structure of the French BACS A Version was determined by performing a principal components analysis with oblique rotation. The relationship between the French BACS sub-scores and the standard battery sub-scores was determined by calculating Pearson's correlations among the sub-scores, with a level of significance of alpha<0.05., Results: All the 35 patients completed the standard battery and each subtest of the French BACS A Version without interruption and with good understanding of the instructions. The average duration of the BACS test sessions was 36.51min (S.D.=12.14.) compared to the standard battery in which the sessions lasted more than one hour with more difficulty during the Wisconsin tests. The factor analysis conducted on the data collected from patients suggests that there is a single dimension, a factor of general cognitive performance, which accounted for the greatest amount of variance. The BACS thus permits an assessment of overall cognitive function as a global score, more than some individual specific cognitive domains. The sub-scores from the French BACS A Version were strongly correlated with the standard battery corresponding sub-scores. We observed significant correlations for all the subtests evaluating: verbal memory (Pearson=0.83; p<0.001; IC [0.69; 0.91]), working memory (Pearson=0.67; p<0.001; IC[0.43; 0.80]), verbal fluency (semantic: Pearson=0.64; p<0.001; IC[0.40; 0.80]), alphabetical (Pearson=0.87; p<0.001;IC[0.77; 0.93]), attention and speed of information processing (Pearson=0.69; p<0.001; IC[0.47; 0.83]), executive function (Pearson=0.64; p<0.001; IC[0.39; 0.80]). We almost found a significant correlation for motor speed (Pearson=-0. 32; p=0.06; IC [-0.59; -0.014])., Conclusion: The French adaptation of the BACS scale is easier to use in schizophrenic patients with French as mother tongue, with a completion rate equal to 1, and also with less than 35min to complete and check. We obtained significant correlations for all domains except motor speed, which is almost significant. The BACS is as sensitive to cognitive impairment in patients with schizophrenia as a standard battery of tests that required over 2h to complete. Moreover, these results demonstrate that the BACS, the global score of which may be the most powerful indicator of functional outcome, can also be a good neuropsychological instrument for assessing global cognition in patients with schizophrenia.

Summary: The potential for drug-drug interactions in psychiatric patients is very high as combination psychopharmacotherapy used to treat comorbid psychiatric disorders, to treat the adverse effects of a medication, to augment a medication effect or to treat concomitant medical illnesses, etc. Interactions can be pharmacodynamic or pharmacokinetic in nature. In clinical practice the benzodiazepines (BZD) are often prescribed together with antidepressant drugs for the treatment of depression. Although there has been no convincing evidence to show that such a combination is more effective than antidepressants alone and no clear indication for the use of this combination. Yet, anxiety frequently coexists with depression, and an anxiolytic is often added. But, it is BZD which are systematically prescribed together with antidepressants. However, BZD themselves have no antidepressive effects and we lack firm evidence for or against this combination therapy. We are focused on the pharmacodynamic interactions between anxiolytic such as BZD, and antidepressant drugs which may resulting in a reduction of the effects of one of the drugs. It is known that BZD decrease the serotoninergic transmission. Also, it may be suggested that combined BZD-specific serotonin reuptake inhibitors, should be avoided. This paper reviews, in vitro and in vivo and particularly in clinical, the evidences for drug interactions between BZD and antidepressant drugs. In clinical, all trials that compared antidepressant-benzodiazepine treatment with antidepressant alone for adult patients with major depression were sought by electronic searches of Medline and several other databases (1970 to 2005), combined with hand searching, reference searching and SciSearch.

Unlabelled: Failure of the French health care services to diagnose and manage problem drinkers has been established on many occasions. This results from a relative lack of knowledge of the basics of alcoholism and the low level of involvement of health care professionals in the management of these patients. In response to this inadequacy, the French Public Health Ministry promoted the development of managed care and coordination of care for these patients. Teams in charge of coordinating care for problem drinkers have been implanted in 96 French hospitals since 1996. These teams aim to provide support to health care providers caring for problem drinkers. For this purpose, they have delivered continuing medical education designed to prepare health care providers to identify and manage these patients in various settings. However, no formal assessment of the impact of these interventions on the knowledge, perceptions, and practices of health care professionals has been planned. The assessment of these interventions can rely on qualitative methods such as observation, focus groups, or individual interviews. However, qualitative methods require specific skills, are time-consuming, and cannot be implemented on a large scale. In contrast, quantitative methods using survey questionnaires or standardized instruments appear to be more appropriate for large scale or repeated evaluations. However, the accuracy of ratings provided by these instruments can be affected by many methodological factors, including the quality of the instrument in terms of validity, reliability, and sensitivity to changes. The aim of this paper is to describe the properties of French and English language questionnaires designed to assess the knowledge, perceptions, and practices of health care professionals with regards to alcoholic patients., Methods: The instruments were retrieved by searching the Medline, Pascal, and Sudoc computerized bibliographic databases from January 1964 to December 2002. The following medical Subject Headings (MeSH) and text words were used: "*alcoholism/psychology/therapy", "questionnaire", "healthy care surveys", "attitude of health personnel", and "*knowledge/attitude/practice". In addition, the table of contents of the French journals devoted to alcoholism that were not indexed in electronic bibliographic databases were examined (Alcoologie et addictologie, Alcoologie). The bibliographies of relevant articles were also examined for additional citations. Finally, a phone survey of 34 professionals caring for alcoholic patients located in French university hospitals was carried out to retrieve unpublished questionnaires. Two authors independently extracted data from each study using a standard date abstract form. Disagreements were resolved through consensus. They extracted information on the development process and properties of validity, reliability, and sensitivity to changes. Validity is a concept concerned with the extent to which an instrument actually measures what it is supposed to measure. It is assessed through different facets (content, construct, criterion, discriminant, and predictive validity). Reliability reflects the amount of error inherent in any measurement. Sensitivity to change corresponds to the property of an instrument to identify small but clinically significant changes in attitude or practice., Results: A total of 57 relevant publications involving 39 original instruments were identified. Eighty questionnaires were not available, despite the solicitation of their developers. Overall, the study included 21 instruments. Of these, 20 were English-language questionnaires and one was in French. The conceptual frameword was specified for only two questionnaires: "the Addiction Belief Scale" and "the Alcohol and Alcohol Problems Perception Questionnaire". The number of items ranged from 9 to 122. Items were derived from qualitative surveys in only two cases. In the other cases, they were derived from the literature, expert panels, or form unknown sources. The internal construct validity of eight questionnaires was assessed using principal component analysis, factor analysis, or cluster analysis. We considered that external construct validity was analyzed by testing empirical hypotheses derived from the literature for 15 of the instruments studied. Predictive validity cas evidenced for only one questionnaire. Internal consistency was documented for seven instruments, using Cronbach's coefficient. Test-retest or inter-rater reliability was assessed for none of the instruments. The sensitivity to change of two instruments was analyzed. The response rate to the instruments ranged from 46% to 93%., Discussion: The main finding of this study is that properties of validity, reliability, and sensitivity of questionnaires designed to assess the knowledge, perceptions, and practices of health care professionals with regards to alcoholic patients are neglected. Moreover, these questionnaires generally lack a theoretical background. Hence, the interpretation of responses to these questionnaires may be misleading. The present study has several limitations. The search strategy could be criticized for searching only a small number of databases, and selecting French and English language questionnaires. However, given the large range of journals included, it was unlikely that the strategy has limited the generality of the results. In addition, we identified no additional relevant articles by contacting professionals working with alcoholic patients in French university hospitals. Articles reporting instruments designed to assess the knowledge, perceptions, and practices of health care professionals with regards to alcoholic patients are incomplete. Journals should require minimum evidence of validity, reliability, and sensitivity when reporting results of surveys, development of questionnaires or standardized instruments., Conclusion: The psychometric characteristics of French language questionnaires were given very little attention. In order to evaluate the effectiveness of their continuing medical education programs, the teams that train French medical staff caring for alcoholic patients should either develop a standardized survey questionnaire following a strict methodology or translate an English language instrument, which would also require a cross-cultural validation.

Unlabelled: The commercial introduction of atypical antipsychotics (AAP) constitutes a considerable step forward in the sense that it has led to a world-wide reappraisal of the established treatment strategies for people with psychoses (including schizophrenia and affective psychoses). They have allowed refinements in the pharmacologic management of psychoses but they have a higher acquisition cost than conventional neuroleptics. The cost of the newer AAP had a substantial effect on medical resources: the AAP account for only 43.2% of neuroleptic prescriptions, but 76.1% of medical costs associated with neuroleptic drugs, and in terms of treatment costs, a reduction (50%) was found with risperidone compared with olanzapine for a same number of treated patients. The aim of this paper was to examine the use of these drugs, to compare them and to assess their impact within the context of psychiatric hospital practice, by means of analysis of prescribing practices for amisulpride, clozapine, olanzapine and risperidone for all treated patients. We conducted an observational, naturalistic study at Charles Perrens psychiatric Hospital in Bordeaux (France) that reproduced the clinical conditions in which these new drugs are used. Four photographies of all the medical prescriptions concerning atypical antipsychotic drugs were done between October 1999 (four months after the introduction in France of the olanzapine, the last of the new antipsychotics) and June 2001 (n=682 prescriptions). The total amount of these prescriptions corresponded to 527 patients. Treatment groups were compared - first overall and after by considering 2 groups: psychotic and non-psychotic patients - through descriptive analyses of sociodemographic characteristics of patients, diagnosis, percentages of patients receiving concomitant psychotropic medication and/or receiving treatment-emergent side effects and mean dosages of AAP therapy according to concomitant medication. In the same way, we compared the four AAP through their prescribing practices'evolution during the four survey., Results: AAP drugs account for 43.2% of prescriptions (and conventional neuroleptics 56.8% of them). We recorded a significant increase between the four surveys (p<0.02): 36.6% at the beginning to 47.8% at the end of the study. From the 682 collected prescriptions, 72 (10.6%) included clozapine, 130 (19.1%) amisulpride, 229 (33.6%) olanzapine and 251 (36.8%) risperidone. Sixty five percent of AAP prescriptions involved psychotic patients. A relative stability in characteristics of AAP prescriptions during the four surveys was found. So, no significant differences were observed between amisulpride, olanzapine, risperidone, in terms of age, sex, sociodemographic characteristics, unlike clozapine. However, there were statistical differences between all the AAP in the concurrent use of other neuroleptic agents (p<0.02), hypnotic drugs (p<0.006), mood stabilizer drugs (p<0.03), and anticholinergic drugs (p<0.007). Statistically, the mean dosage of amisulpride increased when a mood stabilizer drug was coprescribed (p<0.0007), but it decreased with an antidepressant drug (p<0.004) or an hypnotic drug (p<0.02); clozapine 's one decreased every time an antidepressant drug was coprescribed (p<0.02); with olanzapine, there was a significant increase every time an other neuroleptic agent (p<0.03) or an anticholinergic drug (p<0.006) was associated; then for risperidone, the mean dosage increased with the coprescription of an other neuroleptic agent (p<0.00002), an anticholinergic (p<0.00003) or an adrenolytic drug (p<0.04). The pattern of prescribing practices that emerges from our four surveys suggests that these new AAP are significantly more and more often associated with a stabilizer mood drug (p<0.009) (particularly the olanzapine) or/and an anxiolytic drug (p<0.05) (like the amisulpride in particular). Considering the four AAP globally, but more with the risperidone, the association with a neurovegetative corrector agent decreased (p<0.004) during the four surveys. Then, concerning the psychoticng the four surveys. Then, concerning the psychotic patients, the AAP were significantly more often associated with other neuroleptic agents (p<0.03), the amisulpride in particular, with anticholinergic drugs (p<0.00005), but significantly less with mood stabilizer drugs (p<0.00003) principally the amisulpride and the risperidone, with antidepressant drugs (p<0.02) particularly the risperidone. This kind of survey, however it is too much rare, is very important because it shows the clinical conditions in which these new drugs are really used. The results show that AAP appear to be the replacements of the older neuroleptics used in the treatment of psychoses, including particularly schizophrenia, but also in the treatment of mood disorders, and they reflect actual clinical practices. Other surveys must be achieved to see if our study confirms the general trend concerning the use of these drugs and so as to reassess these prescribing practices.

The study of sleep disorders in the general population involves several methodological issues that need to be defined prior to proceeding to the epidemiological study. The rigor of the methodology is an important issue since it will determine the reliability of the data gathered. This paper describes the methodology used in an epidemiological study performed in the French general population using telephone interviews with the help of Sleep-EVAL, an expert system designed for this purpose. The study aimed to investigate the prevalence of insomnia disorders according to the DSM IV classification and the use of psychotropic medications in the general population. The methodological choices for this study were based on several considerations. First, the sample had to be representative of the French population. Second, the study had to be conducted in the shortest period of time. Third, the interviews had to be conducted with respect to a strict standardization and fourth, the realization costs had to be minimal for a maximum of data collected. The telephone interview procedure was chosen over postal and face-to-face interviews because it offered the possibility of conducting all the interviews from the same site. Supervision was easier. It also offered an absolute control in the application of the selection procedure. To draw the sample, a two-stage procedure was adopted. At the first stage, we pulled a random series of telephone numbers in each Nielsen region with respect to the size of the settlement. At the second stage, during the initial telephone contact, a household member was chosen using the Kish selection procedure. This method is based on the utilization of eight tables of selection that allows for the choice of the person to interview in a given household and keeps the representativeness of the sample. This technique is little used in telephone surveys because of its burden and its intrusive nature: the interviewer must collect the age and gender of all eligible subjects, to classify men from the oldest to youngest and then to classify women. However, it is the most rigorous selection method for epidemiological surveys. To reduce the refusal rates and to alleviate the work of interviewers, the Kish method was implanted in the computer software used for this study. For this study, the exclusion criteria were minimal. Only individuals younger than 15 years of age, those with a speech or hearing impairment and those who were too ill to perform the interview were not included. Subjects who refused to participate, those who hung up without speaking to the interviewer and those who hung up before completing at least half of the interview were tabulated as refusal. The participation rate was calculated by dividing the number of completed interviews by the number of eligible participants (completed interviews, refusals and telephone numbers where the interviewer was unable to determine if the individuals met an exclusion criterion). In this study, the participation rate was 80.8% (5 622 completed interviews/6 966 eligible households). The diagnostic tool used for this study was the Sleep-EVAL system, an expert system designed to conduct epidemiological studies in the general population. It is a level 2, non-monotonic system endowed with a causal reasoning able to provide sleep and mental disorders diagnoses according to the DSM IV classification for this study. Subsequent versions of Sleep-EVAL also included the International Classification of Sleep Disorders. System symbolic representation of the classifications was put in a compiled knowledge base. This knowledge base was read and interpreted by the inference engine at the beginning of the interview. During the interview, this interpretation changed as a function of the answers provided by the interviewee and by deductions made from the analysis of information the system already knew. All interviews began with a standard questionnaire about sociodemographic information and sleep habits. From these first answers, the Sleep-EVAL system emitted a series of diagnostic hypotheses that were confirmed or rejected with supplementary questions. The interview ended once all diagnostic possibilities were exhausted. The validity of the Sleep-EVAL system was demonstrated in different studies performed in sleep disorders clinics. There were several advantages in using such a tool to conduct epidemiological surveys. No special skills from the interviewers nor specific knowledge of sleep and mental disorders were required. All the questions were chosen and formulated by the Sleep-EVAL system. The interviewer had simply to read the questions as they appeared on the monitor screen and enter the interviewee's responses by clicking the appropriate answer or typing it on the keyboard. Missing answers were non-existent because there was no possibility of skipping a question or entering inconsistent answers. It also ensured the uniformity of the interviews. Furthermore, it allowed the exploration of infrequent diagnoses. In summary, the methodology used for this study allowed for the investigation of the sleep pathology of the French population in a short period of time: only three months were necessary to complete the 5 622 interviews. The use of a computerized tool greatly facilitated the training of the interviewers and also their work. Furthermore, it ensured a standardized administration of the interviews and the exploration of a broad range of disorders that could hardly be realized with traditional paper-pencil questionnaires.

During the two last decades, several epidemiological studies have been conducted on bulimia nervosa. According to recent studies, prevalence rates were estimated to be 1%. There are a very few studies on eating behaviour conducted in Arab countries. The aims of the current study were to assess prospectively the prevalence of Bulimia Nervosa and its characteristics in a Moroccan context in a randomly selected and representative sample of students attending six secondary schools in Casablanca. A second group composed of the students of the French secondary school of Casablanca was included in the survey in order to verify the influence of socio-cultural factors. Subjects completed a sociodemographic questionnaire and the Bulimic Investigatory Test of Edinburgh (BITE), a 33-item self-report measure of both the symptoms and severity of bulimia nervosa. A score of 25 or higher suggests a bulimic syndrome; 2,044 subjects returned their questionnaires (participation rate = 75.8%). The group of Moroccan school included 1,887 subjects and the French school 157 subjects. Females were preponderant (59%). The mean age was 18.3 +/- 1.2 years (15-22 years). For the first group, at least one substance was taken by 290 (15.3%) students: 12.7% were addicted to tobacco and 5.7% consumed occasionally alcohol. 16.3% reported a familial history of disturbed eating behaviour. According to the BITE, the overall prevalence of bulimia was 0.8% (1.2% in female and 0.1 in male subjects). The mean age of bulimic subjects was 18.6 +/- 1.7 years (16-24 years). The only male case in our sample was aged 24 years, without personal nor familial psychiatric history, consumed regularly tobacco and alcohol. His BITE symptoms score was 20 and severity score was 17, the highest score in our sample. Analyses of correlates of bulimia nervosa in the Moroccan sample showed that the group of bulimic subjects did not differ from the non bulimic with regard to any sociodemographic characteristics except sex: the female sex was predominant (p < 0.005) with 14 cases, the prevalence of bulimic syndrome was 1.2% among girls. This prevalence was 0.1% among boys. The bulimic subjects have regularly used different compensatory behaviours to control their weight: 6 (33.3%) used appetite suppressants, 3 (16.6%) used diuretics and 4 (22.2%) were engaged in self-induced vomiting. In the group of the french school, the prevalence of bulimia was 1.9% in the whole sample (3.4% among girls and no case among boys). These results are comparable to those reported recently in occidental countries and in an Egyptian study. However, the prevalence of bulimic syndrome in our sample was lower to those reported in countries with similar culture. The elevated prevalence of 10% reported in a tunisian study could be explained by the composition of the sample (medical students, aged 22-28 years) and the cut-off point for the BITE was determined to be 20 without taking into account severity criteria. A South African survey, conducted on 1,435 college students representing South Africa's ethnically and culturally diverse population comparable to our sample regarding the age (17-25 years), found a prevalence of 5% with a cut-off of 25 in the BITE. The majority of epidemiological community-based studies estimated the prevalence of bulimia nervosa to be 1 to 3% according to the diagnostic instruments used (self-report questionnaires versus clinical interviews) and the diagnostic criterias operationalized (DSM III, III-R or IV). The rate of occurrence of this disorder in males usually one-tenth of that in females was more decreased among our sample. However, the prevalence among males was comparable to the data of literature. Except the sex, we did not find other risk factors identified in the previous papers. Although in the bulimic group, we noted a higher rate of substance abuse (26.6% versus 15.2%, p > 0.5), familial histories of disturbed eating behaviour (26.6% versus 16.2%, p > 0.3) and less regular practice of sportive activity (72.2% versus 92.3%, p > 0.1), these differences are not statistically significant. The review of the literature identified at least 5 domains associated to bulimic disorder: parental problems (lower parental contact or separation, disruptive events), vulnerability to obesity, parental psychiatric disorder (alcoholism, depression), sexual or physical abuse and a premorbid psychiatric disorder. With the enormous media coverage and the globalisation of the media, cultural differences are disappearing. In order to estimate the prevalence of bulimia nervosa in the Moroccan population and to identify the risk factors, further epidemiological community-based studies using structured psychiatric interviews are required.

This paper presents the definite data from a French multi-center study (EPIDEP). The aim of EPIDEP was to show the feasibility of validating the spectrum of soft bipolar disorders by practicing clinicians. In this report we focus on data concerning the frequency of BP-II disorder and the key characteristics of BP-II by systematic comparison versus Unipolar depression. EPIDEP involved training 48 french psychiatrists in 15 sites; it is based on a common protocol following the DSM IV criteria (Semi-Structured Interview for Hypomania and Major Depression), and Akiskal (Soft Bipolarity), as well as criteria modified from the work of Angst (Hypomania Checklist), the Ahearn-Carroll Bipolarity Scale, HAM-D and Rosenthal Atypical Depression Scale; Semi-Structured Interview for Affective Temperaments (based on Akiskal-Mallya), self-rated Cyclothymia Scale (Akiskal). Comorbidity and family history (Research Diagnostic Criteria) were also obtained; EPIDEP was globally scheduled in two phases: Phase 1 devoted to recruiting major depressives, and phase 2 involved in more sophisticated assessment of soft bipolarity and administrating related measures. Results are presented on the total of 537 patients included at "visit 1" and 493 assessed for soft bipolarity at "visit 2". The BP-II global rate which was 21.7% at initial evaluation, nearly doubled (39.8%) by systematic evaluation of hypomania. Intergroup comparison versus unipolar depressives showed the following key characteristics of BP-II disorder: 1) distinct clinical presentation at index depressive episode despite uniformity in global intensity of depression (overrepresentation in BP-II of "suicidal thoughts", "guilt feelings", "depersonalisation-derealisation", "hypersomnia" "and weight gain"; and of "psychic anxiety" and "initial insomnia" in UP); 2) different course of illness with younger age of onset of first depression, higher rate of suicidal attempts, recurrency and hospitalisations; 3) more difficulties for recognition of the correct diagnosis; 4) more complex temperamental dysregulations (mixture of cyclothymic, hyperthymic and irritable traits which are highly represented in BP-II group); 5) higher rate in family history of mental disorders, especially bipolar disorders. Finally, EPIDEP data confirmed the diagnostic reliability of self-rating of hypomania and cyclothymia. With a systematic search of hypomania, almost 40% of major depressive episodes seen in psychiatric settings were classified as BP-II, of which only half were recognized by the clinicians at study inclusion. The BP-II validity as a distinct disorder from Unipolars was confirmed. Moreover, EPIDEP emphasized the reliability of self-rating in assessing soft-bipolarity (hypomania and cyclothymia). In total, EPIDEP data indicated that recognition of BP-II is feasible in diverse practice settings and proposed for clinicians some adapted clinical tools for assessing soft bipolarity.

The Addiction Severity Index (ASI) is an instrument that provides, in a 45-minutes semi-structured interview, a multidimensional assessment of substance abuse patients. It was designed in 1980 by A.T. McLellan et al., from Philadelphia PA, in North-America and introduced in France by our group in 1990. Over the past five years we have used it in different substance abuse populations including alcohol users. The goal of this paper is to review the adaptation procedure into French context and to present ASI data from different substance abuse sub-groups: opioïd dependent subjects seeking treatment and former heroïn addicted patients in maintenance treatment. After description of the ASI, presentation of the training procedure for its optimized use and methodological issues, we present for each opiate dependent group acceptability data, results of some of the ASI's 240 items and the severity scores. The Addiction Severity Index provides assessment of problem severity in seven functional areas in which substance abusers are commonly impaired and unable assessment of need for treatment. Objective and subjective patient data are collected in the following seven areas: medical, employment/ support, alcohol, drug use, legal, family/social relationship, and psychiatric. The ASI is both broad in the extent of its evaluation and yet easy to use for appropriately trained interviewers. Use of the ASI over the past five years allows us to underline the following characteristics: in the clinical setting the ASI unable a common descriptive analysis for need and adaptation for treatment of different patients populations; in the research setting the ASI is particularly suited for epidemiological studies of addiction and description, analysis or evaluation research.

Rapid cyclers are defined by the occurrence of four or more mood episodes during the previous 12 months. Clinical, epidemiological and population characteristics of these patients are presented as well as studies that validate them. Hypotheses and theoretical models allowing their analysis are reviewed. The last part of the paper deals with treatments.

Unlabelled: A prospective study on para-suicide has been conducted in all 4 "départements" of a french region, Brittany. This paper analyses the distribution of the sociodemographic data collected in one of the "département" of the region, Ille-et-Vilaine. The comparison between urban and rural areas is presented., Inclusion Criteria: Parasuicide was defined as any autoaggressive act which required to be taken in charge either medically or surgically, independently of the nature and seriousness of the somatic consequences. Patients included in the study were over ten years of age., Analysis: Three types of ratios have been calculated: the crude incidence ratios obtained by dividing the total number of events of parasuicide (including repeated admissions for the same individual) by the number of individuals in the catchment area; the age-specific ratios, for which the denominator consists of all the persons of particular age-group in the area and the standardized ratios, for which the total number of parasuicide events in each "département" has been reported to the french population (general population census 1990) taken as a reference, in order to eliminate the influence of the age structure. Comparisons between the general population and the one of parasuicidal patients in the area, were done using a chi-square test. GEOGRAPHICAL COMPARISON: Crude incidence rates of parasuicides calculated for each "département" in Brittany are compared with recent figures published for other parts of France., Results: 2,040 persons domiciled in the "département" were admitted in one of the emergency wards of Ille-et-Vilaine during the year 1990. The crude incidence rates of parasuicides in Ille-et-Villaine was of 2.4/1,000 for men and 3.8/1,000 for women, 3.7/1,000 for men and 5.4/1,000 for women residing in the town of Rennes. The sex ratio is 1.8 female/male in the "département" and 1.7 in town. DEMOGRAPHIC DATA: In the male group, the incidence ratio was maximum for the 25-34 years old (4.2/1,000). In the female group, there was no significant difference between the ratio for the 15-24 and the 25-34 years old (5.9/1,000). For each age group, the ratios are higher for the women. The specific rates of parasuicide calculated in the breton towns of more than 50,000 inhabitants are twice as high as those calculated for the whole region. MARITAL STATUS: The marital status is correlated to the incidence rates of parasuicide events for both sexes (p < 0.001). The incidence of parasuicide is higher for married, single and/or divorced women than for men. One notes the high impact of divorce on parasuicide events for men (10.1/1/1,000) and women (11.8/1,000). The correlation is significative (p < 0.001). In contrast, rates of parasuicides are higher for widows than for widowers. OCCUPATION: The incidence rate of parasuicide is 8 times higher for unemployed men and twice as high for unemployed women than for those having an occupation (regular or temporary). Unemployment is significatively linked with the occurrence of parasuicides (p < 0.001). PLACE OF ABODE: Comparative rates in towns (calculated for both sexes together) and twice as high as those observed in rural districts. GEOGRAPHICAL COMPARISON: The crude incidence rates in various french "département" vary from 0.8 to 2.4/1,000 for men and from 1.7 to 3.8/1,000 for women. The highest rates are observed for both sexes in Ille-et-Vilaine. In Rennes, the standardized ratios of parasuicide among men are maximum for the 35-44 years old (7.68/1,000) and decrease drastically after the age of 45. Among the women, the ratios are nearly identical for the 25-34 and the 35-44 years old (9.90 and 9.87/1,000)., Conclusion: The survey conducted in 1990 confirms the overall conclusions drawn in previous surveys on parasuicide in France or in other countries. The distribution of the incidence rates of parasuicide among single and unemployed and the percentages of single or unemployed persons is weak but not at random. An increase of the incidence rates among single women and unemployed men is concomitant with higher percentages of single women and unemployed men in the general population. One cannot infer the existence of a cause effect relationship, and these indicators may only be confounding factors.

Until recently, Obsessive-Compulsive Disorder (OCD) was considered rare trouble with rather poor outcome. Currently progress in behavioral psychology, psychopharmacology and methodology of epidemiologic studies multiplying by 50 the traditional prevalence rates, give an impetus to the interest in this pathology. Recent clinical and epidemiologic data in OCD are reported in this paper. Multiple questions are evoked such as the issue of OCD homogeneity, the meaning of comorbidity with other psychological disorders: depression, panic attacks, schizophrenia, Gilles de la Tourette syndrome, the reality of OCD prevalence rate in general and psychiatric populations, the usefulness of classical demarcation between psychosis/neurosis in the treatment of OCD, and finally the search for a genetic diathesis and risk factors implicated in predisposition to OCD. A close relationship between clinical, epidemiologic and genetic approaches seems to be required in order to answer these questions and constitutes a first step prior to carrying on basic and applied research.