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Promoting the cessation of smoking in mental healthcare is a priority of international health organizations as it is the most cost-effective intervention in psychiatry.To explore the representations of psychiatrists on their role in active smoking cessation prevention in severe psychiatric disorders.Psychiatrists and residents in psychiatry were recruited at a national level by professional mailings.One thousand four hundred and sixty participants were included in the study, and only 46% reported actively promoting smoking cessation. In multivariate analyses, participants aged35years were more likely to promote cessation of tobacco smoking, as well as the two thirds who believe that psychiatry is a systemic discipline with complex interactions between brain, body and mind. Almost two thirds of those promoting tobacco cessation reported lacking time to combine psychiatric and physical examination during one session. The psychiatrists who reported not promoting tobacco smoking cessation also reported never dealing with physical health in case of the absence of a general practitioner and thinking that physical examination may have a negative impact on the therapeutic relationship. Almost all (96%) reported promoting the need for a general practitioner for their patients. We found no significant difference between the public and private sectors (P0.05).Young psychiatrists are more prone than their elders to promote smoking cessation but report lacking time to include it in their daily practice. Promotion of tobacco smoking cessation should be included in the components for quality evaluation for mental health services and specific sessions dedicated to this intervention.

Resume Les patients atteints de schizophrenie representent une population vulnerable qui a ete sous-etudiee dans le cadre de la recherche COVID-19. Nous avons cherche a etablir si les resultats et les soins de sante differaient entre les patients atteints de schizophrenie et les patients sans diagnostic de maladie mentale. Nous avons mene une etude basee sur la population de tous les patients presentant des symptomes respiratoires et une infection a COVID-19 identifies qui ont ete hospitalises en France entre fevrier et juin 2020. Au total, 50 750 patients ont ete inclus, dont 823 etaient des patients avec schizophrenie (1,6 %). Ces derniers ont connu une augmentation de la mortalite hospitaliere (25,6 % contre 21,7 % pour les autres patients) et une diminution du taux d’admission en unite de soins intensifs-reanimation (23,7 % contre 28,4 %) par rapport aux temoins. Les patients schizophrenes âges de 65 a 80 ans presentaient un risque de mortalite significativement plus eleve que les temoins du meme âge (+7,89 %) alors qu’ils ont ete moins admis en USI que les temoins du meme âge (−15,44 %). Cette etude montre l’existence de disparites en matiere de sante et d’acces aux soins entre les patients schizophrenes et les patients sans diagnostic de maladie mentale. Ces disparites different en fonction de l’âge et du profil clinique des patients, ce qui suggere l’importance d’une gestion clinique personnalisee du COVID-19 et de strategies de soins de sante avant, pendant et apres l’hospitalisation pour reduire les disparites de sante dans cette population vulnerable. Les patients schizophrenes âges de 65 a 80 ans etaient plus souvent envoyes par les hopitaux ou les institutions que les patients sans diagnostic de maladie mentale grave, ce qui peut expliquer les mauvais resultats de sante des patients schizophrenes. Une etude francaise a rapporte que la plupart des patients psychiatriques hospitalises avec un diagnostic COVID-19 etaient gardes dans des services psychiatriques specialises et non dans des hopitaux generaux. La division entre medecine physique et psychiatrique entraine une confusion quant au secteur du service de sante (c’est-a-dire les niveaux de soins primaires, de sante mentale ou de soins aigus) qui devrait assumer la responsabilite de la gestion des patients ayant des besoins de sante complexes. Nous manquons de donnees nationales sur le taux de patients âges schizophrenes qui sont institutionnalises, mais nous pouvons raisonnablement supposer que l’institutionnalisation est un facteur de risque d’infection grave par COVID-19 chez les patients âges avec schizophrenie. Nos resultats soutiennent une strategie de detection systematique chez les patients avec schizophrenie institutionnalises et d’intervention precoce dans cette population. Cela a deja ete fait dans un refuge pour sans-abri a Boston ou 36 % des residents ont ete testes positifs. Le taux d’admission en reanimation etait plus faible chez les patients schizophrenes que chez les patients sans diagnostic de maladie mentale grave, ce qui illustre parfaitement le debat entre les arguments fondes sur l’utilite et ceux fondes sur l’equite. Les patients schizophrenes presentaient l’un des plus mauvais indicateurs de pronostic justifiant le triage en reanimation. Cependant, ce triage base uniquement sur le pronostic exacerbe les inegalites existantes en matiere de sante, laissant les patients defavorises dans une situation plus difficile.

Resume Objectifs L’objectif etait de determiner la prevalence de l’exposition des jeunes medecins aux violences professionnelles hospitalieres. Les objectifs secondaires etaient de determiner leurs caracteristiques, leurs consequences rapportees ainsi que les differences entre etudiants et internes/jeunes chefs. Methodes L’etude MESSIAEN est une enquete epidemiologique observationnelle transversale nationale par questionnaire anonyme en ligne s’adressant aux etudiants et jeunes medecins des 37 facultes de medecine francaises. Resultats Au total, 2003 etudiants et jeunes medecins ont participe a l’enquete. Parmi eux, 93,7 % ont rapporte avoir ete exposes au moins une fois a des violences hospitalieres et 41,7 % a du harcelement moral selon la definition legale. Pres de 80 % des internes et jeunes chefs declarent travailler plus de 48 heures par semaine. Les victimes de violence sont autant des hommes que des femmes. Les internes/jeunes chefs rapportent plus souvent des consequences de ces violences sur leur sante mentale, leurs addictions, leur vie personnelle et professionnelle que les etudiants. La majorite des victimes en ont parle mais dans moins de 10 % des cas a une instance responsable ou representative qui aurait pu agir. Quarante-deux pour cent des etudiants pensent que cela fait partie des etudes medicales et qu’il faut en passer par-la. La quasi-totalite rapporte que les actes de violence se sont poursuivis apres les evenements. Limites Ces resultats doivent toutefois etre interpretes avec precaution car des violences subjectives et pouvant etre considerees comme mineures ont ete prises en compte dans un souci d’exhaustivite. L’echantillon (plus de 2000 participants) est faible au vu du nombre total de jeunes medecins, mais est comparable a une etude anterieure menue en 2016–2017, ce qui suggere un taux de participation constant et non biaise. Conclusion Il est necessaire de developper des programmes d’information et de prevention sur les violences professionnelles hospitalieres et d’evaluer le respect du temps de travail et du repos de securite chez les jeunes medecins.

The professional risk factors for depression and anxiety are underexplored in young physicians. While there has been increasing research on the mental health and well-being of lesbian, gay and bisexual patients, few studies have examined the mental health and well-being of lesbian, gay and bisexual young physicians.The objective of the present study was to determine the prevalence of Sexual Orientation-Based Discrimination (SOBD) in French young physicians and if SOBD was associated with increased anxiety and depression in this population.This national study is a cross-sectional observational epidemiological national study. The participants were recruited between April 1On the 2003 participants, 148 (7%) reported SOBD exposure, 647 (32%) current anxiety disorders and 174 (9%) a current major depressive disorder according to their HAD score. SOBD was almost twice more frequently reported in participants with anxiety disorder and major depression (respectively 10%,vs 6% and 12% vs. 7%, p0.05). In the first model of multivariate analyses, current anxiety disorder was significantly associated with being woman (adjusted odds ratio aOR=1.688, 95%CI 1.350-2.110, p0.001) and SOBD (aOR=1.729, 95%CI 1.226-2.440, p=0.002). In the second model of multivariate analyses, current major depression was significantly associated with only SOBD (aOR=1.748, 95%CI 1.057-2.888, p=0.029).SOBD has been associated with increased rates of anxiety disorder and major depression in young physicians and should be targeted in mental health prevention programs.

Background Burnout syndrome is the consequence of chronic work-related stress exposure and is 2–3 times higher than in physicians than in other professions. Many studies exploring burnout in French physicians have been published with inconsistent data regarding its prevalence and associated factors. Objective To assess the prevalence of burnout and associated factors in French physicians in a systematic review and meta-analysis. Material and methods Studies assessing the prevalence of French physician's burnout and its three dimensions emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA) were selected in the following databases from 2000 to April 2017: MEDLINE, BIOSIS WEB OF SCIENCE, PASCAL ET FRANCIS, SCIENCES DIRECT, PSYCHinfo, and BDSP. Burnout was defined by one abnormal score in one or more of the 3 dimensions of the MBI scale (EE, DP or PA). Severe burnout was defined by the association of high scores of EE and DP, and low score of PA. High EE was defined by an EE score ≥27. High DP was defined by a score ≥10. Low PA was defined by a score ≤33. Results A total of 37 studies and 15,183 French physicians were included in the present meta-analysis. The random effects pooled prevalence estimate was 49% (95% CI 45%–53%, P Conclusion Burnout is highly prevalent in French physicians. Some recommendations may be suggested to reduce this rate, including reducing the number or duration of night shifts to increase personal accomplishment and targeting emergency physicians and junior residents in priority. Other specialties should be explored in future studies.

The aim of this study was to investigate the factors associated with violent behavior in a large multicenter sample of Homeless Schizophrenia (SZ) and Bipolar Disorder (BD) (HSB) subjects.This multicenter study was conducted in 4 French cities: Lille, Marseille, Paris and Toulouse. Violent behavior was defined by at least one episode of verbal or physical violence in the last 6 months.Overall, 675 HSB patients, mean aged 38 years and 82.5% men were included, 458 SZ (68.4%) and 212 BD (31.6%). During the 6 months before evaluation, 213 (34.3%) committed at least one physical or verbal violence. In multivariate analysis, violence has been associated with younger age (aOR = 0.96[0.94-0.99], p = .001), number of nights in the street (aOR = 1.01[1.01-1.01]), BD diagnosis (aOR = 1.63[1.01-2.65], p = .04), higher current illness severity (CGI score) (aOR = 1.32[1.07-1.64], p = .01), higher rates of current manic episode (aOR = 2.24[1.32-3.81], p = .002), current alcohol use disorder (aOR = 2.05 [1.33-3.15], p = .001), antisocial personality disorder (aOR = 2.51[1.55-4.07], p .001) and with antidepressant consumption (aOR = 2.01[1.01-4.04], p = .04). No specific antipsychotic or mood stabilizer has been associated with decreased rates of violent behavior, however clozapine, lithium and carbamazepine remained poorly prescribed.In case of violent behavior in HSB subjects, clinicians should focus in priority on the treatment of mania, antidepressant iatrogenic effect and alcohol use disorder by pharmacological and non-pharmacological treatments. Clozapine, lithium and carbamazepine should be chosen as the treatments of reference in this population but may be hard to manage in some cases. The current clinical trial number is NCT01570712.

Objective The aim of this study was to investigate the prevalence and associated factors of physical pain in a large multicenter sample of Homeless Schizophrenia and Bipolar (HSB) patients. Methods This multicenter study was conducted in 4 French cities: Lille, Marseille, Paris and Toulouse. Pain was measured by EQ5D-3 L questionnaire with no specified period or location. In addition, sociodemographic information, duration of homelessness, illness severity using the Modified Colorado Symptom Index (MCSI) and drug information were collected. Results Overall, 655 HSB patients, mean age 38.8 years and 82.6% men were included, 448 (68.9%) were diagnosed with schizophrenia and 202 (31.1%) with bipolar disorder. More than half patients (N = 337, 51.5%) reported moderate to extreme physical pain while only 2.7% were administered analgesic drugs. In the multivariate analysis, self-reported moderate to extreme physical pain was associated with antidepressant consumption (adjusted odd ratio aOR = 2.56[1.25;5.26], p = .01), female gender (aOR = 1.72[1.03;2.86], p = .04), bipolar disorders (vs. schizophrenia) (aOR = 1.81[1.19;2.77], p = .006), older age (aOR = 1.03 [1.01;1.05], p = .01), with higher MCSI psychotic score (a0R = 1.04[1.01;1.06],p = .002), independently of the number of days in the street during the last 180 days, MCSI depression score, alcohol and substance use disorders, psychotropic drugs and analgesic treatments. No association with education level, antipsychotics, mood stabilizers, anxiolytic, hypnotic or medication adherence was found (all p > .05). Conclusion Physical pain was highly reported in homeless patients with severe mental illness with insufficient care. Physical pain should be systematically explored and treated in this population. Bipolar disorders, antidepressant consumption and female gender may be targeted in priority. Age and psychotic symptomatology were found to influence self-reported pain in a marginal way.

Septic shock is responsible for high morbidity and mortality rates and its incidence is increasing worldwide. Its evolution over the last few years and the leverage points for action to improve associated outcomes remain unclear. Our aim was to determine trends in the incidence and mortality of septic shock and associated risk factors in intensive care unit (ICU) patients and readmission rates after hospital discharge.We performed a retrospective cohort study using data from the French national hospitalisation database, including adult patients with septic shock from 2014 to 2018. Primary outcomes were the incidence of septic shock and the hospital mortality rate at 30, 90 and 365 days. Secondary outcomes were all-cause hospital readmission.Septic shock was identified in 187,587 ICU stays. The age- and sex-adjusted incidence rate of septic shock per 100 ICU admissions increased from 6.5% to 6.8% (P .001); age- and sex-adjusted hospital mortality rates decreased from 47.3% to 44.5% (P .001). The hospital readmission rate at 365 days was 65.0%. Older age, higher Charlson score, occurrence of organ failure and previous hospitalisation were associated with increased risk of mortality. Identification of a specific microorganism and a time between hospitalisation and ICU admission of less than one day were associated with a decreased risk of death.Our study revealed an increase in the incidence of septic shock and a decrease in mortality rates. Pathogen identification and rapid admission to the ICU were associated with better outcomes. The rate of hospital readmission increased, raising questions about the discharge criteria for these patients.

Resume Le microbiote intestinal est considere de plus en plus comme un partenaire symbiotique contribuant au bon etat de sante general de l’organisme. Les approches metagenomiques, en pleine expansion, permettent de mieux en mieux apprehender la complexite de l’ecosysteme intestinal et de son impact sur le developpement et le fonctionnement du systeme nerveux central de son hote. Le but de la presente revue est de synthetiser les donnees actuelles, d’une part, sur l’association entre la dysbiose du microbiote intestinal, et le declenchement ou l’entretien de troubles psychiatriques.

This study was aimed to explore clinical differences between women and men with schizophrenia (SZ) in Latin-America. It was conducted in public mental health centers in Bolivia, Peru and Chile. Two hundred forty-seven SZ patients participated in the study, 83 (33.6%) were women and 115 (46.6%) were Aymara. Compared to men, SZ women had slightly lower negative symptoms, reported slightly less social cognitive impairments, lower Family Relationships scores and higher Sentimental Life scores, independently of marital status, illness duration, age at illness onset and type of mental health treatment. All these differences have been replicated in the Aymara subgroup except for Sentimental Life scores. Aymara SZ women reported to be significantly less adherent into treatment compared to Aymara men. SZ women were found to have a better clinical profile and higher sentimental life scores than men. However, while SZ women reported more impaired Family Relationships compared to men, they were found to receive less psychotherapy in addition to pharmacological treatment. SZ Aymara women were also identified as a specific subgroup that may be targeted for increased observance strategies.

Resume Le microbiote intestinal est un champ therapeutique en plein essor depuis dix ans, de par l’avancee des progres technologiques et les decouvertes de la recherche fondamentale et clinique. Dans cet article, nous retracons un bref historique des decouvertes therapeutiques dans les troubles mentaux severes ainsi que des arguments actuels pour developper les therapies orientees sur le microbiote dans la depression majeure, le trouble psychiatrique le plus frequent et avec l’impact le plus lourd sur la sante des populations.

Background Existing studies evaluating the association between schizophrenia and complications associated with pregnancy, delivery and neonatal outcomes are based on data prior to 2014 and have reported heterogeneous results. The objective of our study was to determine whether pregnant women with schizophrenia were at increased risk of pregnancy, delivery and neonatal complications compared with women without severe mental disorders. Methods We performed a population-based cohort study of all singleton deliveries in France between Jan. 1, 2015, and Dec. 31, 2019. We divided this population into cases (i.e., women with schizophrenia) and controls (i.e., women without a diagnosis of severe mental disorder). Cases and controls were matched (1:4) inside the same hospital and the same year by age, social deprivation, parity, smoking, alcohol and substance addictions, malnutrition, obesity, and comorbidities. Univariate and multivariate models with odds ratios and 95% confidence intervals (ORs [95% CIs]) were used to estimate the association between schizophrenia and 24 pregnancy, delivery and neonatal outcomes. Findings Over 5 years, 3,667,461 singleton deliveries were identified, of which 3,108 occurred in women with schizophrenia. Compared to controls, women with schizophrenia were found to be older; have more frequent smoking, alcohol and substance addictions; suffer from obesity, diabetes and chronic obstructive pulmonary disease; and often be hospitalized in tertiary maternity hospitals. Compared to matched controls, women with schizophrenia had more pregnancy complications (adjusted OR=1.41[95%CI 1.31-1.51]) (i.e., gestational diabetes, gestational hypertension, genito-urinary infection, intrauterine growth retardation and threatened preterm labour). They had more delivery complications (aOR=1.18[95%CI 1.09 1.29]) with more still births/medical abortions (aOR=2.17[95%CI 1.62-2.90]) and caesarean sections (aOR=1.15[95%CI 1.05-1.25]). Newborns of women with schizophrenia had more neonatal complications (aOR=1.38[95%CI 1.27-1.50]) with more born preterm (aOR=1.64[95%CI1.42 -1.90]), small for gestational age (aOR=1.34[95%CI 1.19-1.50]) and low birth weight (aOR=1.75[95%CI 1.53-2.00]). Interpretation Our results highlight the importance of health disparities between pregnant women with and without schizophrenia, as well as in their newborns. Our study calls for health policy interventions during and before pregnancy, including proportionate intensified care to the level of needs, effective case management and preventive and social determinant approaches. Funding No funding.

International audience; The aim of our study was to compare the performance of three different instruments measuring clinical and cognitive dimensions of insight. Data on 182 outpatients with schizophrenia and one-year follow-up assessments was drawn from the FACE-SZ cohort. Awareness of clinical state (« clinical insight ») was measured using both a clinician-rated measure (the Scale to assess Unawareness of Mental Disorder (SUMD)), and a self-report measure (the Birchwood Insight Scale (BIS). Cognitive insight was measured using a self-report measure (the Beck Cognitive Insight Scale (BCIS)). For each scale, change in insight was examined at the follow-up. Correlations between SUMD and BIS subscales measuring same dimensions were significant. BIS-BCIS correlations were weak for all combinations except between BIS illness dimension and BCIS composite score. At the follow-up, BIS and SUMD awareness of treatment need improved whereas illness and symptom awareness increased only on the SUMD. Conversely, cognitive insight composite scores decreased. Despite relatively good overall agreement between the two clinical insight instruments, considerable variability for similar insight dimensions measured by different instruments was found. Agreement between cognitive and clinical insight is moderate. Our study strengthens the argument that insight is harder to operationalize than other symptoms and may explain why it is so seldom explicitly targeted in schizophrenia treatment.

Resume L’analyse des donnees de vie reelle a partir des systemes d’information hospitaliers pourrait permettre de trancher sur l’efficacite et la securite des traitements prescrits dans le Covid-19 en evitant les ecueils des etudes preliminaires et des essais cliniques randomises. Les differentes therapeutiques testees dans les essais cliniques en cours sont deja largement prescrites aux patients par les medecins dans les hopitaux, et peuvent donc faire l’objet d’analyses immediates selon des standards methodologiques valides.

While many studies have looked into the consequences of climate change on physical health, its impact on mental health is still relatively unknown. Climate-related disasters lead to psychotrauma in populations, as well as sleeping disorders, anxiety and depression. Rising temperatures increase the level of agression and violence. Climate migration also leads to psychological disorders in migrants. Mental health professionals must be trained in these pathologies which are set to become more common over the decades to come.

Mental, neurological and substance-use disorders (MNS) constitute 13% of the global disease burden, surpassing both cardiovascular diseases and cancers. Three types of studies may yield insightful data to guide the improvement of clinical care of severe mental illnesses. First, cohort studies are needed to analyze the illness trajectories of severe mental illnesses. The FACE-SZ cohort has been created in 2010 and has yielded important data on the trajectory of schizophrenia. More specifically, the staging model conceptualized in psychiatry 25 years ago has been confirmed and developed. Pierre-Michel Llorca will present the cohort and major recent findings including some modifiable factors of poor prognosis and relapse prevention that have been identified and may change our vision of schizophrenia as an irreversible neuroprogressive illness. Second, French national databases are now available to analyze epidemiologic events at a national level. Laurent Boyer will present recent findings on the French hospital national database (PMSI) on the somatic care of SZ subjects (with a focus on trauma, perinatal and end-of-life cancer hospitalizations). Last but not least, systematic reviews and meta-analyses have become indispensable methods for the evaluation of medical treatments. Stefan Leucht will present the results of recent meta-analyses about the treatment of schizophrenia. These will comprise a network meta-analysis of antipsychotic drugs compared with each other and new findings on relapse prevention. Methodological problems of current trials will also be addressed.

While forecasts predict an increase in the prevalence of mental health disorders in the worldwide general population, the response rate to classical psychiatric treatment remains unsatisfactory. Resistance to psychotropic drugs can be due to clinical, pharmacological, pharmacokinetic, and pharmacodynamic factors. Among these factors, recent animal findings suggest that microbiota may have an underestimated influence on its host's behavior and on drug metabolism that may explain ineffectiveness or increased side effects of psychiatric medications such as weight gain. The following issues were identified in the present review: (i) microbiota dysbiosis and putative consequences on central nervous system functioning; (ii) chronic microbiota dysbiosis-associated illnesses in humans; (iii) microbiota-oriented treatments and their potential therapeutic applications in psychiatry.

Resume Introduction La therapie d’acceptation et d’engagement (ACT) fait partie de la troisieme vague des therapies cognitivo-comportementales. Il s’agit d’un modele integratif, qui consiste a aider le patient a acquerir une flexibilite psychologique en vue de parvenir a l’acceptation des evenements mentaux ou sensations physiques qu’il ne peut changer durablement, pour reinvestir l’energie de la lutte dans des actions en directions de ce qui est important pour lui. Objectifs de l’etude (i) Presenter les concepts de base de l’ACT et (ii) proposer une revue systematique de la litterature sur les domaines d’efficacite de cette psychotherapie. Methodes (i) Les principaux concepts de l’ACT sont presentes a partir des livres de reference de Monestes et Villatte (2011), Schoendorff (2011), et Harris (2012) (ii) realisation d’une revue systematique de la litterature, selon les criteres PRISMA, sur les domaines d’efficacite de l’ACT. Le paradigme de recherche etait « acceptance and commitment therapy AND randomized controlled trial ». Les bases de recherche MEDLINE, Cochrane et Web of science ont ete explorees. Resultats (i) Cette approche est organisee en six points (defusion, acceptation, contact avec l’instant present, valeurs, action, soi comme contexte) que le therapeute applique en privilegiant une approche experientielle ; (ii) l’effet benefique de l’ACT se retrouve dans une importante variete de troubles psychiatriques de l’axe I (troubles psychotiques, troubles de l’humeur, troubles addictifs, troubles anxieux, troubles du comportement alimentaire) ainsi que dans le trouble de personnalite borderline. Il a egalement ete demontre dans d’autres domaines de la medecine (prise en charge de la douleur chronique, epilepsie, gestion du diabete, gestion du stress au travail, arret du tabac, gestion des acouphenes et souffrance psychologique des patients atteints de sclerose en plaque). Discussion La perte de flexibilite psychologique etant le socle commun de la souffrance engendree par les troubles psychiatriques et le vecu douloureux des affections medicales chroniques, des etudes supplementaires seront necessaires pour explorer les pleines potentialites d’application de l’ACT.

Resume La specialisation de la medecine est un processus de differenciation des disciplines medicales engage depuis le xviii e siecle. La psychiatrie est sans nul doute, parmi toutes les autres specialites, celle dans laquelle les enjeux pour la definition de la discipline et de ses sur-specialites generent le plus de passions. Le processus de specialisation de la psychiatrie voit en effet s’opposer, depuis la loi de 1838 qui met en place dans chaque departement un asile d’alienes, deux conceptions de la psychiatrie : celle de la « medecine asilaire » et celle de la « clinique des maladies nerveuses ». Cette dichotomie entrave une organisation de soins efficiente et de qualite en psychiatrie. Une nouvelle forme de sur-specialisation fondee sur les outils pragmatiques developpes par la sante publique et la psychologie de la sante pourrait permettre de depasser ce clivage. Elle impliquerait, d’une part, de savoir identifier epidemiologiquement des groupes de patients definis par leurs besoins de sante specifiques afin d’organiser une offre de soins adaptee dans un systeme donne, d’autre part, d’eviter toute caricature distinguant la psychiatrie des autres specialites medicales au nom d’une specificite supposee de l’homme malade en psychiatrie.

Resume Depuis 25 ans, des travaux sont en cours en France pour la mise en œuvre d’une alternative au mode de financement de la psychiatrie publique qui repose encore a ce jour sur des dotations annuelles de financement (DAF). En l’absence d’avancement sur les travaux relatifs au financement de la psychiatrie, certaines agences regionales de sante se sont engagees dans des travaux relatifs a la reallocation des DAF entre etablissements de psychiatrie (perequation financiere). Nous proposons ici une reflexion avec des suggestions d’evolution sur la methode proposee par l’Agence regionale de sante Provence Alpes Cote d’Azur. Sans remettre en cause la necessite d’une reallocation de moyens entre les etablissements psychiatriques, la methode de perequation proposee ici doit encore evoluer pour etre appliquee de facon legitime et pertinente. Il existe une forme d’urgence a realiser une perequation financiere des moyens de la psychiatrie en France, nul ne le conteste. Notre propos n’est pas d’imposer des detours theoriques et pratiques qui seraient autant de mesures dilatoires face a cette urgence, il appelle une reflexion collective et surtout la definition de modalites d’evaluation des modeles retenus et de jalons au cours du temps pour cette evaluation. C’est a ces conditions que nous pourrons garantir la qualite de la psychiatrie francaise et l’equite dans l’acces aux soins psychiatriques.

Resume De nouveaux defis se presentent a la medecine et en particulier a la psychiatrie. Le role du psychiatre pourrait se transformer a l’avenir en une gestion d’equipes de sante mentale (medecins generalistes, infirmiers, psychologues, educateurs specialises…). Interviennent ici les concepts de charisme et de leadership. Le charisme est « une qualite qui permet a son possesseur d’exercer un ascendant, une autorite sur un groupe ». Le leadership designe, « la fonction, la position de chef, et par extension, une position dominante ». Objectif de l’article Proposer quelques pistes de reflexion sur le charisme et le leadership, les moyens de les developper dans trois situations de la pratique psychiatrique au quotidien : la communication duale (entre soignants ou avec le patient), la communication orale lors d’un colloque et la gestion d’une equipe de sante mentale. Methode Les bases Medline et Web of science ont ete explorees selon les criteres PRISMA sans limite de date de publication. Le paradigme de recherche etait ([psychiatrist OR physician] AND mental health AND [leadership OR charisma]). Resultats Trente-quatre articles ont ete inclus dans l’analyse qualitative. Le chef doit d’abord s’interroger sur sa vision de l’avenir, pour la transmettre avec passion a son equipe de sante mentale. Le leadership ne depend pas de la position hierarchique et des responsabilites administratives. Le clinicien travaillera sur les moyens de developper son charisme, par ses interactions avec ses pairs et son equipe, par l’attention apportee a son apparence et a son lieu de travail, par le renforcement positif. Il apprendra a gerer et harmoniser les differents types de personnalites au sein de son equipe en prenant particulierement garde aux attitudes passive-agressives. Il comptera parmi ses qualites la ponctualite, la politesse, le sourire, l’auto-derision, la regulation de ses propres emotions. Discussion et conclusion Le charisme semble etre une dimension indispensable du chef qui va pouvoir mettre en place efficacement son leadership et la gestion de son equipe. Bien au-dela de la psychiatrie, ces reflexions nous semblent utiles a l’ensemble de la medecine.

Resume Introduction Quarante a soixante pour cent des patients presentant un trouble obsessionnel compulsif (TOC) sont resistants a un traitement par inhibiteur selectif de la recapture de la serotonine (ISRS) bien conduit pendant huit semaines. Les donnees de la litterature concernant l’efficacite de l’adjonction d’antipsychotiques dans cette indication sont controversees. Objectifs de l’etude Effectuer une synthese des mecanismes neurobiologiques a l’œuvre dans le TOC afin d’apprehender le mecanisme d’action des traitements pharmacologiques utilises et proposer une revue systematique de la litterature sur l’efficacite des differents antipsychotiques selon leurs profils pharmacologiques, seuls ou en association avec les ISRS. Methode Nous avons realise une revue systematique de la litterature selon les criteres PRISMA avec le paradigme de recherche « obsessive compulsive disorder AND antipsychotic agents ». Les bases de recherche MEDLINE , Cochrane et Web of science ont ete explorees. Resultats Le TOC pourrait resulter d’une hyperactivite dopaminergique striatale, modulee chez certains patients par une hypoactivite serotoninergique sous-jacente, cette hypothese depasse le modele serotoninergique classique. La plupart des etudes rapportent une efficacite des antipsychotiques de premiere generation (haloperidol et amisulpride) et de certains antipsychotiques de deuxieme generation (risperidone, olanzapine, aripiprazole, quetiapine) en association a un ISRS dans le traitement des TOC resistants. La recrudescence ou l’apparition de TOC chez des patients souffrant de schizophrenie ont ete decrites lors d’un relais d’antipsychotique de premiere generation par olanzapine, risperidone, aripiprazole ou clozapine dans des rapports de cas, mais pas pour l’amisulpride et la quetiapine. Discussion Nous proposons en perspective plusieurs schemas d’etudes permettant d’etablir l’efficacite des traitements antipsychotiques dans le TOC.

Resume Soixante-quinze pour cent des patients presentant une phobie du sang-injection-accident (PSIA) presentent des pertes de connaissance lors de l’exposition aux stimuli phobogenes. Cette specificite aurait des implications medicales importantes (pathologies somatiques non diagnostiquees et non traitees) responsables d’un cout individuel et social. Ses mecanismes psychophysiologiques sont peu connus et les donnees de la litterature concernant les therapeutiques n’ont pas fait l’objet d’une revue a notre connaissance. Synthese des mecanismes psychophysiologiques a l’œuvre dans la PSIA : la specificite psychophysiologique de la PSIA est la survenue d’une syncope vasovagale biphasique. La vision du stimulus phobogene est suivie de l’apparition d’une emotion de peur et de l’activation du systeme sympathique. L’emotion de degout serait secondairement associee a la stimulation du systeme parasympathique qui serait responsable de la perte de connaissance. Une dysfonction circulatoire predisposante au malaise vasovagal serait presente chez ces patients, meme en l’absence de stimulus phobogene. Plusieurs etudes suggerent que les individus presentant une PSIA ont un plus haut niveau de sensibilite au degout. Efficacite des differentes therapeutiques evaluees dans la PSIA : les techniques de psychotherapie comportementale telles que l’exposition seule, la relaxation durant l’exposition, la tension durant l’exposition, et la tension seule, ont demontre leur efficacite, sans difference significative entre les techniques. L’exposition repetee prealable au degout ne permettrait pas d’optimiser l’efficacite de l’exposition. Nous avons montre les specificites psychophysiologiques de la PSIA. Leur comprehension est necessaire pour developper des techniques specifiques visant a ameliorer le pronostic de ce trouble.

The motivational interview aims to help patients to resolve their ambivalence regarding problematic behaviors and to guide them into change. It differs from other therapeutic approaches mainly through the attitude of the therapist. In motivational interviewing, the therapist defends the statu quo. By reactance, the patient defends the change and enhance her/his motivation. This article provides a summary of the other concepts of motivational interviewing and its applications in the psychiatric daily practice.

INTRODUCTION: Nanomedicine is defined as the area using nanotechnology's concepts for the benefit of human beings, their health and well being. The field of nanotechnology opened new unsuspected fields of research a few years ago. AIM OF THE STUDY: To provide an overview of nanotechnology application areas that could affect care for psychiatric illnesses. METHODS: We conducted a systematic review using the PRISMA criteria (preferred reporting items for systematic reviews and meta-analysis). Inclusion criteria were specified in advance: all studies describing the development of nanotechnology in psychiatry. The research paradigm was: "(nanotechnology OR nanoparticles OR nanomedicine) AND (central nervous system)" Articles were identified in three research bases, Medline (1966-present), Web of Science (1975-present) and Cochrane (all articles). The last search was carried out on April 2, 2012. Seventy-six items were included in this qualitative review. RESULTS: The main applications of nanotechnology in psychiatry are (i) pharmacology. There are two main difficulties in neuropharmacology. Drugs have to pass the blood brain barrier and then to be internalized by targeted cells. Nanoparticles could increase drugs' bioavailability and pharmacokinetics, especially improving safety and efficacy of psychotropic drugs. Liposomes, nanosomes, nanoparticle polymers, nanobubbles are some examples of this targeted drug delivery. Nanotechnologies could also add new pharmacological properties, like nanohells and dendrimers; (ii) living analysis. Nanotechnology provides technical assistance to in vivo imaging or metabolome analysis; (iii) central nervous system modeling. Research teams have modelized inorganic synapses and mimicked synaptic behavior, essential for further creation of artificial neural systems. Some nanoparticle assemblies present the same small world and free-scale network architecture as cortical neural networks. Nanotechnologies and quantum physics could be used to create models of artificial intelligence and mental illnesses. DISCUSSION: Even if nanotechnologies are promising, their safety is still tricky and this must be kept in mind. CONCLUSION: We are not about to see a concrete application of nanomedicine in daily psychiatric practice. However, it seems essential that psychiatrists do not forsake this area of research the perspectives of which could be decisive in the field of mental illness.

Resume Alors que les autorites publiques francaises pointent la necessite d’une prescription rationnelle des medicaments, et en particulier des psychotropes, peu de donnees ont ete synthetisees a l’usage du clinicien sur la prescription des antidepresseurs de seconde generation (SGA). Objectif de l’etude Proposer pour chaque SGA une description de l’efficacite et de la tolerance/acceptabilite selon les donnees des meta-analyses les plus recentes. Methode Nous avons recherche pour chaque SGA la meta-analyse de meilleure qualite et la plus recente dans les bases Medline (1966–present), Web of Science (1975–present) et Cochrane (toutes les revues). Resultats Le traitement de premiere intention de l’episode depressif majeur, en incluant le rapport efficacite–tolerance et le prix (generique), serait actuellement la sertraline (50 mg/j). Elle serait cependant plus mal toleree que d’autres ISRS sur le plan digestif (par l’action serotoninergique), ce qui appellerait de la prudence dans l’augmentation des posologies. La fluoxetine semble interessante dans le traitement des symptomes negatifs de la schizophrenie (20 mg/j) et de la boulimie (60 mg/j). La fluvoxamine semble interessante en cas d’effets secondaires sexuels indesirables lors d’un traitement par un autre ISRS, ainsi que dans le traitement des depressions anxieuses (son affinite pour les recepteurs sigma-1 pourrait lui conferer une action specifique), des troubles anxieux et des depressions psychotiques. La mirtazapine serait un traitement interessant lorsque le clinicien souhaite un amendement plus rapide des symptomes.

Resume La litterature sur le traitement de la phobie specifique de l’enfant est tres rare a ce jour, alors qu’il s’agit du trouble anxieux le plus frequent dans cette population, avec un retentissement qui peut parfois s’averer invalidant. Ce trouble semble apparaitre en moyenne vers l’âge de neuf ans et demi, et a une duree moyenne de 20 ans ; il est deux fois plus frequent chez les femmes. La phobie specifique est un defaut du processus d’extinction de la peur, se traduisant par une hyperactivation chronique de l’amygdale droite. Elle est divisee cliniquement en trois sous-types : phobie animale, phobie du sang et phobie situationnelle-environnementale. L’origine de la phobie, de meme que les renforcateurs, ne sont pas toujours trouves dans l’histoire et peuvent etre hautement biaises par la memorisation. Les phobies specifiques repondent particulierement bien a l’exposition in vivo, mais les traitements sont associes a un fort taux de perdus de vue et une mauvaise acceptation du traitement. La dose d’exposition, l’implication du therapeute, le contexte, l’espacement des expositions, les facteurs attentionnels pendant l’exposition, l’aide a l’induction de reponse, le feedback physiologique pendant l’exposition et l’usage d’aides secures peuvent influencer grandement l’efficacite et l’acceptabilite du traitement. Les phobies specifiques sont tres souvent comorbides, particulierement avec les autres troubles anxieux et phobiques, mais aussi avec les troubles de l’humeur et du comportement. Contrairement a une idee recue, la presence d’une comorbidite ne semble pas predictive de l’echec de la therapie. L’un des traitements les plus efficaces et les mieux evalues a ce jour se nomme One Session Treatment (OST). Il combine une exposition graduee et intensive du patient, du « modeling », de la psychoeducation, des defis cognitifs, un apprentissage des habiletes et du renforcement positif, le tout maximise sur une seance de trois heures. Aucun traitement medicamenteux — seul ou en adjonction — n’a prouve son efficacite dans le traitement de ce trouble a ce jour.

INTRODUCTION: Toxoplasma gondii is the most common protozoan parasite in developed nations. Up to 43% of the French population may be infected, depending on eating habits and exposure to cats, and almost one third of the world human's population may be infected. Two types of infection have been described: a congenital form and an acquired form. Although the medical profession treats these latent cases as asymptomatic and clinically unimportant, results of animal studies and recent studies of personality profiles, behavior, and psychomotor performance have led to reconsider this assumption. PRECLINICAL DATA: Among rats: parasite cysts are more abundant in amygdalar structures than those found in other regions of the brain. Infection does not influence locomotion, anxiety, hippocampal-dependent learning, fear conditioning (or its extinction) and neophobia in rats. Rats' natural predator is the cat, which is also T. gondii's reservoir. Naturally, rats have an aversion to cat urine, but the parasite suppresses this aversion in rats, thus influencing the infection cycle. Tachyzoites may invade different types of nervous cells, such as neurons, astrocytes and microglial cells in the brain, and Purkinje cells in cerebellum. Intracellular tachyzoites manipulate several signs for transduction mechanisms involved in apoptosis, antimicrobial effectors functions, and immune cell maturation. Dopamine levels are 14% higher in mice with chronic infections. These neurochemical changes may be factors contributing to mental and motor abnormalities that accompany or follow toxoplasmosis in rodents and possibly in humans. Moreover, the antipsychotic haloperidol and the mood stabilizer valproic acid most effectively inhibit Toxoplasma growth in vitro with synergistic activity. CLINICAL DATA: The effects of the parasite are not due to the manipulation in an evolutionary sense but merely due to neuropathological or neuroimmunological effects of the parasite's presence. Toxoplasmosis and schizophrenia: epidemiological studies point to a role for toxoplasmosis in schizophrenia's etiology, probably during pregnancy and early life, this association being congruent with studies in animal models indicating that animal exposures of the developing brain to infectious agents or immune modulating agents can be associated with behavioral changes that do not appear until the animal reaches full maturity. Psychiatric patients have increased rates of toxoplasmic antibodies, the differences between cases and controls being greatest in individuals who are assayed near the time of the onset of their symptoms. The increase of dopamine in the brain of infected subjects can represent the missing link between toxoplasmosis and schizophrenia. Toxoplasmosis and Obsessive Compulsive Disorder (OCD): the seropositivity rate for anti-T. gondii IgG antibodies among OCD patients is found to be significantly higher than the rate in healthy volunteers. Infection of basal ganglia may be implicated in the pathogenesis of OCD among Toxoplasma seropositive subjects. Toxoplasmosis and personality: infected men appear to be more dogmatic, less confident, more jealous, more cautious, less impulsive and more orderly than others. Conversely, infected women seem warmest, more conscientious, more insecure, more sanctimonious and more persistent than others. It is possible that differences in the level of testosterone may be responsible for the observed behavioral differences between Toxoplasma-infected and Toxoplasma-free subjects. CONCLUSION: In the future two major avenues for research seem essential. On one hand, prospective studies and research efforts must still be carried out to understand the mechanisms by which the parasite induces these psychiatric disorders. On the other hand, it has not yet been demonstrated that patients with positive toxoplasmic serology may better respond to haloperidol's or valproic acid's antiparasitic activity. These results may appear as a major issue in the drug's prescribing choices and explain variability in response to the treatment of patients with schizophrenia that is not explained by the genetic polymorphism.

Resume Le terme d’homoparentalite definit un couple d’homosexuel(le)s ayant un enfant a charge et concernerait 200 000 a 300 000 enfants en France aujourd’hui. L’etude de l’homoparentalite en pedopsychiatrie se heurte a plusieurs limites, notamment methodologiques : definition des familles homoparentales, difficulte d’echantillonnage, rarete de consultation dans les services de psychiatrie de l’enfant. Plusieurs dizaines d’etudes avec des questionnaires standardises et des entretiens semi-structures n’ont pas montre de difference entre les enfants de familles homoparentales et les enfants de familles heterosexuelles en termes de developpement, de capacites cognitives, d’identite ou d’orientation sexuelle. La relative faiblesse des effectifs est une donnee a prendre en compte. La plupart des etudes de la litterature portent sur des enfants jeunes (de quatre a 16 ans) et une seule etude s’est interessee au systeme d’attachement de femmes adultes elevees dans une famille dont le pere etait gay, revelant que ces femmes avaient plus de problemes dans leur vie intime que les femmes elevees dans des familles heterosexuelles. Le ressenti des enfants de familles homoparentales vis-a-vis de leurs pairs, de la difference et de la discrimination depend de la culture de chaque pays et n’a pas ete evalue a notre connaissance a ce jour en France par des questionnaires standardises. Notre pratique de pedopsychiatre doit trouver de nouveaux reperes pour comprendre les enjeux et les difficultes de ces configurations pour une meilleure empathie avec l’enfant et sa famille.