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Resume Nous avons mene une etude retrospective a la fois descriptive et comparative sur une periode s'etalant du 1 er mars au 30 septembre 2000. La population a ete determinee a partir de 45 patients hospitalises presentant un trouble bipolaire de type I, dont 30 tunisiens et 15 francais.

IntroductionIn the Tunisian cultural context, the mother is in charge of childcare, housekeeping and the well-being of the whole family, which can lead to exhaustion and depression.ObjectiveTo estimate the frequency of depression among mothers aged between 20 and 40 years, its consequences and the possible solutions.MethodTransversal study using an anonymous questionnaire of 26 questions published through social media sites to mother with young aged children.ResultsThree hundred and twenty-seven mothers participated in the study: 20% of them aged between 20 and 30 years and 80% between 30 and 40. Ninety-seven percent of the participants were married; 96% of them had university education. Seventy-nine percent of them were working mothers and 50% of them did not get any help in childcare. Forty-two percent of the participants had only 1 child, 49% had 2 children, 8% 3 children and only 1 mother had 4 children. Depressive symptoms were present in 73% of the participants and were significantly higher among mothers aged between 30 and 40. However, depression was certain in only 36% of them and there was no significant difference between the two age groups. Eighteen percent of the participants noticed an increase in consummation of cigarettes, 31% resorted to tranquilizers, 25% needed sick leaves, and 2% resorted to alcohol use. Less working hours was suggested as a solution in 36% cases, sharing house chores in 30% cases.ConclusionDepression among young mother is a public health problem in Tunisia. It is underestimated and not always treated, which can have a serious impact on the whole family well-being.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionStroke is an important cause of morbidity and is responsible for 9% of all deaths worldwide. The most frequent neuropsychiatric consequence of stroke is post-stroke depression (PSD). It has been shown to be associated with both impaired recovery and increased mortality. The aim of our study is to determine the benefits of antidepressant prescription after a stroke.MethodThe databases from Medline and PubMed were reviewed for articles related to post-stroke depression (PSD), antidepressant treatment and stroke, post-stroke depression and functional recovery, stroke related impairment.ResultsAntidepressant drugs have been shown to be effective in treating PSD in six double blind randomized studies. Patients treated with antidepressants had better recovery from disability than patients who did not receive antidepressant therapy: it was proved that antidepressant drugs cause an improvement in cognitive skills and functional recovery in PSD patients. In patients with ischemic stroke and moderate to severe motor deficit, the early prescription of fluoxetine with physiotherapy enhanced motor recovery after 3 months. Some studies showed that PSD can be effectively prevented: nortriptyline, fluoxetine, milnacipran and sertraline appeared to be efficacious in preventing depression after stroke and are to use without significant adverse effects in stroke patients.ConclusionAntidepressant treatment plays an increasing role in the management of patients with acute stroke. Therefore, early initiation of antidepressant therapy, in non-depressed stroke patients, may reduce the odds for development of PSD, and improve cognitive and functional recovery.Disclosure of interestThe authors have not supplied their declaration of competing interest.

IntroductionThe propensity of atypical antipsychotics (AAP) for having a therapeutic effect with fewer side effects and the balancing of these supposed benefits with tolerance are the subject of many studies.Aims and objectivesWe focused on adverse drug events (ADEs), occurred under AAP, in a population of patients with schizophrenia to assess the prevalences and describe how the practitioner deal with these ADEs.MethodsWe have used a retrospective and descriptive study of 63 Tunisian patients with schizophrenia, consulting in the adult outpatient of Razi hospital and treated by one type of AAP. The study period was 6 months from the 1st January 2015. We used the Birchwood Insight Scale (BIS), Positive and Negative Syndrome Scale (PANSS) and Udvalg for Kliniske Undersogelser (UKU) to assess the insight, psychotic symptoms and ADEs.ResultsTwenty-four patients were on risperidone, 22 on olanzapine, 8 on amisulpride and 9 on clozapine. Antiparkinsonism drug (15.9%) was associated because of neurological ADEs mainly Parkinsonism. Asthenia had a prevalence of 20.6%. Hypersalivation and palpitation were estimated at 7.9% both. Weight gain's prevalence was 25.4%, including 1 case associated with hypercholesterolemia and 1 case of unbalanced non-insulin-dependent diabetes. The erectile dysfunction's prevalence was 36.3% and decreased libido 27%. There were 2 cases of neutropenia and thrombocytopenia. The management of these ADEs was observed when they moderately began to influence the patient's daily activity.ConclusionADEs must be subject to an appropriate treatment and if necessary resort to a specialist consultation to confirm or deny imputability to AAP.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Introduction There is now an extensive body of data showing that depression is associated with a chronic low-grade inflammation. The obvious question is “What are the sources of this inflammation?” and “Could smoking be one of them?” Objectives The aim of the study is to investigate the association between depression and inflammation, and to highlight the role of smoking in this process. Methods The study included 65 depressed patients and 30 healthy controls. Blood samples of both groups were used for the measurement of the high-sensitivity CRP (hs-CRP) and the interleukin 6 (IL6). Results The mean value of hs-CRP was 2.02 mg/L among depressed patients and 1.42 mg/L among healthy controls (p=0.198). Higher values of hs-CRP (>=3mg/L) were found among depressed patients (20%) than among healthy controls (3.3%) (p=0.033). The mean value of IL6 was 4.12 ng/ml among depressed patients and 2.68 ng/ml among healthy controls (p=0.008). Higher values of IL6 (>=4ng/ml) were found among depressed patients (29.2%) than among healthy controls (3.3%) (p=0.004). The table below resume the relation between smoking and the elevation of inflammatory markers. Conclusion The causal relationship between smoking and depression is complex. Cigarette smoking increases the levels of inflammatory markers but did it leads to depression? Or did the depression increases smoking behavior? Or is there shared vulnerability factors for the both?

Objectives Lithium is a drug which may cause thyroid dysfunction. The most widely known dysfunctions associated with long-term lithium treatment are goiter and hypothyroidism. Lithium associated thyrotoxicosis is however uncommon. This current review explores the common mechanisms of lithium induced hyperthyroidism. Methods A systematic review of database was made using PubMed. The search keywords used were lithium therapy, thyroid side effects, thyroid dysfunction mechanism, hyperthyroidism, thyrotoxicosis. Results Lithium induced hyperthyroidism is uncommon, the incidence rate varying from 0.1% to 1.7%. The mechanisms of lithium associated hyperthyroidism are uncertain. Recent studies have proved that high proportion of investigated patients experienced transient thyrotoxicosis and painless thyroiditis. Different mechanisms have been discussed, including autoimmune inflammation, direct cellular destruction, susceptible individuals with preexisting Grave’s disease, a rebound effect of lithium therapy interruption… The pathogenesis of painless thyroiditis is unclear but different studies suggest a possible direct toxic effect of lithium on the thyroid gland. Lithium stimulates thyroid autoimmunity: lithium treated patients presented more positive antithyroid peroxidase antibodies than not lithium treated patients. This could be explained by an increased activity of B-cell lymphocyte activity and reduced ratios of suppressor to cytotoxic T-cell lymphocyte. Conclusion Long term lithium treated patients should be monitored for the development of thyroid dysfunction. It’s recommended to perform thyroid function test, thyroid antibodies and thyroid ultrasonography with a closer follow-up for lithium-treated patients with thyroid antibodies, or family history of thyroid disease.

The psychiatric disorders are the most frequent cause of the long term sick leave not only in Europe but also in Tunisia. Four diseases have been fixed by the Tunisian national register since 1959, give the right to the public employees institution of this type of vacation. These disease are: tuberculosis, cancer, paralysis and mental diseases. The aim of this study was to describe the evolutionary profile of these patients. Patients and methods The study was a comparison of two retrospective studies led in the department of emergency and external consultation of the Razi hospital. The first study had concerned 300 patients examined within the framework of a medical supervision during year 2001. The second study had concerned 430 patients having consulted for the first time in our department during the year 2012 and benefited from a long term sick leave. Results Forty was the age the most represented with a net feminine ascendancy in both studies. More than 60% of the patients were married in both study but a decrease of the number of single men has been reported in2012. The middle manager was the most represented professional category: the transport had been the most represented body employer in 2012. Depression was the most represented diagnosis. Conclusion The economical impact of the long term sick leave can be important but never considered. The low social support, the dissatisfaction, the workload and the indistinctness of the professional task are at the same time inductive but also aggravating factors.

Introduction Movement disorders are a frequent finding in psychiatric practice, even in emergency. Studies on acute movement disorders in psychiatric emergency are rare. Objectives To determine characteristic features of patients presenting with movement disorders in psychiatric emergency. Methods We conducted a retrospective study over one year period including all patients presenting in psychiatric emergency of Razi Hospital for movement disorders (from October2012 to September2013). Clinical, etiological and therapeutic features were analyzed. Results We included 335patients consulting in emergency for movement disorders (3.36% of all consultations in psychiatric emergency; sex-ratio: 3.53; mean age of 37.8 years). Main movement disorders (unique or in association) were acute and tardive dyskinesia(40%), Parkinsonian syndrome(34%), tremor(28%), acute dystonia(16.2%) (Mainly torticolis(22%), orofacial dystonia(17%)), akathisia(5.7%), oculogyric crisis(2.4%). Only one patient presented with neuroleptic malignant syndrome. Etiologies were mostly iatrogenic causes (drug abuse, weaning, errors, incomplinace). Most of patients had chronic psychosis (38.5%); 6.8% had simulated mevement disorders and 3.9% hysterical conversions. Anticholinergics (Trihexyphenidyle chlorhydrate in 64.5%) and benzodiazepines(14.3%) were the most used drugs in emergency. Only 3.9% of patients were admitted in hospitalization in emergency. Conclusion Our series shows the relative frequency (>3%) of movement disorders as a chief complaint in psychiatric emergency. The predominance of young male adults may be explained by the higher prevalence of dyskinesias in our series, for which younger age and masculine sex are risk factors. It is necessary to distinguish authentic movement disorders from psychogenic ones and simulations to avoid abusive prescriptions of anticholinergics, often explicitly claimed by simulators.

Background & aims Dementia is one of the most common neuropsychiatric disorders in nursing home residents. Despite a high prevalence and a major impact on daily activities, dementia remains largely underdiagnosed and therefore rarely treated in nursing homes throughout the world. This study aims to determine the prevalence of dementia among residents of Manouba nursing home (in Tunis) and to identify the proportion of recognised cases of dementia among this population. Methods A cross-sectional study was performed from September to October 2012 among all consenting residents of Manouba nursing home. Sociodemographic data were collected by the means of a semi-structured questionnaire. Cognitive functions were assessed using the Montreal Cognitive Assessment (MoCA) test in its Arabic version. We excluded subjects who could not take the MoCA test because of a severe sensory deficit or a severe psychiatric condition. Results At the time of the study, the population of Manouba nursing home residents consisted of 116 subjects. After applying the exclusion criteria, we retained 77 subjects: 48 males (62.3%) and 29 females (37.7%). The average age was 72.6 years. The average MoCA score was 14.4 +/− 6.5 (range: 3 to 29). The prevalence of dementia in our population was 58.4% (n=45). Among these 45 subjects with dementia, only three (or 6.7% of dementia cases) were already diagnosed as such. Of these three patients, only one was on anticholinesterase treatment. Conclusion Dementia is largely underrecognised and hence undertreated in nursing homes in Tunisia as in other countries. Routine screening for cognitive deficits seems paramount in order to ensure early diagnosis and treatment of this debilitating condition.

Introduction The addiction to buprenorphine hight dose (Subutex®) is a new plague of drug addiction in Tunisia. The absence of a substitute treatment in this substance as well as the only ambulatory care of these drug addicts, make that is the weaning in the BHD is difficult. The aim of this study was to describe the follow-up and the weaning of these patients. Patients and methods A retrospective study was conducted on the records of 23 patients who consulted the outpatient service of Razi hospital, addicted to BHD, since January 2012 until now. Results Forty eight percent of patients (11 patients) were lost sight at the end of the first consultation. Only 13% of patients (3 patients) are followed up until now. Most of the patients had been put under classic neuroleptic essentially chlorpromazine in association with a benzodiazepine. 2 patients have weaned at the end of 13 months. These 2 patients are at present in relapse but in lesser doses than their initial dose of BHD. Conclusion The coverage of the patient dependent on drug was upset by the substitution treatments. But BHD don’t benefit from it and this hinders the care of the patients.

Introduction Buprenorphine haut dosage (Subutex) est le medicament le plus couramment utilise dans le traitement de medicament de substitution. Mais cette molecule est egalement bien connu pour son usage detourne ou abusif. Depuis la revolution tunisienne, le trafic de plusieurs medicaments a ete une montee tres dangereux. Objectifs Pour etudier la prevalence de la dependance a la buprenorphine haute dose en consultation psychiatrique en 2010 (avant la revolution tunisienne) et 2012 (apres la revolution). Comparer les caracteristiques cliniques du patient accro a la buprenorphine haut dosage avant et apres la revolution tunisienne. Methodologie Une etude retrospective, descriptive et comparative a ete effectuee sur les fichiers de patients qui ont consulte le service de consultation externe de l’hopital Razi a Tunis depuis deux ans: 2010 et 2012 dont diagnostic etait la dependance a la buprenorphine haut dosage. Resultats 34 patients dependants a la buprenorphine haute dose ont ete recrutes: six patients en 2010 et 28 patients en 2012. Tous etaient des hommes. L’âge moyen etait de 31,83 annees en 2010 et 32,13 annees en 2012. 44,11% de l’ensemble de la population de l’etude a developpe une symptomatologie depressive: quatre patients en 2010 et 11 patients en 2012. Les groupes d’âge, la periode de chomage et le montant des benzodiazepines consommees ont ete correles avec l’annee de consommation. Conclusion Ces resultats confirment l’impact de la revolution tunisienne sur la prevalence et le profil de dependance a la buprenorphine haute dose dans notre pays. D’ou la necessite de mesures generales de gestion de ces toxicomanes est imposee.

Introduction Women take sick-leave more often than men, in general and especially because of psychiatric disorders. Objective The aim of the present study was to describe and analyse sick-leave due to psychiatric morbidity and its relation to age and occupation, with a special focus on sex differences. Method We conducted a retrospective and descriptive study in external consultation of the psychiatric hospital Razi. We collected the records of patients seen between 01/07/2011 and 30/09/2012 and who received sick leave for psychiatric illness. Results 92 patients were included (78 female, 14 male) with mean age of 43,6 years. Sick-leave duration was longer for women. The greatest gender differences were found in the youngest and oldest age-groups. Women had higher incidence also in the longest spells (86% vs 14%). Depressive disorders were found among 73% of cases. Highest incidence of sick-leave was found among those with a combination of psychiatric and physical morbidity. Conclusion Psychiatric disorder is an important factor in sick-leave among women, especially regarding length of absence. Further studies on the influence of sex integration on sickness absence need to be done.

Introduction Discussions about the limitation of the prescription and dispensing of buprenorphine hight dose (Subutex ®) emphasize the need for a systematic and formalized cooperation between the various contributors in health. Objective Describe the course of caring for patients addicted to Subutex followed at the outpatient service of Razi hospital. Methods A retrospective study was conducted on the records of patients who consulted the outpatient service of Razi hospital during a six-month period and whose diagnosis of dependence to Subutex was retained. Results Twenty three patients were addicted to Subutex. 100% male. The mean age of the patients was 32.13 years. Almost 82.6% of patients had a low socioeconomic level and 78.3% of them did not have insurance. 16 were unemployed. A history of incarceration was found in 82.6% of patients. The duration of use of Subutex ranged between 2 and 168 months. Places of acquisition of this molecule were precised only by 26% of consumers. Fifteen consultants do not have any history of detoxification cure and 8 of them had 1 or 2 cures. In addition, 78.3% of patients reported being motivated to stop their addiction. Regarding collaboration of physicians, 8 patients (34% of the patients) were referred by generalist physicians, 7 patients by specialist physicians, 4 patients by emergency and 2 by psychiatrists. Conclusion The management of patients addicted to Subutex in our country is deficient. These results argue for the necessity of general measures of support dependent on psychoactive substances.

Introduction Delusions, hallucinations, aggression, and agitation affect more than half of patients with dementia. Antipsychotic drugs are used to treat these behaviors and symptoms. They are among the most frequently used psychotropic drugs in this disease, but their benefits are uncertain and concerns about safety have emerged. We assessed the current practice in use of antipsychotics medication in outpatients with dementia. Method We conducted a retrospective cohort study involving patients older than 65 years who began outpatient treatment with antipsychotic drugs following a dementia diagnosis. Results 22 patients were included (16 female, 6 male) with mean age of 78.6 years. All patients consulted for behavioral problems. Most received typical aantipsychotic drugs (72,8%), while 36,4% received atypical antipsychotic drugs. 13 patients (59,1%) were receiving haloperidol. Improvement was observed in 54,5% of patients. The comparisons of haloperidol with risperidone suggest no difference in efficacy for the treatment of global behaviour disturbance. On the other hand, use of haloperidol is, however, associated with a higher incidence of extrapyramidal and other side effects. Conclusion The treatment of elderly patients requires daily careful management and monitoring because of their polypathology, polymedication and of their greater sensitivity to the toxic effects of drugs. Overall, the study findings suggest that there is a need to monitor antipsychotic drug use by elderly patients in light of recent efficacy and safety data on atypical agents.

Introduction Tramadol, initially introduced in Germany in 1977, is a synthetic analgesic and appears to have a dual mechanism of action; a weak μ-opioid receptor agonism and a reuptake inhibition of serotonin and noradrenaline. It is marketed in Tunisia since 2001. Generally, Tramadol is considered to have a very low risk of dependence and abuse, but rare cases of tramadol dependence have been described in patients without prior substance abuse history. We describe one such case in a relatively young, otherwise healthy patient. Case report Mr AR, a 47-year-old man, presented to get help with tramadol addiction. He had no previous history of illicit drug use, did not smoke cigarettes or drank alcohol. Mr AR was started on tramadol treatment about 2 years earlier for back pain. He did have better pain control with tramadol, but he gradually started taking more and more. Ultimately, his pain resolved but he was unable to stop taking tramadol: he was taking up to 1700 mg/d of tramadol and had made multiple efforts to stop. When he stopped taking tramadol, he had dysphoria, muscle cramps, anxiousness, restlessness, and a sensation of insects crawling all over his body. His withdrawal symptoms were severe enough to interfere with his work and family life. Conclusion Tramadol dependence is very rare but can happen in a patient without substance abuse history. We, as medical practitioners, should be open to the possibility of tramadol dependence and should resort to optimal and judicious use of such a substance.

Introduction High dosage buprenorphine (Subutex) is actually the principal treatment for substitution medication. Some misappropriations and wrong uses have been seen; the most frequent and sever being using tablets for injections. Since the introduction in different countries, the high dose buprenorphine as a substitition treatment for opioid drug dependence, the number of overdose deaths and heroin users are significantly declined. But the existence of non-use replacement of this processing, mainly intravenously, was born a new scourge of addiction, especially in Tunisia. Besides the risk of overdose, there is a risk of viral contamination. Objectives To study the sexually transmitted diseases among patients addicted to high dose buprenorphine in Tunisia and followed in the outpatient hospital Razi. Materials and methods It is a retrospective study of twenty-three (23) patients (23 men), injection of high dose buprenorphine, having consulted the outpatient clinic of Razi Hospital between January and July of 2012. Results 8 patients had a communicable disease: 1HIV, 5 Hepatitis C, 1Hepatitis B, 1 syphilis. 4 patients had infectious complications: 3 cases of skin infections and 1 case of endocarditis. 9 had never been screened. 8 recognized using a used needle. Conclusion The addiction to high dose buprenorphine is a widespread phenomenon in Tunisia. Lack of information and awareness of companion in Tunisia is at the origin of serious infectious complications. Health professionals have to play an important role in drug addict patients’ education and supervision, to prevent addiction to buprenorphine and related infectious complications.

Introduction Schizophrenia is still one of the most difficult diseases to treat, whose direct and indirect costs remain high, both for the patient, family and society. The duration of the untreated psychosis is one of the factors likely to influence the evolution of this disease. To know the factors that may lengthen the period of care would improve the evolutionary course of the disease. Objectives Determine the factors contributing to the delay in treatment of schizophrenia within the Tunisian population. Methodology Retrospective study of patients in Razi hospital with schizophrenia admitted in 2004 and 2005. Results Our sample consisted of 91 patients. The poor family support (p = 0,032), the death of the mother (p Other factors that were correlated to longer period of support are: advanced age of onset of disorders (p = 0.013), family history of psychiatric illness (p = 0,03) and of schizophrenia (p = 0,04) and disorganized form of schizophrenia (p = 0,049). Conclusion We can stipulate that the application of certain measurements like the improvement and the extension of the social coverage to the poorest classes and most marginalized as well as the fight against the stigmatization of the schizophrenic patients and the mentally ills in general would be more than useful.

Introduction The use of monotherapy with mood stabilisers during bipolar disorder concerns only few patients. Neuroleptics, benzodiazepines and recently the new-generation antipsychotic molecules are widely used as adjuvant therapy to mood stabilizers, indeed beyond the indications held by the guidelines. Objectives Modalities of prescription of psychotropic medication during the first admission and over a three-year follow-up in subjects with bipolar disorder. Aims Evaluate the adequacy of prescribing practices in naturalistic conditions and international guidelines. Methods Retrospective study of all first-admitted patients with bipolar disorder in two psychiatric wards of Razi Hospital between 2006 and 2008 and over a three-year follow-up. Results Our sample consisted of 72 patients. Over 80% of patients had initially received an incisive antipsychotic drug in combination with mood stabilizer; it was a conventional antipsychotic in 65.3%. Sedative neuroleptics were prescribed in 40.3% of cases with a duration average of 19.21 ± 11.97 months. The combination of two antipsychotic drugs was found in 33.3% of patients. The most frequent association was “haloperidol-chlorpromazine” (79%). Benzodiazepines were prescribed in acute phase in the majority of the sample (94%) with a duration average of 27 mo is ±8.4 months; it was the lorazepam in 70.6%. Conclusions Theoretical recommendations do not always reflect the practical situations. Evaluating indications and conditions of polytherapy are critical issues in future studies on the biological treatment of bipolar disorder.

Background Although fundamentally a psychiatric disorder, factitious disorder challenges physicians of any specialty as it might simulate a wide variety of medical conditions. Insulin or sulfonylurea-induced hypoglycemia, in particular, might mimic insulinoma. Objectives To examine the risk factors, to highlight the diagnostic difficulties and to discuss the management options for factitious hypoglycemia. Methods A case report. Results A twenty-nine-year-old was admitted at the endocrinology department for recurrent episodes of “spontaneous” hypoglycemia resulting in several seizures and even in a deep coma state. Investigations concluded that the patient had factitious hypoglycemia due to surreptitious insulin and glibenclamide use. She was referred to the psychiatric outpatient clinic for examination and management. Psychiatric interview found no associated axis I disorder. Treatment included olanzapine along with psychotherapy. Conclusions Diagnosis of factitious hypoglycemia is often a daunting task, management remains difficult and long-term prognosis is unpredictable. Close cooperation between endocrinologists and psychiatrists can further clarify the diagnosis and help optimize the treatment.

Background Every death at a psychiatric hospital raises questions about its cause and the forensic responsibilities it engages. Objectives - To assess the rate of deaths posing forensic problems at a psychiatric hospital. - To determine the patients’ victimological profile. - To identify the causes and risk factors of these deaths. Methods We conducted a retrospective and descriptive study based on the forensic autopsies and the medical files of patients who died during their stay at AlRazi psychiatric hospital between January 2000 and December 2010. Results During the study period, 115 deaths were recorded. We studied the deaths of 33 autopsied patients (28.69% of all deaths). Patients are predominantly male (60%), aged 43 on average, mostly smokers (66%), with a low socioeconomic level (61%) and a medical history (40%) primarily of hypertension and diabetes. 40% of our casualties are schizophrenic, mostly of the paranoid form (60%). Antipsychotics are the most prescribed drugs (87.5%). High doses are used (mean chlorpromazine equivalent dose: 1237 mg/day). Most deaths occurred at night, during weekends. 21% died within the first 24 hours of their hospital stay. A cause for death was identified in ¾ of cases. 75.75% are sudden deaths mainly due to respiratory (40%), or cardiovascular causes (20%). Accidental deaths (18.18% of all deaths) include choking (50%), thermal burns (33.4%) and iatrogenic causes (16.6%). Suicides account for 6% of all deaths. Conclusions Reducing the incidence of deaths posing forensic problems at psychiatric hospitals is an important goal to achieve through careful identification of risk factors.