Fear extinction learning improvement in PTSD after EMDR therapy: an fMRI study.

Objective: Neurobiological models of Posttraumatic Stress Disorder (PTSD) implicate fear processing impairments in the maintenance of the disorder. Eye Movement Desensitization and Reprocessing (EMDR) is one of the most efficient psychotherapies to treat PTSD. We aimed at exploring the brain mechanisms of the fear circuitry involved in PTSD patients' symptom remission after EMDR therapy. Method: Thirty-six PTSD participants were randomly assigned to either EMDR group receiving EMDR therapy or Wait-List (WL) group receiving supportive therapy. Participants underwent a behavioural fear conditioning and extinction paradigm during functional magnetic resonance (fMRI). In the EMDR group, patients were scanned at baseline, before EMDR and one week after remission. In the WL group, patients were scanned at baseline and within the same time interval as the EMDR group. Results: In the EMDR group after treatment, fear responses in the late extinction were significantly lower than before therapy. In parallel, significant functional activity and connectivity changes were found in the EMDR group versus the WL during the late extinction. These changes involve the fear circuit (amygdalae, left hippocampus), the right inferior frontal gyrus, the right frontal eye field and insula (pFWE < .05). Conclusion: These functional modifications underlie a significant improvement of fear extinction learning in PTSD patients after EMDR therapy.

Objetivo: Los modelos neurobiológicos del TEPT implican deficiencias en el procesamiento del miedo en el mantenimiento del trastorno. EMDR es una de las psicoterapias más eficaces para tratar el TEPT. Nuestro objetivo fue explorar los mecanismos cerebrales de los circuitos de miedo implicados en la remisión de los síntomas de los pacientes con el TEPT después de la terapia EMDR.Método: Treinta y seis participantes con el TEPT fueron asignados aleatoriamente a un grupo EMDR que recibió terapia EMDR o un grupo de Lista de Espera (LE) que recibió terapia de apoyo. Los participantes se sometieron a un paradigma de condicionamiento y extinción del miedo conductual durante la resonancia magnética funcional (fMRI). En el grupo EMDR, los pacientes fueron escaneados al inicio del estudio, antes de EMDR y una semana después de la remisión. En el grupo LE, los pacientes fueron escaneados al inicio y en el mismo intervalo de tiempo que el grupo EMDR.Resultados: En el grupo EMDR después del tratamiento, las respuestas de miedo en la extinción tardía fueron significativamente más bajas que antes de la terapia. En paralelo, se encontraron cambios significativos en la actividad funcional y en la conectividad en el grupo EMDR v/s el grupo LE durante la extinción tardía. Estos cambios involucran el circuito de miedo (amígdala, hipocampo izquierdo), el giro frontal inferior derecho, los campos del ojo frontal derecho y la ínsula (pFWE < .05).Conclusión: Estas modificaciones funcionales subyacen a una mejora significativa del aprendizaje de extinción del miedo en pacientes con el TEPT después de la terapia EMDR.

[Benefit of mortality and morbidity reviews in psychiatry]. / Intérêt des revues de mortalité et de morbidité en psychiatrie.

A mortality and morbidity (M&M) review consists in analysing, collectively and retrospectively, the cases of patients whose evolution has been marked by a complication or death. This analysis must question whether such an outcome could have been avoided, making it possible to identify the causes and correct the factors having contributed to its occurrence. After a presentation of the methodological and organisational principles, as well as the M&M reviews carried out in France, attention is turned to those performed in psychiatry and identifying the main perspectives for the discipline.

Grey matter density changes of structures involved in Posttraumatic Stress Disorder (PTSD) after recovery following Eye Movement Desensitization and Reprocessing (EMDR) therapy.

Recovery of stress-induced structural alterations in Posttraumatic Stress Disorder (PTSD) remains largely unexplored. This study aimed to determine whether symptoms improvement is associated with grey matter (GM) density changes of brain structures involved in PTSD. Two groups of PTSD patients were involved in this study. The first group was treated with Eye Movement Desensitization and Reprocessing (EMDR) therapy and recovered from their symptoms (recovery group) (n = 11); Patients were scanned prior to therapy (T1), one week (T2) and five months after the end of therapy (T3). The second group included patients which followed a supportive therapy and remained symptomatic (wait-list group) (n = 7). They were scanned at three time-steps mimicking the same inter-scan intervals. Voxel-based morphometry (VBM) was used to characterize GM density evolution. GM density values showed a significant group-by-time interaction effect between T1 and T3 in prefrontal cortex areas. These interaction effects were driven by a GM density increase in the recovery group with respect to the wait-list group. Symptoms removal goes hand-in-hand with GM density enhancement of structures involved in emotional regulation.

Mental Disorders among Children and Adolescents Admitted to a French Psychiatric Emergency Service.

The aim of this study was to describe the characteristics of children and adolescents admitted to the psychiatric emergency department (ED) of a French public teaching hospital over a six-year study period (2001-2006). Data for all episodes of care in the psychiatric ED from January 1, 2001, to December 31, 2006, delivered to adolescents aged less than 18 years were retrospectively analyzed. During the six-year study period, 335 episodes of care in the psychiatric ED were experienced by 264 different adolescents. They accounted for 2.0% of the 16,754 care episodes of the ED; 164 patients (62.1) were female and the average age was 16.5 (SD = 1.6). The neurotic, stress-related, and somatoform disorders were the most frequent (25.4%) and concerned mainly anxiety disorders (15.2%). The frequency of the absence of psychiatric diagnosis (22.7%) was high. A total of 48 children and adolescents (18.2%) benefited from more than one episode of care. Several factors were associated to a higher number of visits to the ED: substance use, schizophrenia, disorders of adult personality and behaviour, disorders occurring in childhood and adolescence, and dual diagnosis. In conclusion, mental health disorders in children and adolescents are a serious problem associated with several potentially modifiable factors.

Attentional bias in post-traumatic stress disorder diminishes after symptom amelioration.

BACKGROUND: Avoidance and hypervigilance to reminders of a traumatic event are among the main characteristics of post-traumatic stress disorder (PTSD). Attentional bias toward aversive cues in PTSD has been hypothesized as being part of the dysfunction causing etiology and maintenance of PTSD. The aim of the present study was to investigate the cognitive strategy underlying attentional bias in PTSD and whether normal cognitive processing is restored after a treatment suppressing core PTSD symptoms. METHODS: Nineteen healthy controls were matched for age, sex and education to 19 PTSD patients. We used the emotional stroop and detection of target tasks, before and after an average of 4.1 sessions of eye movement desensitization and reprocessing (EMDR) therapy. RESULTS: We found that on both tasks, patients were slower than controls in responding in the presence of emotionally negative words compared to neutral ones. After symptoms removal, patients no longer had attentional bias, and responded similarly to controls. CONCLUSION: These results support the existence of an attentional bias in PTSD patients due to a disengagement difficulty. There was also preliminary evidence that the disengagement was linked to PTSD symptomatology. It should be further explored whether attentional bias and PTSD involve common brain mechanisms.

Frequent visits to a French psychiatric emergency service: diagnostic variability in psychotic disorders.

OBJECTIVE: This study examined characteristics of frequent visitors to a psychiatric emergency service in a French public teaching hospital over six years. Diagnostic variability of psychotic disorders was documented. METHODS: A retrospective review of the service's administrative and medical databases identified 1,285 patients with more than one visit during the period who were given at least one diagnosis of a psychotic disorder. A total of 317 patients with six or more visits (frequent visitors) were compared with 968 patients with between two and five visits (occasional visitors). RESULTS: Frequent visitors were significantly more likely to be single and homeless and to have diagnostic variability, substance use disorders, and personality disorders. A total of 177 patients experienced diagnostic variability, which was found mainly in three diagnostic categories: schizophrenia, schizoaffective disorder, and bipolar disorder with psychotic features. CONCLUSIONS: Future studies should further examine the link between increased use of emergency services and diagnostic variability.

Amygdala activity correlates with attentional bias in PTSD.

Post-traumatic stress disorder (PTSD) is an anxiety disorder arising in the aftermath of a traumatic event. The most prevalent hypothesis is that of an increased amygdala activity to threat cues. The amygdala has also shown an implication in orienting attention toward threat. The aim of the study was to explore the correlations between amygdala activity, symptom severity and attentional bias in PTSD. Patients and healthy controls were assayed on an fMRI emotional face matching task and an attentional detection of target (DOT) task. The amygdala showed enhanced activity in PTSD (vs. controls). It positively correlated with anxiety scores and PTSD symptomatology. It also positively correlated with the disengagement index. Mostly, these results provide preliminary support for an implication of the amygdala in attention orientation to threat in PTSD. These results are further discussed in light of recent theories concerned with cortico-limbic functioning.

[Electronic records in psychiatry]. / Le dossier patient informatisé en psychiatrie.

Electronic patient records are very slowly being introduced into French hospitals. It is therefore necessary to consider the factors which contribute to or, on the contrary, hinder the implementation of this tool in a public psychiatric institution.

A social network analysis of healthcare professional relationships in a French hospital.

PURPOSE: This paper aims to describe relationships among healthcare professionals in a French public hospital using social network analysis (SNA) and to improve health service quality by strengthening health service management and leadership. DESIGN/METHODOLOGY/APPROACH: This study was based on a questionnaire sent to randomly selected French public hospital professionals and administrators. Network composition measures were obtained using a name generator. Analysis focused on three main indicators: "centrality", "prestige", and "clique participants". The SNA was carried out using UCINET and statistical analyses were performed with SPSS version 15.0. FINDINGS: A total of 104 questionnaires were returned and analysed. Centrality, prestige and clique indicators were highly correlated (all p-value were less than 0.01). Physicians had the highest scores for the three indicators. Older age (> or = 45 years) was associated with higher centrality and clique numbers scores. Transversal activity was associated with higher scores than other specific activities (hospitalisation, ambulatory care), except for emergency care. ORIGINALITY/VALUE: The paper shows how networks and SNA techniques provide novel and useful means to understand communication and collaboration between hospital professionals.

Pure-tone auditory thresholds are decreased in depressed people with post-traumatic stress disorder.

BACKGROUND: Depression has been related to sensory modulation and notably to auditory modifications such as alterations in auditory event-related potentials, abnormal patterns of auditory habituation, increased activation of primary and secondary auditory cortex, and higher bilateral auditory thresholds. However, few experiments have considered the exploration of the auditory system in depression. The aim of the experiment is to further explore auditory thresholds across a higher number of frequencies than has previously been undertaken in depressed subjects, to determine whether thresholds are modified as compared to controls, and if so, at which frequencies. METHODS: 25 pure-tones covering a large range of frequencies from 125Hz to 8kHz were used to measure both air and bone conduction (AC and BC respectively) hearing thresholds. 13 patients with depression and post-traumatic disorder matched for age, sex and education level with 13 healthy subjects, were tested. RESULTS: Hearing thresholds were found to be significantly poorer in depressed participants than in controls for frequencies from 2.75Hz to 8kHz in BC, and for 0.5, 0.75, 0.875 and 2.0-8.0kHz pure-tone frequencies in AC. LIMITATIONS: Given that the depressed patients also had comorbid post-traumatic disorder, it should be verified whether their modified pure-tone audiometry is only related to depression. CONCLUSIONS: The AC and BC pure-tone auditory threshold measurement may provide new and different insights into the aetiology and evolution of depression.

Clinical variations modulate patterns of gene expression and define blood biomarkers in major depression.

The aim of the study is to compare the expression level of candidate genes between patients suffering from a severe major depressive episode (MDE) and controls, and also among patients during MDE evolution. After a comprehensive review of the biological data related to mood disorders, we initiated a hypothesis-driven exploration of candidate mRNAs. Using RT-qPCR, we analyzed peripheral blood mononuclear cells (PBMCs) mRNA obtained from a homogeneous population of 11 patients who suffered from severe melancholic MDE. To assess the evolution of MDE, we analyzed PBMC mRNAs that were collected on Day 1 and 8 weeks later. Data from these patient samples were analyzed in comparison to age- and sex-matched healthy controls. Among 40 candidate genes consistently transcribed in PBMCs, 10 were differentially expressed in at least one comparison. We found that variations of mRNA levels for NRG1, SORT1 and TPH1 were interesting state-dependent biological markers of the disease. We also observed that variations in other mRNA expression were associated with treatment efficacy or clinical improvement (CREB1, HDAC5, HSPA2, HTR1B, HTR2A, and SLC6A4/5HTT). Significantly, 5HTT exhibited a strong correlation with clinical score evolution. We also found a state-independent marker, IL10. Moreover, the analysis of 2 separate MDEs concerning a same patient revealed comparable results for the expression of CREB1, HSPA2, HTR1B, NRG1 and TPH1. Overall, our results indicate that PBMCs obtained at different time points during MDE progression represent a promising avenue to discover biological markers for depression.

Mental disorders among homeless people admitted to a French psychiatric emergency service.

OBJECTIVE: The aim of this study was to identify factors associated with homelessness status among patients admitted to the psychiatric emergency ward of a French public teaching hospital over a six-year study period (2001-2006). METHODS: The study was based on a retrospective review of the psychiatric emergency ward's administrative and medical computer databases. Each emergency care episode had accompanying data that included demographic, financial, clinical, and management information. RESULTS: During this six-year study, the psychiatric service recorded 16,754 care episodes for 8,860 different patients, of which 591 were homeless (6.7%) and 8,269 were nonhomeless (93.3%). The mean+/-SD number of visits to the psychiatric emergency service was higher for homeless patients (4.9+/-12.3) than for nonhomeless patients (1.7+/-2.4) (p<.001). A total of 331 homeless patients (56.0%) had more than one care episode, whereas 2,180 (26.4%) of nonhomeless patients had more than one care episode. Factors associated with homelessness included being male, being single, and receiving financial assistance through government social programs. Schizophrenia (43.7%) and substance use disorders (31.0%) were the most common disorders among homeless patients. Aggressive behavior and violence were reported equally among homeless patients (3.5%) and nonhomeless patients (3.2%). Homeless patients were less likely than nonhomeless patients to be hospitalized after receiving care in the emergency ward (47.8% versus 51.1%) (p=.002). CONCLUSIONS: Although there is near-universal access to free mental health care in France, study findings suggest that the quality and adequacy of subsequent care are not guaranteed. Multidisciplinary and collaborative solutions are needed to improve the management of mental health care for homeless patients.

Implementing electronic medical records in a psychiatric hospital: A qualitative study.

Abstract The objective of this study is to examine health care professionals' opinions of the critical events (opportunities and barriers) surrounding EMR implementation in a French teaching psychiatric hospital. This qualitative study was based on semi-structured interviews with 115 health care professionals: 16 psychiatrists, 84 nurses, six psychologists or social assistants and nine secretaries or administrative professionals. Interviews were thematically analysed. Most responders (96%) used EMR. Among these EMR users, 70% perceived EMR positively. Concerning the opportunities from implementing an EMR, the most represented theme was "the improved access to medical record information" (75%), followed by "the strategy to guarantee the adhesion of professionals and the use of EMR" (69%), and "the technological performances of EMR" (49%). Concerning the barriers to implementation, four themes emerged, as follows: "the workflow and efficiency decrease" (73%), "the triangulation of the patient-professional relationship" (47%), "the information sharing and confidentiality" (32%), and "the ambiguity of EMR" (26%), which answers both to the production of care and to an economic issue. In conclusion, EMR implementation involved several critical components, and the strategy of implementation is particularly important. Implementing an EMR should be considered a continuous process, and the principle and theory of continuous quality improvement appears pertinent for addressing this problem.