Stigma resistance is associated with advanced stages of personal recovery in serious mental illness patients enrolled in psychiatric rehabilitation.

BACKGROUND: Stigma resistance (SR) is defined as one's ability to deflect or challenge stigmatizing beliefs. SR is positively associated with patient's outcomes in serious mental illness (SMI). SR appears as a promising target for psychiatric rehabilitation as it might facilitate personal recovery. OBJECTIVES: The objectives of the present study are: (i) to assess the frequency of SR in a multicentric non-selected psychiatric rehabilitation SMI sample; (ii) to investigate the correlates of high SR. METHODS: A total of 693 outpatients with SMI were recruited from the French National Centers of Reference for Psychiatric Rehabilitation cohort (REHABase). Evaluation included standardized scales for clinical severity, quality of life, satisfaction with life, wellbeing, and personal recovery and a large cognitive battery. SR was measured using internalized stigma of mental illness - SR subscale. RESULTS: Elevated SR was associated with a preserved executive functioning, a lower insight into illness and all recovery-related outcomes in the univariate analyses. In the multivariate analysis adjusted by age, gender and self-stigma, elevated SR was best predicted by the later stages of personal recovery [rebuilding; p = 0.004, OR = 2.89 (1.36-4.88); growth; p = 0.005, OR = 2.79 (1.30-4.43)). No moderating effects of age and education were found. CONCLUSION: The present study has indicated the importance of addressing SR in patients enrolled in psychiatric rehabilitation. Recovery-oriented psychoeducation, metacognitive therapies and family interventions might improve SR and protect against insight-related depression. The effectiveness of psychiatric rehabilitation on SR and the potential mediating effects of changes in SR on treatment outcomes should be further investigated in longitudinal studies.

[Effectiveness of peer helper interventions for people with schizophrenia or bipolar disorder: A literature review]. / Efficacité des interventions de pair-aidants (schizophrénie, trouble bipolaire). Revue systématique de la littérature.

OBJECTIVE: The effectiveness of programs integrating trained and paid peer helpers on symptoms, quality of life and recovery of persons with bipolar disorder or schizophrenia is still poorly understood. The factors influencing the integration of peer helpers into healthcare teams are also poorly understood. METHOD: A systematic review of the literature was performed. We systematically searched multiple electronic databases for articles: (i) exploring the effectiveness of the intervention of trained and paid peer helpers in bipolar disorder and schizophrenia (ii) reporting barriers and facilitators to the integration of peer helpers. RESULTS: Forty-eight articles were included, 24 on the effectiveness of the intervention of peer helpers, 18 on barriers and 13 on facilitators to the integration of peer helpers in health teams. Of them, 25 were based upon qualitative methods (7 concerning the effectiveness of the intervention of peer helpers, 14 the barriers and 7 the facilitators to their integration); 23 were based upon quantitative methods (9 studies focused on the effectiveness of peer helper intervention, 2 on barriers and 6 on integration facilitators). The 23 quantitative studies included 8 randomized controlled trials. CONCLUSION: In spite of their heterogeneity, the results suggest that that interventions of peer helpers have a positive impact on the recovery, quality of life, social functioning, physical health and clinical outcome of persons with bipolar disorder or schizophrenia. The results also showed that the integration of peer helpers is favored by caregivers' awareness about the role of peer helpers and knowledge about the recovery model. The results highlight the need for peer helpers to have a well-defined role and to be supervised, preferably by another peer helper.

Educational needs and psychoeducation interventions in clozapine users: a narrative review.

OBJECTIVE: Increasing users' knowledge about the expected benefits and risks of clozapine may contribute to the initiation and maintenance of clozapine in persons with treatment-resistant schizophrenia (TRS). The objective was to identify the educational needs of clozapine users and the interventions aimed at addressing these needs. METHOD: We systematically searched multiple electronic databases for articles: (i) exploring educational needs of clozapine users and of their relatives; and (ii) reporting educational interventions aimed at addressing these needs. Data were synthesized narratively. RESULTS: A total of 30 articles published from 1990 to 2019 in 8 countries fulfilled our inclusion criteria. As most studies on educational needs (n = 18) were carried out in persons already taking clozapine, educational needs of TRS patients who were candidates for clozapine treatment are not well documented. Users' level of knowledge about clozapine was often poor, especially about adverse effects or interactions with other substances, with a poor retention of information delivered at treatment initiation. Among 12 studies reporting educational interventions in clozapine users, five provided quantitative outcomes. Their findings suggest that structured educational programmes may contribute to promote clozapine initiation and to improve users' knowledge about this drug. CONCLUSION: The literature is sparse on structured educational interventions about clozapine, and only one randomized controlled trial was identified. A promising strategy emerging from this review may be staging educational interventions according to the evolving needs of persons with TRS before clozapine use, at initiation and during maintenance treatment.

Assessing metacognition during or after basic-level and high-level cognitive tasks? A comparative study in a non-clinical sample.

This study explored in a non-clinical sample whether metacognitive awareness assessments measured during ("on line") and after ("end line") a neuropsychological task lead to comparable results in tests exploring basic-level or high-level cognitive functions. Short-term memory and working memory tests (forward and backward digit recall of the WAIS-III) were used to measure basic-level cognitive function. A social cognition test, the French adaptation of the Faces Test, was used to assess high-level cognitive function through recognition of facial emotions. For these two tests, we explored "on line" metacognitive awareness using a method based upon Koriat and Goldsmith's protocol. After each answer, participants were asked to rate their level of confidence in the correctness of their response. Persons had also to rate their confidence in their answer only once, at the end of the neuropsychological test, in order to explore "end line" metacognitive awareness. They were then asked "do you feel you have passed this test?" and had to rate their feeling of success on a 4-point Likert-type scale ("no", "rather not", "rather yes", "yes"). No association was found between "on line" and "end line" metacognitive awareness scores on memory tests. Poor "end line" metacognitive awareness was associated with lower "on line" metacognitive awareness score in the social cognition test. It might be of interest to assess both "on line" and "end line" metacognitive awareness in persons with schizophrenia to better take into accounts the multi-faceted structure of metacognition.

[Electroconvulsive therapy in combination with psychotropic and non-psychotropic pharmacological treatments: Review of the literature and practical recommendations]. / Électroconvulsivothérapie en association avec des traitements pharmacologiques psychotropes et non psychotropes : revue de la littérature et recommandations pratiques.

CONTEXT: Electro-convulsive therapy (ECT) is the most effective treatment for treatment resistant mood disorders and catatonia. ECT also appears to be an effective treatment in combination with clozapine in the context of treatment resistant schizophrenia spectrum disorders. Although increasingly codified (guidelines on indications, contraindications, methods of implementation), the practice of ECT still lacks consensual protocols. The concomitant use of psychotropic and/or non-psychotropic medication is a common situation when ECT treatment is considered. To our knowledge, there is to date no summary of studies or case reports in France, nor any proposal for guidelines concerning the management of medication of the patient to whom ECT sessions are offered. Indeed, several particularities must be considered. This article proposes to specify for each pharmacological class the possible interaction between ECT and medication. A first section of this article will be devoted to non-psychotropic treatments, and a second section to psychotropic treatments. A practical summary table is also provided. METHOD: A review of the literature was conducted including all articles published prior to January 2019 referenced in Pub Med database, combining research with Medical Subject Headings "Electroconvulsive Therapy" and each following pharmacological class: "Cardiovascular Agents" "Bronchodilator Agents" "Bronchoconstrictor Agents" "Theophylline" "Anticoagulants" "Hypoglycemic Agents" "Insulin" "Potassium" "Benzodiazepines" "Valproic Acid" "Carbamazepine" "Lamotrigine" "Lithium" "Antidepressive Agents" "Antipsychotic Agents". RESULTS: After reading the titles, abstracts and whole articles, then searching for additional articles in the references, 50 articles were selected. A summary table summarizing the main risks and proposing a course of action has been produced. DISCUSSION: It is essential to take into account the specificity and the different physiological mechanisms involved in the ECT treatment in order to adjust the associated pharmacological treatments. The prescription for each molecule should be reviewed when ECT treatment is initiated.

Multi-trajectories of antidepressant and antipsychotic use: a 11-year naturalistic study in a community-based sample.

OBJECTIVE: To explore the temporal dynamic of antidepressant and antipsychotic co-prescribing in real-life conditions. METHODS: The study was performed using reimbursement data from the French Insurance Healthcare system in a cohort of 118 454 persons with at least one dispensing of antidepressants and/or antipsychotics over the period 2006-2016. Latent class analyses were used to identify homogeneous groups of persons following similar multi-trajectories of antidepressant and/or antipsychotic dispensing. Multivariate polynomial logistic regression models were used to explore the characteristics independently associated with distinct trajectories. RESULTS: Five multi-trajectories of antidepressant and/or antipsychotic dispensing were identified: more than half of the sample (58%) had very low antidepressant and antipsychotic use; two groups had chronic (12%) or decreasing (11%) antidepressant use with very low antipsychotic use; two groups used both antidepressants and antipsychotics simultaneously either in an increasing (12%) or chronic (7%) way. Persons with chronic antidepressant-antipsychotic use presented with markers of poor social and mental health conditions. CONCLUSIONS: Most persons using antipsychotics over the follow-up also used antidepressants over the same period. The benefit/risk ratio of these prescribing practices should be further explored as the long-term efficacy of antidepressant-antipsychotic polypharmacy is poorly documented, while this combination increases the risk of adverse effects.

Trajectory analysis of anxiolytic dispensing over 10 years among new users aged 50 and older.

OBJECTIVE: To identify temporal trajectories of anxiolytic benzodiazepine (A-BZD) use over 10 years among new A-BZD users aged 50 and older and describe treatment patterns and demographic and clinical characteristics associated with each trajectory. METHOD: A representative cohort of the French national health insurance fund users was tracked from 2006 through 2015. We used latent class mixed models to identify the trajectories. RESULTS: We observed four trajectories among new users (no A-BZD dispensing in 2005) plus one non-use trajectory. The proportion of occasional use among users was 60%; early increasing use, 10%; late increasing use, 17%; and increasing/decreasing use, 13%. Prevalence of occasional use decreased with age in women, but not men. Duration of treatment episodes and doses differed between trajectories. Multiple regression analyses with occasional use as the reference showed that the other three trajectories shared characteristics (age, coprescriptions of other psychotropic drugs, and more general practitioner consultations) but differed by the presence at inclusion or occurrence during follow-up of psychiatric, neurodegenerative, and somatic conditions. CONCLUSION: We found four different long-term temporal trajectories in new A-BZD users (occasional, early increasing, late increasing, and increasing/decreasing use). Difficulties quitting or reducing consumption may be very different for each trajectory, requiring tailored care approaches.

[Impact of education program and clinical posting in psychiatry on medical students' stigmatizing attitudes towards psychiatry and psychiatric disorders]. / Impact de la formation théorique et clinique sur les attitudes de stigmatisation des étudiants en médecine envers la psychiatrie et la pathologie psychiatrique.

OBJECTIVE: The aim of the study was to explore whether a medical student education program and clinical posting in psychiatry had an impact on medical students' stigmatizing attitudes towards psychiatry and psychiatric disorders. METHODS: Medical students from the University of Bordeaux were recruited during their 4-year course at the beginning of the academic education program in psychiatry. Medical students who were concomitantly in a clinical posting in wards of psychiatry or neurology were invited to participate in the study. The medical student version of the scale Mental Illness: Clinicians' Attitudes (MICA) was used to measure their attitudes towards psychiatry and persons with psychiatric disorder. This 16-item scale is designed to measure attitudes of health care professionals towards people with mental illness, a higher score indicating more stigmatizing attitudes. Items exploring history of psychiatric disorders in close persons were added at the end of the MICA scale. The questionnaire was completed twice by each student, at the beginning and the end of the 11-week clinical posting. All questionnaires were strictly anonymized. Multivariate linear regression analyses were used to identify the variables independently associated with MICA total score. RESULTS: At the beginning of the education program and clinical posting, 174 students completed the MICA scale: the mean MICA total score was equal to 46.4 (SD 6.9) in students in clinical posting in psychiatry (n=72) and 45.1 (SD 7.01) in those in neurology (n=102). At the end of the academic and clinical training, 138 students again completed the questionnaire, with mean MICA total scores equal to 41.4 (SD 8.1) in students in clinical posting in psychiatry (n=51) and 43.5 (SD 7.3) in those in neurology (n=87). Multivariate analyses showed that lower total MICA scores were independently associated with the time of assessment (lower scores at the end of education program and clinical posting) (b=-2.8; P=0.001), female gender (b=-1.8; P=0.03) and history of a psychiatric disorder in a close person (b=-1.92; P=0.02). Type of clinical posting (psychiatry vs. neurology) was not independently associated with MICA total scores (b=-0.02; P=0.98). A significant interaction was found between the variables "time of assessment" and "type of clinical posting" (P=0.05): stratified analyses showed that MICA total scores decreased significantly only when the clinical posting was in psychiatry (b=-4.66; P=0.001), with no significant change in medical students in neurology wards (b=-1.45; P=0.16). CONCLUSION: Stigmatizing attitudes of medical students towards psychiatry and psychiatric disorders are reduced by an education program in psychiatry, with a positive impact more marked when the education program is concomitant to a clinical posting in psychiatry. As future health professionals in charge of persons with psychiatric disorders, medical students are key targets of actions aimed at reducing stigma towards mental health disorders. It is hence of great importance to promote clinical training in psychiatric wards during medical studies for all future practitioners, irrespective of their future specialty.

[Computer-assisted therapy and video games in psychosocial rehabilitation for schizophrenia patients]. / L'utilisation des thérapies assistées par ordinateur et des jeux vidéo à visée thérapeutique dans les soins de réhabilitation psychosociale chez les sujets souffrant de schizophrénie, revue de la littérature.

OBJECTIVES: Video games and virtual reality have recently become used by clinicians for training or information media or as therapeutic tools. The purpose is to review the use of these technologies for therapy destined for schizophrenia patients. METHODS: We conducted a review in October 2016 using Pubmed, Scopus and PsychInfo using the following Medical Subject Headings (MESH): "video games", "virtual reality" and "therapy, computer-assisted/methods", each associated with "schizophrenia". Papers were included in the review if: (a) they were published in an English, Spanish or French-language peer-reviewed journal, (b) the study enrolled patients with schizophrenia or schizo-affective disorder, (c) the patients used a therapeutic video game or therapeutic virtual reality device. RESULTS: Eighteen publications were included. The devices studied are mainly therapeutic software developed specifically for therapeutic care. They can be classified according to their therapeutic objectives. These targets corresponded to objectives of psychosocial rehabilitation: improvement of residual symptomatology, cognitive remediation, remediation of cognition and social skills, improvement of everyday life activities, support for occupational integration. Very different devices were proposed. Some researchers analysed programs developed specifically for patients with schizophrenia, while others were interested in the impact of commercial games. Most of the studies were recent, preliminary and European. The impact of these devices was globally positive, particularly concerning cognitive functions. CONCLUSIONS: Computer-assisted therapy, video games and virtual reality cannot replace usual care but could be used as adjunctive therapy. However, recommending their use seems premature because of the recent and preliminary character of most studies. Moreover, a link is still lacking between this field of research in psychiatry and other fields of research, particularly game studies. Finally, it might be interesting to analyse more precisely the neuropsychological impact of existing commercial games which could potentially be useful for psychosocial rehabilitation.

Maternal depressive symptoms and early childhood cognitive development: a meta-analysis.

BACKGROUND: Previous findings have been mixed regarding the relationship between maternal depressive symptoms and child cognitive development. The objective of this study was to systematically review relevant literature and to perform a meta-analysis. METHOD: Three electronic databases (PubMed, EMBASE, PsycINFO) were searched. Initial screening was conducted independently by two reviewers. Studies selected for detailed review were read in full and included based on a set of criteria. Data from selected studies were abstracted onto a standardized form. Meta-analysis using the inverse variance approach and random-effects models was conducted. RESULTS: The univariate analysis of 14 studies revealed that maternal depressive symptoms are related to lower cognitive scores among children aged ⩽56 months (Cohen's d = -0.25, 95% CI -0.39 to -0.12). The synthesis of studies controlling for confounding variables showed that the mean cognitive score for children 6-8 weeks post-partum whose mothers had high depressive symptoms during the first few weeks postpartum was approximately 4.2 units lower on the Mental Developmental Index (MDI) of the Bayley Scales of Infant and Toddler Development (BSID) compared with children with non-symptomatic mothers (B̂ = -4.17, 95% CI -8.01 to -0.32). CONCLUSIONS: The results indicated that maternal depressive symptoms are related to lower cognitive scores in early infancy, after adjusting for confounding factors. An integrated approach for supporting child cognitive development may include program efforts that promote maternal mental health in addition to family economic wellbeing, responsive caregiving, and child nutrition.

Risk of discontinuation of antipsychotic long-acting injections vs. oral antipsychotics in real-life prescribing practice: a community-based study.

OBJECTIVE: To compare the risk of discontinuation of ambulatory antipsychotic treatment in persons treated with antipsychotic long-acting injections (LAIs) or by oral antipsychotics (OAPs). METHODS: The study was performed in a representative sample of persons newly treated with OAPs (n = 6904) affiliated to the French Insurance Healthcare system. The risk of all-cause discontinuation was compared in patients prescribed OAPs (n = 246) vs. matched patients prescribed LAIs (n = 246) using multivariate survival analyses. Confounding by indication was minimized by matching on type of antipsychotic drug and by the high-dimensional propensity score method. RESULTS: Discontinuation was more frequent with OAPs (69%) compared to LAIs (57%) [adjusted relative risk (aRR) = 1.6, 95% CI 1.23-2.07]. Risk of discontinuation was higher for first-generation (FGA) OAPs vs. FGA LAIs (aRR = 1.94, 95% CI 1.22-3.08) as well as for second-generation (SGA) OAPs vs. SGA LAIs (aRR = 1.58, 95% CI 1.15-2.17). Over the 6-month period after discontinuation of LAIs, a new antipsychotic drug was dispensed in 58% of patients, the most frequent pattern being dispensing of the same LAI as that prescribed before discontinuation. CONCLUSIONS: Although less frequent than with OAPs, the rate of ambulatory treatment discontinuation was high with LAIs. Prescription of LAIs should be associated with intervention strategies aimed at promoting medication adherence.

International trends in clozapine use: a study in 17 countries.

OBJECTIVE: There is some evidence that clozapine is significantly underutilised. Also, clozapine use is thought to vary by country, but so far no international study has assessed trends in clozapine prescribing. Therefore, this study aimed to assess clozapine use trends on an international scale, using standardised criteria for data analysis. METHOD: A repeated cross-sectional design was applied to data extracts (2005-2014) from 17 countries worldwide. RESULTS: In 2014, overall clozapine use prevalence was greatest in Finland (189.2/100 000 persons) and in New Zealand (116.3/100 000), and lowest in the Japanese cohort (0.6/100 000), and in the privately insured US cohort (14.0/100 000). From 2005 to 2014, clozapine use increased in almost all studied countries (relative increase: 7.8-197.2%). In most countries, clozapine use was highest in 40-59-year-olds (range: 0.6/100 000 (Japan) to 344.8/100 000 (Finland)). In youths (10-19 years), clozapine use was highest in Finland (24.7/100 000) and in the publicly insured US cohort (15.5/100 000). CONCLUSION: While clozapine use has increased in most studied countries over recent years, clozapine is still underutilised in many countries, with clozapine utilisation patterns differing significantly between countries. Future research should address the implementation of interventions designed to facilitate increased clozapine utilisation.

Geographical disparities in prescription practices of lithium and clozapine: a community-based study.

OBJECTIVE: To explore the socioeconomic and health resource characteristics associated with geographical variations of lithium and clozapine dispensing rates in France. METHOD: The study was performed using reimbursement data from the French Insurance Healthcare system over the period 2006-2013 in a community-based sample of persons aged 16 years and over. An ecological design was used to assess whether lithium and clozapine prescribing rates were associated with socioeconomic and health resource characteristics of the zone of residence (n = 95 French administrative subdivisions). RESULTS: Large geographical disparities were observed in dispensing rates: lithium dispensing rates by zone of residence ranged from 0 to 6.6 per 1000 (mean 2.4 per 1000) and clozapine dispensing rates ranged from 0 to 4.9 per 1000 (mean 0.8 per 1000). Higher density of GPs and regular communication between mental health services and primary care were independently associated with higher rates of lithium and clozapine dispensing and with a higher proportion of lithium users among mood-stabilizer users. CONCLUSION: A sufficient density of GPs and an effective communication and collaboration between mental healthcare services and primary care seems to favor greater access to psychotropic drugs with demonstrated efficacy but often viewed as 'risky' to prescribe.

[Involuntary hospitalization under the Act of July 5th 2011: A study of patients' experience and understanding of their hearing with the judge ruling on civil detention cases]. / Étude du vécu et de la compréhension par les patients hospitalisés sans consentement de l'audience devant le juge des libertés et de la détention.

OBJECTIVE: To assess involuntary admitted patients' experience and understanding of their hearing with the judge ruling on civil detention cases according to the Act of July 5th 2011. METHODS: The evaluation was conducted through face-to-face interviews, from a semi-structured questionnaire, with 48 involuntary admitted patients under psychiatric care admission on a third party request (ASPDT) or on state representative decision (ASPDRE) (participation rate=96%). RESULTS: Few participants knew the name of the hearing place (13%) and the judge's exact title (21%). About 58% of them had benefited from lawyer services. During the hearing, half of the patients contested the need for hospitalization. The judge was perceived as clear (79%), listening (69%) and benevolent (58%), but only 46% of patients believed that he/she was impartial and 35% that he/she was independent from medical decisions. More than half of the patients disagreed with the judge's decision (56%). However, only 19% of them planned to appeal. Three out of four were in favour of a judicial review of involuntary hospitalization. A feeling of protection was more common in people with a higher educational level (65% versus 35%, Chi(2) (1) = 3.9, P = 0.05) and who suffered from mood disorders (75% versus 46%, Chi(2) (1) = 3.8, P = 0.05). A feeling of being accused was more frequent in persons with hospitalization under psychiatric care admission on state representative decision (ASPDRE) than on a third party request (ASPDT) (37% vs 10%, Chi(2) (1) = 4.9, P = 0.03). Persons under guardianship were also more likely to report such feelings (32% versus 10%, Chi(2) (1) = 3.4, P=0.06). The feeling that "everything was preordained" was more common in younger patients (m = 36.4 years [SD = 13.9] vs m = 46.2 years [SD = 17.8], t-test [46] = 2.01, P = 0.04), as well as among those who used the advice of a lawyer, with an association at a trend level (73% versus 46%, Chi(2) (1) = 3.5, P = 0.06). CONCLUSION: Systematic judicial review of involuntary hospitalization represents a major evolution in the patients' rights field. This study shows that their experience and understanding of the hearing with the judge ruling on civil detention cases are quite mixed. In clinical practice, informing the patient about the upcoming hearing may allow the physician who initiates the hospitalization to reassure him/her as the intervention of a third party will be required to confirm the legality of involuntary admission. Furthermore, such information about the judicial intervention might avoid unproductive confrontation between the patient and the physician when the person remains opposed to the hospitalization. However, some patients may be disappointed as they are heavily invested in the preparation of their "defence" and have high hopes in the intervention of a judge who most often maintains the hospitalization.

Assessing metacognition during a cognitive task: impact of "on-line" metacognitive questions on neuropsychological performances in a non-clinical sample.

Whereas metacognition is of great interest for neuropsychological practice, little is known about the impact of metacognitive questions during a neuropsychological assessment. This study explored the impact of measuring "on-line" metacognitive processes on neuropsychological performances in a non-clinical population. Participants were randomly assigned to a "standard" or a "metacognitive" neuropsychological test procedure. The "standard" procedure assessed executive functions (Modified Card Sorting Test), episodic memory ("Rappel libre Rappel indicé" 16), working memory (digit span test Wechsler Adult Intelligence Scale III) and social cognition (Faces Test). In the "metacognitive" procedure, two questions were added after each item of these tests to evaluate "on-line" metacognitive monitoring and control. Working memory performances were better and episodic memory performances lower in the "metacognitive" versus the "standard" procedure. No significant difference was found concerning executive functioning or social cognition. The assessment of "on-line" metacognition might improve working memory performances by enhancing concentration, and might impair episodic memory performances by acting as a distractor. These findings may have implications for the development of cognitive remediation programs.

Clozapine use pattern in persons with and without treatment for Parkinson's disease in real-world conditions: a naturalistic study in a community-based sample.

OBJECTIVE: To explore the pattern of clozapine use in persons with severe mental illness and in persons with Parkinson's disease and the characteristics associated with early discontinuation in naturalistic conditions. METHOD: A historical fixed cohort study of persons newly treated with clozapine was performed on a representative community-based sample of persons affiliated to the French health insurance system (n = 611,393). Treatment for Parkinson's disease was used as a proxy for this condition and lack of such treatment as a proxy for severe mental illness (SMI). RESULTS: The prevalences of antipsychotic and clozapine use were 4.4% and <0.1% respectively. Of the 237 persons with a new outpatient prescription of clozapine, 25% were prescribed an antiparkinsonian treatment. In persons with SMI, the median duration of the index episode of clozapine treatment was 4.9 months (Interquartile range 1.0-20.5). Longer duration was independently associated with coprescription of anxiolytics or antidepressant. Few new additions of antipsychotics were observed during the clozapine episode. CONCLUSION: Efforts have to be made to optimize clozapine treatment in real-world conditions. Considering the high frequency of persons with Parkinson's disease among clozapine users, further studies have to be performed in this population.

Economic impact of antidepressant treatment duration in naturalistic conditions.

OBJECTIVE: To assess the economic impact of the duration of antidepressant drug treatment in a real-life setting. METHOD: A historical fixed cohort study included 27 917 patients aged 18 and over with a new antidepressant treatment registered in the national insurance database. The economic impact concerned healthcare expenditure in the first 3 months after treatment discontinuation. Generalized linear models were used to compare two groups of treatment duration: <6 months and 6 months and over. RESULTS: After adjustment for care costs before and during treatment episode, gender, age, chronic diseases, welfare and prescriber specialty, total healthcare costs (in log) [-0.06 (-0.14;0.01) P = 0.11] and psychiatric care costs (in square root) [-0.08 (-0.41;0.25) P = 0.6] were similar in both groups. Non-psychiatric care costs were significantly lower in the 'long treatment duration' group compared with the 'short treatment duration' group [-11.4 (-15.8; -7.0) P < 0.0001]. The decreases in total and non-psychiatric care costs over the antidepressant treatment episode were larger in the 'long treatment duration' group compared with the 'short treatment duration' group. CONCLUSION: With regard to healthcare costs and global health, antidepressant drug treatments of short duration appear less effective than treatment of recommended duration.

[Patient therapeutic education in psychiatry. A survey of practice in Aquitaine public hospitals]. / Pratiques d'éducation thérapeutique en psychiatrie. Enquête auprès des psychiatres hospitaliers d'Aquitaine.

OBJECTIVE: The aims of this study were to assess the characteristics of therapeutic education practice in French public psychiatric hospitals and to describe the ongoing patient education programs. METHODS: We conducted an online survey. Adult and child psychiatrists (n=264) of Aquitaine's public hospitals (n=9) were asked to describe their daily educational practice using an internet questionnaire. Coordinators of patient education programs were invited to complete a specific questionnaire describing these programs. RESULTS: Of the 264 psychiatrists contacted, 95 participated in the only survey (participation rate 36%), 85.7% were adult psychiatrists and 14.3% child psychiatrists. Most psychiatrists (85% or more) "always or often" educated their patients on the disease (name, etiology, symptoms), its treatment and the prevention of relapses and complications. Other mental health professionals, such as nurses, were rarely involved in this educational process. Less than a quarter of the psychiatrists "always or often" invited their patients to participate in a structured patient education program. Twelve education programs were described by their coordinators (13.6% of the participants). Compared to non-coordinators, coordinators had graduated significantly more frequently less than 10years before (92% vs. 49%) but did not differ regarding other characteristics. Bipolar disorder (n=4) and schizophrenia (n=7) were the most frequent indications of these programs. Half of the programs were distributed by pharmaceutical companies. Almost half (45%) of the programs were opened to patient's carers and relatives. Increase in knowledge and competence were evaluated in 73% of the programs, and satisfaction in 64% of the programs. These findings have to be interpretated in the light of a possible selection bias favouring the participation of practitioners supporting or actively implicated in patient education, contributing to inflated estimates of the real frequency of educational practice in public psychiatric hospitals. CONCLUSION: On the one hand, our study shows a strong involvement of psychiatrists in patient therapeutic education in daily practice. On the other hand, very few structured programs were ongoing, mostly concerning bipolar disorder and schizophrenia, i.e. disorders for which evidence of efficiency of patient education has been demonstrated. These findings suggest that implementation of further patient education programs should be encouraged and that formation of further professionals is a priority.

[Characteristics and impact of metacognitive deficits in schizophrenia]. / Caractéristiques et impact des déficits métacognitifs dans la schizophrénie. Revue de la littérature.

OBJECTIVES: The aim of this review of the literature is to summarise the definitions of metacognition, the measurement tools, the results of studies investigating metacognition in persons with schizophrenia and the therapeutic perspectives. METHOD: This review is based upon a selection of articles identified using a PubMed search containing the terms "schizophrenia" and "metacognition". RESULTS: Cognitive deficits are present in 75 to 85% of persons with schizophrenia. According to the disability model of the World Health Organization, these cognitive deficits have an impact on social functioning, community integration and quality of life. However, heterogeneous results have been obtained by studies exploring the functional impact of cognitive deficits, suggesting that there is no direct relationship between these two characteristics. One possible explanation is that subjective factors, notably metacognition, may play an intermediate role moderating the link between cognitive deficits and functional impairment. Metacognition is defined as the evaluation and regulation of its own cognitive processes. The evaluation (or monitoring) monitors the accuracy and reliability of the cognitive task performance. Regulation (or control) promotes behavioural adjustment. Studies carried out in persons with schizophrenia show that most of them experience deficits in metacognitive performance. These metacognitive deficits are thought to be a key barrier to functioning in schizophrenia. Measurement tools are classified into two types: "independent" measurement of the cognitive task and "on line" measurements performed during the cognitive task. The subjective scale to investigate cognition in schizophrenia (SSTIC) and the metacognitive assessment scale (MAS) are two examples of questionnaires measuring metacognition independently of the cognitive task. Online measurements assess the metacognitive "monitoring" by asking the subject to evaluate between 0 and 100% of his/her degree of confidence in his/her response to a question. The metacognitive "control" is assessed by asking the subject to validate his/her answer. Convergent findings are reported by studies exploring metacognitive persons in people with schizophrenia. Dissociation between metacognitive monitoring and metacognitive control has been reported. Regarding metamemory, which has been currently the most studied area, no difference is observed between persons with schizophrenia and controls with respect to the metamemory judgement. However, subgroups of persons with schizophrenia differ significantly from controls: they are over-confident in their response if it is incorrect and they estimate more frequently than the controls if they do not know when their answer is correct. The relationships between metacognitive and cognitive deficits are complex in persons with schizophrenia, with poor matching between subjective and objective deficits. Several studies have reported that metacognitive difficulties strongly interfere with social functioning. It has been suggested that metacognitive deficits more strongly predict community functioning in persons with schizophrenia than cognitive deficits. Metacognitive skills may hence be viewed as a key factor in translating cognitive performance skills in daily life. CONCLUSION: These data suggest that remediation programs specifically targeting metacognitive deficits have to be further developed.

[Metabolic testing rates after initiation of antipsychotic treatment in persons initially treated by conventional mood-stabilizers]. / Surveillance métabolique biologique après initiation d'un traitement antipsychotique chez des personnes traitées par lithium ou anticonvulsivants.

OBJECTIVES: To assess the rate of metabolic testing after initiation of second-generation antipsychotics (SGA) prescription in persons initially treated by conventional mood-stabilizers (lithium or anticonvulsants, as a proxy of bipolar disorder diagnosis) and to compare the rates of metabolic testing in these persons with those in persons with initiation of first-generation antipsychotics (FGA) prescription or with no antipsychotic prescription. METHOD: Data were anonymously extracted from the 2004 to 2006 French national health database of the Régime Social des Travailleurs Indépendants (RSI). Patients aged 18 years and over were included in the cohort if they fulfilled the following criteria over a three-month inclusion period: refunding of lithium or anticonvulsant over the 3 months without discontinuation (as a proxy of bipolar disorder diagnosis), no concomitant refunding over the 3months of antipsychotic, and no concomitant refunding over the 3 months of an anti-diabetic drug (as a marker of diabetes) or a lipid-lowering drug (as a marker of hyperlipidemia). Metabolic testing was assessed using information collected in the RSI database on the reimbursement of glucose-specific serum tests (glycaemia) and lipid-specific serum tests (total cholesterol). Serum glucose and lipid testings were assessed at baseline and at 12-week follow-up for the first episode of antipsychotic dispensing. Multivariate analyses were performed to compare the rate of metabolic testing in users of SGA to those of users of FGA and to those of non-users of antipsychotics. RESULTS: Three thousand one hundred and seventy patients were included. Of the 490 (15.4%) persons with a first episode of antipsychotic dispensing after the index date, 138 (4.3%) were dispensed only FGA over the first episode and 352 (11.1%) SGA (including 37 patients with both SGA and FGA dispensing). Metabolic testing at baseline and at 12-week follow-up was performed for 14% of persons with initiation of FGA and 12% with initiation of SGA. Almost no patient had both baseline and follow-up testing. Testing rates were lower for lipid testing than for glucose testing. Compared to persons with no antipsychotic, persons with SGA were significantly more likely to have metabolic testing at baseline and at follow-up, independently from other characteristics (adjusted OR=0.24, 95% CI 0.16 to 0.36). No difference was found between persons with SGA and those with FGA (adjusted OR=1.12, 95%CI 0.62 to 2.0). Regarding the other characteristics associated with likelihood of metabolic testing (irrespective of the treatment group), women were more likely than men to have metabolic testing at baseline but not at follow-up. Elderly persons and persons with low occupational status were more likely to have metabolic testing at follow-up. CONCLUSION: From a public health point of view, such findings indicate that the metabolic risks associated with SGA use in real-life conditions are widely underestimated. Regarding the temporal trends of antipsychotic prescription, with the dramatic rise of SGA use observed in most countries, it is a public health priority to improve metabolic monitoring in SGA users, irrespective of the underlying diagnosis. Since it is more complex to modify pre-existing inadequate practices than to initiate correct ones in new prescribers, great attention should be paid to the need for delivering strong messages regarding the metabolic risks associated with SGA prescription during the initial training of physicians.