Organization of French outpatient psychiatric clinics and delay to appointment.

OBJECTIVES: The goals of the study were to obtain a glimpse of the several types of organization of outpatient psychiatric clinics, as well as an overview of delays between a request for and the first appointment. We also look at geographical variability of appointment scheduling delays and assess the impact of the number of new applications on delays. METHODS: We analyzed information collected from a phone survey conducted with the 103 adult outpatient psychiatric clinics of the French region Hauts-de-France. This survey had a one-week inclusion period in November 2022 and focused on the organization and delays before obtaining an appointment. RESULTS: This study indicates that organizations seem to be homogeneous. Eighty-one outpatient psychiatric clinics (96.4%) receive with scheduled appointments. The initial evaluation by a nurse followed with a proposal for the organization of care seems to be the common practice. It also appears that primary psychiatric structures were capable of providing a response within a reasonable time frame in making a first appointment with a mental health professional. On the other hand, delays were much longer and heterogeneous for first appointments with psychiatrists and psychologists. CONCLUSIONS: The organizations of the outpatient psychiatric clinics of the French region Hauts-de-France seem homogeneous. The evaluation by a nurse followed with a care proposal is the common practice. Primary psychiatric structures are able to provide a response within a reasonable time, with half the centers proposing an appointment with a nurse within 10.0 days.

Depression restricts visual capture and promotes the perception of negative information.

Emotional deficits in major depressive disorder lead to changes in the distribution of attention in the visual field. We investigate the impact of unpleasant and neutral pictures, presented in central (0°) and peripheral vision (12°; 24°), in 15 depression patients (DP) and 15 matched healthy controls (HC). Heart rate, skin conductance responses (SCRs) and electroencephalogram (EEG) were recorded. A spatiotemporal principal component analysis (PCA) was applied to the EEG, and ANCOVAs controlling for participants' state- and trait-anxiety and patients' medication were performed to assess the effects of visual eccentricity and emotion. Unlike HC, DP showed for CV stimulation 1/ greater sensitivity with a response bias toward unpleasant pictures, 2/ larger SCRs, especially to unpleasant pictures, and 3/ deeper cardiac deceleration. Furthermore, eccentricity and emotion modulated cerebral components. Finally, results bring a new vista on visual capture of negative information and support methods to enlarge the attentional span of depressed patients.

[Mood disorders: When should we use repetitive transcranial magnetic stimulation?] / Troubles de l'humeur : quand recourir à la stimulation magnétique transcrânienne ?

Repeated transcranial magnetic stimulation (rTMS) is still a recent treatment in psychiatry. This article aims at updating the clinicians'knowledge about rTMS in the treatment of mood disorders (uni and bipolar depressive disorders, manic/mixed states, suicidal risk, catatonia). It is intended for clinicians who are required to indicate and/or use rTMS in their current practice. rTMShas the highest level of evidence for the treatment of unipolar depression, provided that effective parameters are used, that is to say, for classical high frequency protocols: 20 to 30 sessions, 1000 pulses/session, 5 to 20Hz, and 110 % of the motor threshold. Low frequency protocol are also efficient and well tolerated. The duration of the efficacy varies with relapses rates around 50 % at one year. Pharmacological treatment generally remains associated. With regard to manic states, and mixed states the results are preliminary and limited to a possible reduction in symptoms. In the suicidal risk associated with mood disorders, the interest of rTMS is still to demonstrate, as well as in catatonia. The current place of the rTMS is no longer disputed in the curative treatment of major depressive disorder, preferentially used after one or two lines of antidepressants upstream. Further studies are needed to confirm preliminary positive findings in other aspects of mood disorders.

[Potentiation strategies]. / Dépression résistante : les stratégies de potentialisation.

Lithium is among the most classically recommended add-on therapeutic strategy for the management of depressive patients showing unsuccessful response to standard antidepressant medications. The effectiveness of the add-on strategy with lithium requires achieving plasma levels above 0.5 mEq/L. Mood-stabilizing antiepileptic drugs such as carbamazepine, valproate derivatives or lamotrigine have not demonstrated conclusive therapeutic effects for the management of depressive patients showing unsuccessful response to standard antidepressant medications. Thyroid hormones are considered among the currently recommended add-on therapeutic strategy for the management of depressive patients showing unsuccessful response to standard antidepressant medications. The effectiveness of the add-on strategy with thyroid hormones requires achieving plasma concentration of TSH close to the lower limits at the normal range (0.4 µUI/L) or even below it. Second-generation antipsychotics such as aripiprazole or quetiapine have consistently demonstrated significant therapeutic effects for the management of depressive patients showing unsuccessful response to standard antidepressant medications. Second-generation antipsychotics however require the careful monitoring of both cardiovascular and metabolic adverse effects.

[How to define treatment-resistant depression?]. / Quelle définition pour la dépression résistante ?

The most largely used definition of the treatment-resistant depression relies on the failure of two successive trials of antidepressant treatment at an adequate dose and duration. The absence of response to previous antidepressant treatments should be assessed using specific and appropriate clinical instruments enabling a correct staging of the therapeutic resistance. A wide range of socio-demographic and clinical factors (i.e. psychiatric/somatic comorbidities) are classically associated with the therapeutic resistance. The aim of the treatment of major depression is to achieve a complete clinical remission. The presence of residual symptoms increases the risk for the subsequent occurrence of relapses and recurrences, hence facilitating the development of therapeutic resistance. The treatment-resistant depression has a deleterious impact on the social, familial or professional functioning, thereby leading to an impaired quality of life with serious socioeconomic consequences and costs.

[Other therapeutic strategies]. / Dépression résistante : les autres stratégies thérapeutiques.

Non-selective and irreversible MAOI have become as third or fourth-line strategy for the management of treatment-resistant depression. Non-selective and irreversible MAOI requires careful monitoring of drug interactions and dietary restrictions. Nutritional supplements such as omega-3 have been found to produce beneficial effects in the management of treatment-resistant depression when administered in combination with the ongoing antidepressant treatment. The glutamate antagonist ketamine has been found to produce beneficial effects in the management of treatment-resistant depression while administered alone. Dopamine and/or norepinephrine agonists, such as methylphenidate, modafinil or pramipexole, have been found to produce beneficial effects in the management of treatment-resistant depression when administered in combination with the ongoing antidepressant treatment.

[Switching and combining strategies of antidepressant medications]. / Dépression résistante : les stratégies de changement et d'association de médicaments antidépresseurs.

Switching antidepressant medication may be helpful in depressed patients having no benefit from the initial antidepressant treatment. Before considering switching strategy, the initial antidepressant treatment should produce no therapeutic effect after at least 4 weeks of administration at adequate dosage. Choosing an antidepressant of pharmacologically distinct profile fails to consistently demonstrate a significant superiority in terms of effectiveness over the switching to another antidepressant within the same pharmacological class. Augmenting SSRI/SNRIs with mirtazapine/mianserin has become the most recommended strategy of antidepressant combinations. Augmenting SSRI with tricyclic drugs is now a less recommended strategy of antidepressant combinations given the increased risk for the occurrence of pharmacokinetic drug-drug interactions and adverse effects.

Dissociation of explicit and implicit responses during a change blindness task in schizophrenia.

BACKGROUND: Patients with schizophrenia are abnormally disturbed by information onsets, which may result in a disadvantage in filtering relevant information. The paradigm of change blindness offers the interesting possibility of studying sensitivity to the sudden irruption of visual information with ecological stimuli in schizophrenia. An increased attentional capture by the irruption of visual information would suggest better performance in patients than in healthy controls. This approach has the advantage of circumventing a non-specific general attentional deficit in schizophrenia. METHODS: Sixteen patients with schizophrenia and 16 healthy controls were asked to detect changes in 99 scenes with 0, 1 or 3 changes. We measured the participants' speed and accuracy in explicitly reporting the changes via motor responses and their capacity to implicitly detect changes via eye movements. RESULTS: Although the controls were faster and more efficient in explicitly reporting changes, the patients' eyes shifted more quickly toward the changes. Regardless of the group, increasing the magnitude of change improved the performance. CONCLUSIONS: The better capacity of the patients to shift their eyes toward changes confirmed the capture by the sudden irruption of visual information in schizophrenia while avoiding the effects of general attentional deficits. However, the striking dissociation between this implicit response and the capacity to explicitly report changes could be interpreted as a deficit in access to conscious perception.

Pernicious anemia presenting as catatonia: correlating vitamin B12 levels and catatonic symptoms.

Pernicious anemia has been associated with various psychiatric manifestations, such as depression, mania and psychosis. Psychiatric symptoms can sometimes occur without hematological and neurological abnormalities and can be prodromal of vitamin B12 deficiency. We report a case of autoimmune B12 deficiency presenting as catatonia without signs of anemia or macrocytosis, in which a correlation was found between the patient's B12 blood levels and catatonic symptoms over time. This catatonic episode was successfully treated with only lorazepam and adequate doses of cyanocobalamin.

Neural functional organization of hallucinations in schizophrenia: multisensory dissolution of pathological emergence in consciousness.

Although complex hallucinations are extremely vivid, painful symptoms in schizophrenia, little is known about the underlying mechanisms of multisensory integration in such a phenomenon. We investigated the neural basis of these altered states of consciousness in a patient with schizophrenia, by combining state of the art neuroscientific exploratory methods like functional MRI, diffusion tensor imaging, cortical thickness analysis, electrical source reconstruction and trans-cranial magnetic stimulation. The results shed light on the functional architecture of the hallucinatory processes, in which unimodal information from different modalities is strongly functionally connected to higher-order integrative areas.

Self awareness and speech processing: an fMRI study.

Language production and perception imply motor system recruitment. Therefore, language should obey the theory of shared motor representation between self and other, by means of mirror-like systems. These mirror-like systems (referring to single-unit recordings in animals) show the property to be recruited both when accomplishing and when perceiving a goal-directed action, whatever the sensory modality may be. This hypothesis supposes that a neural network for self-awareness is involved to distinguish speech production from speech listening. We used fMRI to test this assumption in 12 healthy subjects, who performed two different block-design experiments. The first experiment showed involvement of a lateral mirror-like network in speech listening, including ventral premotor cortex, superior temporal sulcus and the inferior parietal lobule (IPL). The activity of this mirror-like network is associated with the perception of an intelligible speech. The second experiment looked at a self-awareness network. It showed involvement of a medial resting-state network, including the medial parietal and medial prefrontal cortices, during the 'self-generated voice' condition, as opposed to passive speech listening. Our results support the fact that deactivation of this medial network, in association with modulation of the activity of the IPL (part of the mirror-like network previously described), is linked to self-awareness in speech processing. Overall, these results support the idea that self-awareness is present when distinguishing between speech production and speech listening situations, and may depend on these two different parieto-frontal networks.