[Association between screen time and sleep habits in 11-to-12-year-old French middle school students]. / Associations entre les temps d'écran et les habitudes de sommeil chez des jeunes collégiens.

BACKGROUND: Screen media usage has become increasingly commonplace in daily life with children initiating themselves to screen media at an early age. Given the high prevalence of screen viewing among children worldwide, its impact on children's health has become a cause for concern. Unfortunately, little information on the independent association between sleep habits and screen time in French children is currently available. The main aim of this study was to assess possible relationships between screen time and sleep habits (quality, duration, etc.) among young middle school students in France. METHODS: A total of 448 (55 % girls) 11-to-12-year-olds from 5 schools were included. Body weight and height were measured according to standard procedures and BMI percentiles were determined based on international reference values. Sleep parameters were obtained by sleep diaries and visual estimations. A sleep diary was maintained for one week to record sleeping and waking times and related information. Information on lifestyle habits (sedentary behaviours, physical activity, and dietary intake) was obtained via standardised questionnaires. RESULTS: Participants were 11.5 (±0.4) years of age. From total sample, 25.5 % reported screen time ≥2hours/d during school days and 62.7 % during school-free days. High screen time was associated with significantly poorer sleep habits and these results remained valid after adjustment for several confounding factors (body mass index, sex, center and parental level of educational attainment) (P<0.05). CONCLUSION: This study highlights an association between longer screen time and shorter sleep duration in French middle school students aged 11 to 12 years. Preventive measures on use of and exposure to screens are called for. Further studies are necessary to confirm our findings.

[Supervised off-label prescribing of methylphenidate in adult ADHD]. / Prescriptions hors AMM supervisées de méthylphénidate dans le TDAH de l'adulte.

OBJECTIVE: Off-label prescription is a common practice in psychiatry, raising health and economic concerns. Collegial consultation could allow a framed prescription of treatments that are not authorized in specific indications. Attention Deficit Hyperactivity in adult populations (ADHD) is a striking example of a pathology where off-label prescription is frequent. First considered to be a childhood disorder, the awareness of this condition in adults is increasing, leading to the development of new clinical practices and treatments. However, the adult ADHD diagnosis and its management are still emerging in France despite a high prevalence. Treatment of adult ADHD relies on methylphenidate prescription, but the initiation of this drug is not authorized in adult populations. Methylphenidate is a central nervous system stimulant that is structurally close to amphetamine and acts as a norepinephrine and dopamine reuptake inhibitor. Due to these pharmacological properties, neuropsychiatric and cardiovascular side-effects could occur. Furthermore, its addictive potential has led France to classify it as a psychoactive drug, dispensed via secured prescription. The first prescription and the one-year follow-up are restricted to neurologists, paediatrics, psychiatrists and sleep disorders specialists at hospital. The objective of this article is to propose a multidisciplinary framework for the off-label prescription of methylphenidate in adult ADHD. METHODS: The Multidisciplinary Advice Consultation for Exceptional Addiction Treatments (Consultation d'Avis Multidisciplinaire de Traitements d'Exception en Addictologie CAMTEA) was first set up in Lille for the prescription of baclofen in alcohol dependence and was then extended to topiramate in binge eating disorder. This procedure has been adapted to the particularities of ADHD in adult populations, the differential diagnosis (bipolar disorder, depressive disorder, anxious disorder, personality disorder, substance use disorder) and the co-morbidities requiring a full psychiatric and neuropsychological assessment. Moreover, a particular attention has been paid to the monitoring of neuropsychiatric, cardiovascular and misuse risk because of the potential side-effects of methylphenidate. RESULTS: The proposed prescription framework is structured into several specialized consultations. A first psychiatric evaluation aims to diagnose adult ADHD, using the French version of the Diagnostisch Interview Voor ADHD 2.0 questionnaire (DIVA 2.0), and to assess the quality of life impact with the Weiss Functional Inventory Rating Scale (WIFRS). It also searches for the presence of differential diagnosis or co-morbidities. The second appointment consists of a pharmacological evaluation that aims to search for contraindications and potential drug interaction. A neuropsychological evaluation based on standardized tests (Weschler Adulte Intelligence Scale [WAIS IV], Conner's Continuous Performance Test 3 [CPT] and the Minnesota Multiphasic Personnality Inventory [MMPI]) is also required to evaluate neurocognitive disabilities and personality features. Once the parameters of the different assessments have been collected, the synthesis is presented during a multidisciplinary meeting in order to assess the risk-benefit ratio for each patient. Several specialties are involved in this multidisciplinary meeting: psychiatry, addictology, general medicine, addictovigilance, pharmacovigilance and neuropsychology. One strategy among three possibilities can be decided: (1) contraindication to treatment with methylphenidate, (2) attention deficit disorder that does not require medication management, and (3) indication of treatment with methylphenidate with the choice of the pharmacological form (immediate or prolonged release). A biological check-up and an electrocardiogram are carried out systematically before any treatment. If the decision is made to initiate treatment, it is started at the lowest dosage and followed by a titration phase. A weekly follow-up is carried out during the titration phase in order to assess treatment efficacy and safety. After treatment stabilization, the general practitioner can carry out the renewal, and the patient will be reassessed within the framework of the multidisciplinary consultation every 3 months. CONCLUSION: When an off-label prescription is being considered, it must comply with the basic rules of good clinical practice, and the benefit/risk ratio should be constantly reassessed. The proposed multidisciplinary framework, adapted to the characteristics of adult ADHD and the pharmacological properties of methylphenidate, appears to be an interesting strategy to meet the requirements of the good clinical practice. The complementary assessments carried out and the collegial framework allow enhancing the patient's follow-up and minimize the drug risk, particularly in the psychiatric, addictive and cardiovascular adverse events. Finally, this framework could also help the monitoring of other off-label treatments for ADHD, such as atomoxetine or guanfacine.

[Mitochondrial Neuro-Gastro-Intestinal Encephalopathy (MNGIE): When and how to suspect it in front of an atypical anorexia nervosa?] / Encéphalopathie mitochondriale neuro-gastro-intestinale (MNGIE) : quand et comment l'évoquer devant une anorexie mentale atypique ?

INTRODUCTION: The Mitochondrial Neurogastrointestinal Encephalopathy (MNGIE) disease is an extremely underrated syndrome beginning around the age of eighteen years. Because of its severity, this diagnosis should be considered when a patient presents an atypical anorexia nervosa. MNGIE disease is inherited in an autosomal recessive manner and related to mutations of the TYMP gene (ch22q13.32-qter), encoding the thymidine phosphorylase. The MNGIE is often misdiagnosed and is associated with a time to diagnostic of about 12 years after first symptoms. Thus this critical review aims to help clinicians better identify symptoms and paraclinical markers of the MNGIE as a differential diagnosis of atypical anorexia nervosa. METHODS: A literature search was performed using PubMed and Google Scholar databases. RESULTS: The clinical diagnosis of the MNGIE disease should be based on the association of severe loss of weight and some additional symptoms: (1) severe gastrointestinal dysmotility (nausea, vomiting, intestinal pseudo-obstruction), (2) ptosis or external ophtalmoplegia and (3) peripheral sensorimotor neuropathy. When MNGIE disease is clinically suspected, paraclinical testing can help to validate the MNGIE diagnostic: (1) Arterial blood test reveals lactic acidemia (e.g. an increased serum concentration of lactate without pH modifications), and (2) Brain MRI indicates leukoencephalopathy, usually asymptomatic. Direct evidence of MNGIE disease is based on specific testing of: (1) the thymidine phopshorylase enzyme activity in leukocytes is less than 10% of the control, (2) the increase of plasmatic thymidine (>3µmol/L) and the increase of plamatic deoxyuridine (>5µmol/L), (3) the evidence of mutations of the TYMP gene by molecular genetic testing. CONCLUSION: The MNGIE disease is a severe trouble with multisystemic complications. The thymidine phopshorylase enzyme activity in leukocytes should be measured as soon as possible when a patient presents atypical anorexia nervosa.

Stratifying delays for assessment by type of substance to improve the probability of attendance in outpatient services.

AIMS: 1) To confirm the association between delay for assessment (DFA) and probability of first-time attendance in outpatient substance use disorder (SUD) treatment. 2) To evaluate whether this association varies by the type of primary substance for which the assessment was requested. 3) To assess the possibility of estimating differential DFAs to conform to equal probabilities of attendance across various types of primary substance. METHODS: A prospective observational cohort of consecutive patients (N=1015) who requested a first-time assessment appointment at a publicly funded outpatient SUD treatment center in France between January 2014 and December 2015 was conducted. Logistic regression analyses were performed to evaluate associations between DFA (after log-transformation) and attendance and to provide estimates of attendance probability over time by the type of primary substance. FINDINGS: After adjusting for gender, age and referral status, the attendance rate was observed to decrease significantly with longer DFA (OR=0.54; 95%CI: 0.44-0.66). The strength of this association differed across types of primary substance (p for heterogeneity <0.0001), with the strongest association being found for opioids (adjusted OR=0.21; 95%CI: 0.10-0.45). DFA was also associated with attendance for alcohol (OR=0.51; 95%CI: 0.37-0.71) and cannabis (OR=0.60; 95%CI: 0.37-0.96), but not for tobacco (OR=0.95; 95%CI: 0.60-1.50). Differential DFAs reflecting equal probabilities of attendance across types of substance could be estimated. CONCLUSION: Our study suggests that the approach of stratifying DFAs by the type of primary substance could be helpful to improve the probability of first-time attendance in outpatient SUD treatment services.

Screening for eating disorders in outpatient smoking cessation: Feasibility, pertinence, and acceptance of referral to specific treatment.

OBJECTIVE: To estimate (1) the feasibility and pertinence of implementing systematic screening for eating disorders (EDs) in outpatient smoking cessation (SC), and (2) the acceptance of a referral to ED-specific treatment. METHODS: Tobacco smokers (N = 203) who consecutively underwent the initial assessment of a SC program were screened for an ED. Screen-positive patients were administered the Mini International Neuropsychiatric Interview and received a referral to ED-specific treatment using brief advice when identified with a current ED. RESULTS: Among the total sample, the prevalence of a current ED at baseline was 8.9% (men: 1/109, 0.9%; women: 17/94, 18.1%). The acceptance rate of referral to ED-specific treatment was 17%, whereas having a current ED at baseline was significantly associated with a higher probability of dropping out of the SC program at 4 weeks (OR = 21.8, 95%CI: 3.0-161.2, P = 0.003). DISCUSSION: Screening for EDs in outpatient SC seems worthwhile and easily implementable, but patients who are identified with a current ED might not be prone to accept referral to specific treatment and tend to drop out early. This study underlines the need to explore this topic in larger clinical samples. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1018-1022).

Zolpidem test and catatonia.

WHAT IS KNOWN AND OBJECTIVE: There is no consensus regarding treatment of catatonia and the main recent therapeutic progress has been the development of the zolpidem diagnostic and therapeutic test. We report on the use of this test in one of our patients. CASES SUMMARY: Mr. S. suffered from a paranoid schizophrenia. Three episodes of catatonia are described to illustrate the effect of zolpidem in a patient for whom lorazepam was ineffective or inadequate. WHAT IS NEW AND CONCLUSION: Zolpidem with appropriate testing appears to be a credible alternative to electroconvulsive therapy or increased lorazepam dosing and allows continuation of antipsychotic administration.

Interventions for Increasing Subsequent Alcohol Treatment Utilisation Among Patients with Alcohol Use Disorders from Somatic Inpatient Settings: A Systematic Review.

AIMS: Alcohol Use Disorders (AUDs) are common in medical and surgical hospital wards. Brief Interventions (BIs) for reducing alcohol use and consequences are generally inefficacious in this population. Because there is evidence that receipt of formal treatment could be useful, we performed a systematic review to determine efficacious interventions for increasing subsequent alcohol treatment from these settings. METHODS: A systematic literature search of articles published prior to December 2013 to identify articles describing randomised controlled trials (RCTs) in three electronic databases: PubMed, PsycINFO and The Cochrane Library. Data were extracted independently by one reviewer and were checked by a second reviewer. Because of heterogeneity between study groups in treatment utilisation during the follow-up, a meta-analysis was considered inappropriate and a qualitative synthesis was conducted. RESULTS: From the 5030 identified records, only 5 RCTs, including 1113 patients with AUDs, met inclusion criteria. No evidence of efficacy in increasing subsequent treatment utilisation was reported for inpatient BIs alone, but interventions with post-discharge sessions might be beneficial. Increased treatment utilisation was generally associated with favourable drinking outcomes. CONCLUSIONS: Given the small number of included studies and the presence of several alternative methodological explanations for the present findings, no firm conclusions could be drawn on efficacious interventions for increasing subsequent treatment utilisation among somatic inpatients with AUDs. However the findings support efforts to explore this under-researched area.

[Indoor tanning: motivations and beliefs among users and non-users in the population of Lille (Northern France)]. / Cabines de bronzage : étude des motivations et croyances des utilisateurs et non-utilisateurs dans la population lilloise.

BACKGROUND: Uncontrolled use of tanning beds is a major public health problem. The role of UV in skin carcinogenesis has in fact been clearly demonstrated. AIMS: The main purpose of the study was to assess the motivations and beliefs of the population concerning the use of indoor tanning. The secondary objectives were to compare the knowledge of users and non-users and to screen for addiction criteria among users. PATIENTS AND METHODS: This was a transversal descriptive study conducted between April and June 2013 in Lille town center. The motivations of the participants were determined using a multiple-choice questionnaire. A Likert scale was used to assess beliefs and an m-CAGE questionnaire was used to screen for addiction. RESULTS: Of the 200 respondents, 30% (n=60) had used tanning beds in a non-medical setting. The median age of first use was 23 years (15-59). 11.7% of respondents had started before the authorised age of 18 years. "To prepare the skin for exposure to the sun" was the main reason given (68.3%) for use of tanning beds. The population was aware that use of such apparatus favours onset of skin cancer and ageing of the skin. Users were more convinced than non-users that UV cabins "prepare the skin for exposure to the sun" (75% vs. 49.6%, P=0.0009) and that they "favour skin cancer" (56.9% against 36.2%, P=0.0444). Addictive behaviour was detected in 3.3% (2/60) of users. CONCLUSION: Users are aware of the carcinogenic risk of UV cabins but expose themselves to such risk, as they believe it prepares their skin for sun exposure.

Conversion disorders: psychiatric and psychotherapeutic aspects.

Hysteria is still stigmatized and frequently associated with lying or malingering. However, conversion disorder is not malingering, nor factitious disorder. The first step for the clinician faced with suspected conversion disorder is to make a positive diagnosis, which is in fact an integral part of treatment. In the emergency situation, it is important to look for an underlying somatic disorder. Although no specific treatment exists, there is a consensus in favor of a positive role of psychotherapy. First of all, the main problem is to explain to patients that their physical complaint has a psychological cause. In order to deliver the diagnosis in the most appropriate and useful manner, physicians have to first convince themselves before trying to convince patients. Combined consultation (medicine and psychiatry) is a useful tool to help patients. With or without combined consultation, this approach requires patience and open-mindedness to motivate patients to recognize the value of psychotherapy. Coordination between specialists and general practitioners is an important part of this treatment, which frequently requires long-term intervention.

[Involvement of pharmacists in systems for supervising off-label medications: example of the CAMTEA system for the prescription of baclofen in alcohol use disorder in Northern France]. / CAMTEA, un dispositif original de prescription encadrée hors-AMM de baclofène dans le Nord-Pas-de-Calais : quels rôles pour le pharmacien ?

Off-label prescribing matches the using of medications outside the summary of product characteristics. Adverse drug reactions are often poorly studied in off-label situations, which may expose patients to additional safety risks, and impose taking specific precautions. The current off-label prescribing practice of baclofen for alcohol-dependence in France is a typical illustration of such a situation. CAMTEA is a regional system set up in 2010 in Northern France, which gathers addiction and pharmacovigilance specialists, and aims at strengthening the prescription supervising and the monitoring of some off-label medication used for addictive disorders, especially baclofen. Until now, institution or office-based pharmacists have not been implicated, whereas they engaged their liability when delivering off-labeled treatment and they may highly contribute to the patient monitoring and the spotting of adverse events. We propose hereby possible measures for involving pharmacists into the patient supervising system developed within CAMTEA. In the current French context concerning the off-label use of baclofen, which will be the first off-label prescribing practice to be framed by a new legal disposition called "temporary use recommendation", the key role of pharmacists should be highlighted.

Body distortions after massive weight loss: lack of updating of the body schema hypothesis.

Behavioural therapy and bariatric surgery often produce rapid, massive body weight loss that may impact a patient's ability to gauge his/her new body shape. Although the patient is aware of the weight loss, he/she continues to feel obese, as if there was a conflict between the previous body schema and the new one. Here, we report the case of a 40-year-old woman who developed major body distortions after massive weight loss. Psychometric and behavioural assessments revealed strong disturbances in several tasks involving body representation. In particular, we observed abnormal behaviour in a body-scaled action task. Our findings suggest that the rapidity of our patient's weight loss prevented her central nervous system from correctly updating the body schema.

[Penaly ordered care in France: principles of procedures and caregiver's role]. / Les soins ordonnés par la Justice en France : principes des procédures et place du médecin.

BACKGROUND: Penaly ordered care constitutes a type of legal penalty and a form of special care, linking health and legal environments, and as such is a difficult exercise for the various parties involved. METHODS: This article is based on a comprehensive study of medical and legal literature on the subject. RESULTS: Each of the measures presented has a legal basis, procedures for implementation and different application fields. According to the measure, the caregiver has a defined role in the organization of care and flexibility in dealing with specific legal authorities. Doctors are often uncertain of their rights and duties in this type of care. CONCLUSION: Penaly ordered care requires cooperation between two professional bodies with different ethical and professional requirements. Beyond this first difficulty, it appears that these measures are also complicated by the many pieces of legislation published recently, stressing the political will of the ever-expanding scope of ordered care, despite the lack of means downstream, sometimes to the detriment of their effectiveness.

[Determine the patient's position towards psychiatric care: a simple tool to estimate the alliance and the motivation]. / Déterminer la position du patient envers les soins psychiatriques avec le questionnaire Touriste-Plaignant-Client (TPC) : un outil simple pour évaluer l'alliance et la motivation.

OBJECTIVES: For the brief systemic therapy (BST), the evaluation of the patient's position towards the care is a prerequisite to psychotherapy. Three positions of the patient are described. The "tourist's" position: the patient claims to have no problem and doesn't suffer. Someone asks him to make an appointment, sometimes with threats. The "complaint's" position: the patient claims to suffer, but attributes the responsibility of this suffering to others. These two positions are not good for beginning a therapy. The "customer's" position differs from both previous positions. The "customer" considers that he has a psychological problem which depends on him and he is motivated in the resolution of it. In theory, the "customer" is more motivated and the therapeutic alliance is better. It is for this reason that the BST estimates the position of the patient at first, to bring the patient to the "customer's" position. The objective of this study is to assess an interview which identifies the patient's position towards the care, and to validate the theoretical elaborations of the brief systemic therapy. METHOD: The study concerns the follow-up of outpatients who consult a psychiatrist for the first time. The evaluation of the patients checks their position towards care using the Tourist-Complaint-Customer (TCC) inventory, how they suffer, the therapeutic alliance (scale Haq-2) and the compliance during care. The evaluation by the psychiatrists checks the suffering perceived, the motivation perceived and the diagnoses according to the DSM. RESULTS: The typology of these patients is made up of one half "complaint", a quarter of "tourist" and a quarter of "customer". The "customer's" position is correlated with the therapeutic alliance and the motivation perceived by the psychiatrist. The motivation perceived by the psychiatrist is correlated with the therapeutic alliance. These results correspond to the theoretical elaborations of the BST. CONCLUSION: the TCC inventory provides information on the motivation and the therapeutic alliance. If the patient is in "tourist" or "complaint" position, we recommend that the psychiatrist "work" to bring the patient to "customer" position. The evaluation of the position of the patient is simple and rich in information. We recommend that it be given a place in the daily practice of psychiatry.

[Organ donation: point of view of private practice physicians in the region Nord-Pas de Calais in France]. / Le don d'organes : point de vue des médecins libéraux de la région Nord-Pas de Calais en France.

BACKGROUND: In 2008, in France, 222 patients died because they did not receive the graft they expected. The main objective of this study was to determine the attitude of private practice physicians concerning organ donation. METHODS: A postal questionnaire was sent to all private practice office-based physicians in the Nord-Pas de Calais region. This questionnaire was elaborated with a panel of physicians and sociologists. It was sent with the monthly journal of the regional union of private physicians of June 2008. RESULTS: Two hundred and seventy eight questionnaires were returned. One hundred and thirty four (48.2%) respondents declared they knew what the regulations about organ donation were. The majority of respondents approved organ donation. Information to patients was provided during visits by 34.53% (96) of practitioners. For those who were knowledgeable about regulations, 50.75% of them talked about organ donation. Physicians who had already had experience with organ donation were more inclined to talk about it with other patients. The practitioners described three actions they felt could have a positive influence on family acceptance: providing information before death, talking about organ donation in an appropriate sensitive way, and relying on the confidence established by a solid patient-physician relationship. CONCLUSION: Almost 90% of private physicians who responded to the survey were in favor of organ donation but only 34.5% delivered information and discussed the issue with their patients. The physicians coped with the topics more easily when they had experienced cases and when they were informed about existing regulations. A specific educational program on the current regulations and how to interact with patients on this subject during a visit could be a first answer to the problem and would be welcomed by practitioners.

[Patient satisfaction regarding further telephone contact following attempted suicide]. / Vécu subjectif du recontact téléphonique après tentative de suicide.

At a time when increasing importance is given to providing satisfaction to the users of health services, it is surprising that this concept has hardly ever been examined in the field of suicide. Although suicide (prevention and management) is an important part of public health, there seems to be little interest in finding out patients' opinions about the healthcare services which are offered to them. Back in 1976, some authors found a link between the risk of suicide and a low level of satisfaction of healthcare. To date, only two studies looking at management of suicidal patients have included an assessment of patient satisfaction (a strong link between dissatisfaction and suicidal risk was found). During the SYSCALL study, which measured the impact of systematic recontacting by telephone on recurrence of suicide, in the weeks following a suicide attempt, we aimed to find out if this procedure and its methods were well-accepted by the patients. When the patients were first recontacted, 13 months after the suicide attempt, and included in our study, we assessed by means of a questionnaire, their experience of being faced with this intervention, and its impact on their future. Of the 605 patients included, 312 were put into the control group, 147 were recontacted at the end of the first month, and 146 at the end of the third month. The rate of repeat suicide attempts in the year following the initial attempt, was significantly lower in the group that was recontacted after one month, than in the control group [12% against 22%; P=0.03]. It would therefore seem that systematic recontacting by telephone one month after attempted suicide may have contributed in reducing the risk of an early repeat suicide attempt. Of the 482 patients whom we managed to contact by 13 months, 254 had filled out the questionnaire about their subjective experience, in writing or by telephone, this making a response rate of 52.7%. Amongst the patients who replied, female patients are over-represented with more of them being recontacted than males, but no difference was found in the psychiatric symptomatology observed when they were assessed and included in the study. On the other hand, we found a higher incidence of mood disorders and suicidal risk in those who were examined at the final assessment at 13 months. A large majority (78.9%) of the patients who were recontacted, considered recontacting as beneficial, 40.4% considered that it had influenced their lives, and 29.4% thought that recontacting had contributed to avoiding them making a further suicide attempt. Out of the patients recontacted, 94.5% had appreciated the person that had recontacted them, and only 8.3% had been disturbed at being recontacted by a different doctor than the one whom they had met in the Emergency department. A majority of them (54.1%) considered that telephoning was the most appropriate method for recontacting, but of those who were not convinced of being recontacted by telephone, 89.5% of them thought that consultation was the best alternative. Finally, around a third of patients would have preferred being recontacted earlier. On closer examination of the 10 recontacted patients who were dissatisfied by being recontacted, we did not find any elements to characterize them, except for a previous history of more suicide attempts in their family. Finally, a majority of the dissatisfied patients would have preferred being notified in advance of the time of recontacting, and half of them thought that recontacting was too late, but they were not disturbed by being contacted by a different doctor. Telephone recontacting and its methods were surprisingly well-accepted by the patients, even though it is intrusive in nature and unusual in France. We think that despite the inevitable bias that is linked to it, the opinion of patients should be sought and developed in the management of patients who have attempted suicide and in the treatment of the suicidal crisis in general. Even though patients' satisfaction rates may improve the quality of treatment, we should bear in mind that listening to, noting down and examining patients' opinions and words, is in itself a useful factor for patients in their quest for improving their health.

[Addiction and brief-systemic therapy: working with compulsion]. / Addictions et thérapie systémique brève : un travail sous contrainte.

In our daily practice in public hospitals, we are regularly confronted with the paradox of helping patients, who do not ask for help. Although the French law is clearly defined to allow us to treat patients suffering from psychiatric conditions, who are unable to give their consent, it is not the case for those with addictive disorders. In fact, their disorder does not always (or does not yet) justify treatment without their consent, according to the 1990 law (psychiatric treatment without the patient's consent). However, many of them are referred to us because a third party has forced them (spouse, general practitioner, treatment order) and even though some patients consult spontaneously, they often do so more "for others" than for themselves. Because of this, the therapist (doctor, psychologist or nurse), in addition to the paradox of treating patients who do not ask for treatment, find themselves in a situation with two-fold compulsion, fixed by the social (or family) setting, both as a helper and as a coercive agent, thus, putting the fundamental concepts of treatment into question. A therapeutic agreement, free-will and motivation are in jeopardy when the pressure is strong, which removes the therapist from his mission of treating. Although we would not question the necessity for psychiatric treatment in patients who do not ask for it (addictions are a major public-health problem), we should not forget that motivation is one of the essential elements for making any changes in behavior. Although compulsion (external or internal) is recognized by everyone as a limiting factor, we would like to show here how much it can be a lever for change, as long as this compulsion is identified right from the first meeting with the patient, who consults in an addiction centre. Brief systemic therapy may be of interest for these patients, since it reinforces the motivating approach, which is recommended today and since the compulsive nature of the request for treatment is not an obstacle for such treatment to be started. We try to outline here how the therapist can get out of this two-fold compulsion and help the patient to become the instigator of this change, often imposed on him. Two elements are fundamental to understand the function of brief systemic therapy. First of all, "systemic" means "interaction". A systemic approach to treatment requires working in clinical situations, particular attention being paid to interactions. Second, brief therapy does not mean short therapy, but rather therapy with an objective in view. The objective is determined by the patient together with the therapist and they work out together how to reach it, with or without the family's help. Because of this, we use a five-point assessment to offer a concrete response to the patients in these psychotherapeutic consultations. Firstly, is the patient the one who has asked for treatment? We know that in addictive behavior, it is not always the one with symptoms who asks for help (many couples consult who are persuaded that the other one needs to change). Once we know who has asked for treatment, we clarify (with the patient's help) that his/her objectives are not the same as someone who asks for treatment and we can then redefine them (first step in the therapeutic agreement). Once the request for treatment is clarified, we can clearly define what the problem is, the objectives that the patient fixes for him/herself and how to reach them. A large proportion of therapeutic failures result from the request for treatment being unclear. In this way, we define the problem in concrete terms, without using classifications and the previous attempts to solve it (third point). In fact, we often find that the problem itself is the solution, which is chosen to try to resolve it. Knowing which solutions have been tried (and failed) allows the patient to realize what is effective and what is not. The role of the therapist is to help the family and the patient to find other types of solution to their problem. The therapist only offers concrete tasks, which can be done in the near future (minimal changes). Finally, the therapist takes into account the patient's beliefs, values and personal priorities, to which they are attached and which have determined up to now, how they react to the problem. To work with a patient suffering from addiction, it is important, first of all, to find the elements of compulsion, which are hiding behind each request for treatment. This is because, if the patient does not follow the initial therapeutic objectives, there is always the underlying complaint, which should motivate the patient to improve the situation. An individual patient only has a few possibilities for adapting to this type of situation (agreeing, refusal or negotiation) and the role of the therapist is first of all to help him to realize this. This helps to avoid resistance developing, by underlying the compulsive aspect, which originates from the family's request for treatment. We offer a way for setting up the first meeting: working on the role of the patient in the treatment. Three types of patients consult: patients who are "not concerned" (sent by a third party; their main problem is with the person who asked for them to be treated), "victims" (they complain and consult because they put the responsibility of their problem on someone else) and "clients" (they consult because they consider that their problem depends on themselves and they want help to solve it actively). In fact, changing is not easy and does not happen without making an effort. Change comes from a complex cycle of interactions, for which it is often impossible to find a single origin for the situation in question. The psychological world tends towards homeostasis, just like all human systems, and so, suggesting making changes can only be experienced as an intrusion. Pathology begins when an individual can no longer choose what he/she needs to do. We do not consider that a brief-concrete approach is better than any other approach, but its pragmatic nature seems to fit in with the new conception of addiction therapy, with earlier intervention. However, is it possible to make changes outside of a crisis situation? We are unable to answer this question, except to say that the best time for change is that chosen by the patient.

[Severe depression and addictions]. / Dépressions sévères et addictions.

Addictive co-morbidities (or co-occurrent disorder, double diagnosis, associated diagnosis) associated with depression are diagnoses which must be made independently and not only seen as a cluster as symptoms of the disorder or as disorders induced by taking the toxin. The association of an addictive disorder with depression raises a prognostic problem as this association results not only in mutual worsening of the two disorders but in a further problem of penalising access to care with an important sub-diagnosis. This is a common association ; however as 30 to 50% of patients admitted to psychiatric units in Europe have a mental disorder combined with substance abuse (alcohol, sedatives, cannabis). In this article we describe the different findings reported in the literature showing how this association is strong and may have consequences in terms of delayed diagnosis and prognostic and therapeutic impact. We also show that regardless of the origin of the association (attempted self-medication, addiction-induced depression, consequence of depression or a fortuitous association), dual psychiatric and addiction medicine practice is always justified even if this is frequently complex because of the ways in which the different facilities available to us operate in isolation.

[Severe depression : concomitant somatic disease]. / Dépressions sévères : comorbidités somatiques.

The association of somatic disease with a depressive disorder is not uncommon and affects 25% of general hospital inpatient populations. Although not well incorporated into management it is a source of mutual worsening of the two diseases. Several questions arise with this association. Firstly, it is essential to establish whether the depressive disorder is primary or secondary as these situations occasionally involve different (and even opposite) diagnostic and treatment approaches. It is then important to establish whether or not the disorder is adaptatory in nature : although an adaptatory problem does not have the same impact as depression on somatic outcome, it can progress to endogenous depression. Finally it is essential to identify the extent of suicidal risk, which is not only due to the depression but more to the feeling of despair (which is common in patients suffering from severe somatic illness). We will then examine the severity of these interlinked depressions in terms of the diagnostic difficulties (from confusion of symptoms to considering them to be unimportant). We shall then describe all of the consequences of the somatic disease on the prognosis of the depression and vice versa. Finally we will examine the question of severity from the perspective of the most widely studied associated diseases. Whilst the presence of an incapacitating somatic disease is a risk factor for depression in these vulnerable people, depression associated with the different major somatic diseases is a poor prognostic indicator. Somatic co-morbidities are still underestimated and are a factor responsible for chronic progression, deterioration and increased risk of suicide.