Transient improvement in sensorimotor conversion during post-anoxic encephalopathy with bilateral medial temporal ischemia.

We report the case of a patient with sensorimotor conversion that improved transiently during post-anoxic medial temporal ischemia inducing anterograde and retrograde amnesia. Symptoms reappeared in parallel with mnesic recovery. This case raises a hypothesis concerning the role of hippocampi and amygdalae, which are involved in emotionally-associated memory. The amnesia may have modified the patient's "self," giving her a "distant" point of view. Another hypothesis is that cerebral anoxic stress may have "reset" the cerebral network that controls behavior. These findings give clues about the mechanisms of somatoform disorder and highlight the possibility of specific therapeutic strategies to induce cognitive reappraisal of emotionally-associated experiences.

Encouraging French medical students to choose a career in psychiatry: how and why?

There is an increasing demand for psychiatrists in France. This paper reviews the reasons for French medical students choosing psychiatry and the rationale and mechanisms for encouraging them towards this medical speciality. The main factors associated with choosing psychiatry as a career are the quantity and quality of undergraduate training and placements in psychiatry, better attitudes towards psychiatry and more emphasis on a positive life/work balance. The quality of postgraduate training can also influence students' decisions. Medical students should be encouraged to choose psychiatry first to counterbalance the existing stigma towards mental illness within the society, but also towards psychiatry within the medical profession, and second because of the current decline in French medical demography. Ways to improve recruitment are a selection process that favours a large number of psychiatric trainees, and an increase in the quality and quantity of training. Providing medical students with relevant information about training in psychiatry, notably through a national trainees' association, will not only improve the quality of care by increasing recruitment in psychiatry, but also ensure that all future doctors are familiar with and develop positive attitudes towards mental health issues.

Resting motor threshold changes and clinical response to prefrontal repetitive transcranial magnetic stimulation in depressed patients.

AIMS: Several variables are able to influence the antidepressant effects of repetitive transcranial magnetic stimulation (rTMS), particularly the intensity of stimulation, which is generally expressed according to the resting motor threshold (RMT). The aim of our study was to investigate whether or not RMT changes during the treatment of resistant depression by rTMS and whether these fluctuations could alter treatment outcome. METHODS: Seventy-five inpatients suffering from unipolar or bipolar treatment-resistant depression and who had been antidepressant-free or taking a stable antidepressant drug and a daily dose of benzodiazepine for at least a month received a left prefrontal rTMS session once a day for 10 days at 10 Hz and 95% RMT. RESULTS: For the whole group, no significant fluctuation of RMT was observed between the first and the second week of rTMS treatment. However, RMT increased, decreased or remained constant throughout treatment depending on the patient. These RMT changes influenced the outcome of the 10 sessions concerning the severity of depressive and anxiety symptoms, measured by the Beck Depression Inventory and State Trait Anxiety, respectively. CONCLUSIONS: Our results justify calculating RMT regularly, and suggest that its variations play a role in treatment outcome.

Factors influencing French medical students towards a career in psychiatry.

BACKGROUND: There is a need to increase the recruitment to psychiatry in France. Our aim in this study was to compare factors influencing career choice between French medical students considering and not considering psychiatry as a specialty. SUBJECTS AND METHODS: Quantitative cross-sectional online survey on 145 French students in their last year of medical school. RESULTS: 22.7% of our sample considered choosing a career in psychiatry. A preference for a career in psychiatry was associated with more frequent history of personal/familial mental illness, higher ratings of psychiatric teaching, more weeks of compulsory psychiatry teaching and placement, during which students had more often met patients in recovery and been asked their opinion on patients. Students considering psychiatry as a career also emphasized more the need for a good work-life balance, and presented better attitudes toward psychiatry. CONCLUSIONS: Improving opportunities of interactions between students and psychiatrists or psychiatric patients might help to improve recruitment in psychiatry.

Massively multiplayer online role-playing games: comparing characteristics of addict vs non-addict online recruited gamers in a French adult population.

BACKGROUND: Massively Multiplayer Online Role-Playing Games (MMORPGs) are a very popular and enjoyable leisure activity, and there is a lack of international validated instruments to assess excessive gaming. With the growing number of gamers worldwide, adverse effects (isolation, hospitalizations, excessive use, etc.) are observed in a minority of gamers, which is a concern for society and for the scientific community. In the present study, we focused on screening gamers at potential risk of MMORPG addiction. METHODS: In this exploratory study, we focused on characteristics, online habits and problematic overuse in adult MMORPG gamers. In addition to socio-demographical data and gamer behavioral patterns, 3 different instruments for screening addiction were used in French MMORPG gamers recruited online over 10 consecutive months: the substance dependence criteria for the Diagnostic and Statistical Manual of Mental Disorder, fourth revised edition (DSM-IV-TR) that has been adapted for MMORPG (DAS), the qualitative Goldberg Internet Addiction Disorder scale (GIAD) and the quantitative Orman Internet Stress Scale (ISS). For all scales, a score above a specific threshold defined positivity. RESULTS: The 448 participating adult gamers were mainly young adult university graduates living alone in urban areas. Participants showed high rates of both Internet addiction (44.2% for GIAD, 32.6% for ISS) and DAS positivity (27.5%). Compared to the DAS negative group, DAS positive gamers reported significantly higher rates of tolerance phenomenon (increased amount of time in online gaming to obtain the desired effect) and declared significantly more social, financial (OR: 4.85), marital (OR: 4.61), family (OR: 4.69) and/or professional difficulties (OR: 4.42) since they started online gaming. Furthermore, these gamers self-reported significantly higher rates (3 times more) of irritability, daytime sleepiness, sleep deprivation due to play, low mood and emotional changes since online gaming onset. CONCLUSIONS: The DAS appeared to be a good first-line instrument to screen MMORPG addiction in online gamers. This study found high MMORPG addiction rates, and self-reported adverse symptoms in important aspects of life, including mood and sleep. This confirms the need to set up relevant prevention programs against online game overuse.

Bipolar disorder and dementia: where is the link?

Cognitive disorders appearing in the course of bipolar disease have been identified, and recent studies have defined the neuropsychological characteristics of this pathology, which includes attention, executive function, memory and language disorders. However, questions remain concerning the appearance of dementia symptoms over the course of bipolar disorder in certain patients: is it a chance association or is there a connection between bipolar disorders and dementia? If the latter hypothesis is considered, what is the nature of the dementia, which might be considered as a dementia specific to bipolar disorder? Current clinical, neuropsychological and cerebral imaging data are inconclusive, but similarities with frontotemporal dementia might be highlighted. Functional imaging studies might provide answers as well as more specific tests in neuropsychology. The cause of cognitive damage in bipolar disease also raises questions concerning a neurodevelopmental or neurodegenerative process, because several factors seem to influence cognition and these two processes might occur simultaneously. Long-term studies are necessary to determine whether cognitive deterioration in bipolar disease is stable or progressive. There might also be different neurobiological subgroups of patients with bipolar disease.

[Pharmacogenetics of depression in elderly patients]. / Pharmacogénétique de la dépression du sujet âgé

Depression is one of the leading causes of disability and is efficiently treated by antidepressant pharmacotherapy. Pharmacological treatment is still hampered by a delayed time of onset of clinical improvement and a series of side effects. In elderly, it is complicated by an increased risk of adverse drug events, associated with age-related physiological changes, individual variability in drug metabolism mainly related to polymedication, concurrent diseases and diet. Then every physician would like to predict these impairments and to prescribe a "tailored" treatment based on individual characteristics. One of the tools for this tailored medication is the use of pharmacogenetics, leading to an evaluation of the human genome implications in the treatment response (efficacy, time of onset and adverse events). Some candidate-genes have already been identified, showing encouraging results, but only a few studies focus on depressed old subjects. The existing studies have analyzed the polymorphism of the metabolizing enzyme gene CYP2D6 and the serotonin transporter genes implications. The results are promising but more researches are necessary to include pharmacogenetic studies in the clinical practice.

Predictors of remission to antidepressants in late-life depression: a systematic review.

Late-life depression is a heterogeneous mood disorder frequently associated with many adverse conditions, including decreased cognitive function and an elevated risk for comorbid medical disorders, as well as with an elevated mortality rate. Late-life depression encompasses both late-onset as well as early-onset depression that occurs or continues into later years of life. Conventional treatment often required several trials of antidepressants before an effective regimen can be found for an individual. This is associated with persistent depressive symptoms, a disability in activities of daily living and an increased risk of suicide and worsening of medical comorbidities. Thus, in the elderly, it is particularly important to identify predictors of treatment remission to reduce these risks. The purpose of this paper was to review the current status of knowledge regarding predictors of remission to antidepressants among older depressed patients. Patients with high number of cardiovascular risk factors, poor performance in working memory, verbal fluency tests and executive functioning, reduced volumes of cerebral structures (hippocampus, anterior cingular cortex, orbitofrontal cortex) were more likely to reach remission. Reduction of depression score during the first weeks of treatment was correlated with remission. However, more studies are needed to confirm these results.

Amisulpride vs. risperidone in chronic schizophrenia: results of a 6-month double-blind study.

This multicenter, double-blind, randomized study evaluated the efficacy, safety and functional effects of two atypical antipsychotics, amisulpride and risperidone, in patients with chronic schizophrenia (DSM IV) with a recent worsening of symptoms. It was planned as a non-inferiority trial. 309 patients received amisulpride (400-1,000 mg/day) or risperidone (4-10 mg/day) for six months. Amisulpride was demonstrated to be not inferior to risperidone with respect to the decrease in Positive and Negative Syndrome Scale (PANSS) total score from baseline (90% 2-sided confidence interval (-5.6; 4.0)). Symptomatic improvement measured with the Brief Psychiatry Rating Scale (BPRS), the PANSS positive subscale, and the Bech Rafaelsen Melancholia Scale was similar in both groups. Amisulpride was significantly (p <.05) superior to risperidone in terms of response (>/=50% improvement in PANSS and BPRS total scores or "very much/much improved" on the Clinical Global Impression Scale) and also demonstrated better functional effects and subjective response. Both treatments were well tolerated and had a similar low incidence of extrapyramidal symptoms; however, amisulpride was associated with less weight gain and endocrine/sexual symptoms.

A comparative study of milnacipran and paroxetine in outpatients with major depression.

BACKGROUND: Milnacipran is a dual-action antidepressant which inhibits both serotonin and noradrenaline reuptake with no affinity for any neurotransmitter receptor studied. METHODS: A 6-week double-blind multicentre study compared milnacipran (100 mg/day) with paroxetine (20 mg/day) in 300 outpatients with major depression. Efficacy was evaluated using HAMD17, MADRS and CGI for severity of illness and global improvement. Data were analysed on an intention to treat, last observation carried forward, basis. RESULTS: Milnacipran and paroxetine were both effective and well tolerated with no significant difference in their effects. After treatment discontinuation, milnacipran was associated with significantly less emergent symptoms. Responders, at endpoint, to milnacipran had significantly greater levels of psychomotor retardation at baseline than non-responders. LIMITATIONS: The study did not include a placebo group so that it is impossible to determine absolute levels of efficacy. CONCLUSIONS: Both milnacipran and paroxetine were effective and well tolerated by outpatients with major depression treated for 6 weeks. After treatment discontinuation milnacipran was associated with less emergent symptoms. Psychomotor retardation at baseline may be a predictive factor of a favourable response to milnacipran.

Validating antidepressant-associated hypomania (bipolar III): a systematic comparison with spontaneous hypomania (bipolar II).

BACKGROUND: According to DSM-IV and ICD-10, hypomania which occurs solely during antidepressant treatment does not belong to the category of bipolar II (BP-II). METHODS: As part of the EPIDEP National Multisite French Study of 493 consecutive DSM-IV major depressive patients evaluated in at least two semi-structured interviews 1 month apart, 144 (29.2%) fulfilled the criteria for bipolar II with spontaneous hypomania (BP-II Sp), and 52 (10.5%) had hypomania associated solely with antidepressants (BP-H AA). RESULTS: BP-II Sp group had earlier age at onset, more hypomanic episodes, and higher ratings on cyclothymic and hyperthymic temperaments, and abused alcohol more often. The two groups were indistinguishable on the hypomania checklist score (12.2+/-4.0 vs. 11.4+/-4.4, respectively, P=0.25) and on rates of familial bipolarity (14.1% vs. 11.8%, respectively, P=0.68). But BP-H AA had significantly more family history of suicide, had higher ratings on depressive temperament, with greater chronicity of depression, were more likely to be admitted to the hospital for suicidal depressions, and were more likely to have psychotic features; finally, clinicians were more likely to treat them with ECT, lithium and mood stabilizing anticonvulsants. LIMITATION: Naturalistic study, where treatment was uncontrolled. CONCLUSION: BP-H AA emerges as a disorder with depressive temperamental instability, manifesting hypomania later in life (and, by definition, during pharmacotherapy only). By the standards of clinicians who have taken care of these patients for long periods of time, BP-H AA appears as no less bipolar than those with prototypical BP-II. We submit that familial bipolarity ('genotypic' bipolarity) strongly favors their inclusion within the realm of bipolar II spectrum, as a prognostically less favorable depression-prone phenotype of this disorder, and which is susceptible to destabilization under antidepressant treatment. These considerations argue for revisions of DSM-IV and ICD-10 conventions. BP-HAA may represent a genetically less penetrant expression of BP-II; phenotypically; it might provisionally be categorized as bipolar III.

Repeated transcranial direct current stimulation prevents abnormal behaviors associated with abstinence from chronic nicotine consumption.

Successful available treatments to quit smoking remain scarce. Recently, the potential of transcranial direct current stimulation (tDCS) as a tool to reduce craving for nicotine has gained interest. However, there is no documented animal model to assess the neurobiological mechanisms of tDCS on addiction-related behaviors. To address this topic, we have developed a model of repeated tDCS in mice and used it to validate its effectiveness in relieving nicotine addiction. Anodal repeated tDCS was applied over the frontal cortex of Swiss female mice. The stimulation electrode (anode) was fixed directly onto the cranium, and the reference electrode was placed onto the ventral thorax. A 2 × 20 min/day stimulation paradigm for five consecutive days was used (0.2 mA). In the first study, we screened for behaviors altered by the stimulation. Second, we tested whether tDCS could alleviate abnormal behaviors associated with abstinence from nicotine consumption. In naive animals, repeated tDCS had antidepressant-like properties 3 weeks after the last stimulation, improved working memory, and decreased conditioned place preference for nicotine without affecting locomotor activity and anxiety-related behavior. Importantly, abnormal behaviors associated with chronic nicotine exposure (ie, depression-like behavior, increase in nicotine-induced place preference) were normalized by repeated tDCS. Our data show for the first time in an animal model that repeated tDCS is a promising, non-expensive clinical tool that could be used to reduce smoking craving and facilitate smoking cessation. Our animal model will be useful to investigate the mechanisms underlying the effects of tDCS on addiction and other psychiatric disorders.

Metacognitive training for schizophrenia: a multicentre randomised controlled trial.

A psychotherapeutic approach for schizophrenia is now recommended as an adjuvant for psychopharmacology, since antipsychotic medications only have a partial impact especially as regards positive symptoms and insight. In addition, cognitive distortions and the lack of metacognitive skills might increase positive symptoms leading to poor social functioning. This underlines the need for specific approaches which target cognitive processes relevant for insight, and abilities in metacognition. Metacognitive training (MCT) is a structured group intervention, which enhances a patient's reflection on cognitive biases and improves problem-solving. The aim of our study was to assess MCTs' short term impact on insight, symptoms and quality of life. Fifty patients with schizophrenia or schizoaffective disorders and persistent positive symptoms (delusions or hallucinations) were enrolled in the study. After baseline assessment participants were randomised either to supportive therapy or MCT. Both groups used the same design (1h-session twice a week during 8weeks) although the basic knowledge given to participants was different between interventions. Participants were assessed at eight weeks based on the Scale to Assess Unawareness of Mental Disorder, Positive and Negative Syndrome Scale (PANSS), Psychotic Symptom Rating Scales, the Calgary Depression Scale for Schizophrenia and the Quality of Life Scale. Between-group differences were significant in favour of MCT on the PANSS positive scale. Between-group differences in post- and pre-test values showed a trend in favour of MCT for insight on hallucinations. Results of our study indicate that the MCT has an effect on reducing positive symptomatology, and a trend impact on insight and social functioning.

Sociodemographic and psychopathological risk factors in repeated suicide attempts: gender differences in a prospective study.

BACKGROUND: The prevention of the repetition of suicide attempts is an important feature of the care of attempters but current data fail to give actual predictors of repetition. The aim of this study was to characterize sociodemographic and psychopathological features and risk factors associated with future repetition of suicide attempts in two years. The study focused on differences between men and women. METHODS: 273 participants selected in psychiatric emergency units after their admission for a suicide attempt (index) were included in the study. Subsequent suicide attempts occurring within a two year follow-up were identified from the regional observatory of suicide attempts. At inclusion, sociodemographic variables and psychopathological data were collected. In particular, psychometric evaluations were performed using the following scales: BDI-SF, SIS, BIS and BDHI. The lifetime history of suicide attempt was also noted. RESULTS: Repetition of suicide attempt in 2 years was associated with current follow up and treatment, a personal history of multiple suicide attempt, post traumatic stress disorder, current recurrent psychotic syndrome and substance misuse. Specific features of men and women repeaters have been identified. Men repeaters were characterized by substance use disorders whereas the re-attempt in women was associated with current follow up and treatment, post traumatic stress disorder and higher BDI-SF score. CONCLUSIONS: Repeaters must be considered as a specific population among suicide attempters and gender differences must be taken into account in this particular population in order to promote more personalized prevention programs for suicidal recurrence and completed suicide.

Does hospitalisation affect hypnotic and anxiolytic drug prescribing?

OBJECTIVE: The aim of this study was to measure the impact of hospitalisation on hypnotic and anxiolytic (HA) drug prescription, during and after hospitalisation. METHOD: A descriptive study was carried out over three periods: before, during and after hospitalisation (three-month follow-up), examining the presence or absence of HA treatment at each stage. The HA drug list studied was selected using the World Health Organisation (WHO) Anatomical Therapeutic and Chemical (ATC) classification system. Trained final-year pharmacy students asked a series of structured questions during hospitalisation and postal questionnaires were sent to included patients one and three months after discharge. All the in-patient departments in the University Hospital of Besançon-France-were included, except units with pre-, peri-, and post-operative HA treatments. All in-patients present in the selected units on February 12, 2003, aged over 18, who gave their consent and were considered able to answer by the nursing team, were finally included. MAIN OUTCOME MEASURE: An eight-branch descriptive model, including the three study periods with two states (presence or absence of HA treatment) at each stage. RESULTS: A total of 260 in-patients were included, and a further 112 (43%) completed the whole study (alive, non re-hospitalised, one- and three- months post discharge response). 48% (n = 260), 64% (n = 260) and 58% (n = 112) of the included patients had sleep disorder complaints respectively before, during and after hospitalisation. HA usage increased when comparing pre- and during hospitalisation (33% vs. 51%; n = 112; p < 0.0001) and decreased when comparing during hospitalisation and post-discharge (51% vs. 43%; n = 112; p < 0.0001). The descriptive model showed an overall persistence of treatment induced by hospital stay in 5.35% of the patients. CONCLUSION: Hospital appeared to have a significant impact on delayed HA use in the French general population. Our results should incite hospital prescribers to transversally reconsider the whole sleep disorder treatment strategy in hospital settings, from improving patient's accommodation conditions, to working out a consensus on the justification of prescription of HA and precising the exact place of nursing team in sleep disorders management.