Psychological and psychiatric aspects of face transplantation: Lessons learned from the long-term follow-up of six patients.

Since 2005, at least 38 face transplantations have been performed worldwide. Available recommendations on psychological management are based on isolated cases or small case series, either not focused on mental health or with a short follow-up. We propose herein a clinical commentary on psychological and psychiatric outcomes from the follow-up of a prospective single-center cohort of six patients over a period of 3.5 to 9 years. Seven patients received a face transplant between January 2007 and April 2011: two patients with neurofibromatosis, four with self-inflicted ballistic trauma, one with self-immolation. One patient died at 63 days of cerebral sequelae from cardiac arrest in the setting of bacterial infection. The six other patients were routinely evaluated with unstructured psychological interviews up to May 2016 and with the Short Form 36-item health survey and the Mini-International Neuropsychiatric Interview at one year and at the end of the follow-up. Clinically meaningful observations were the following: a history of mental disorders before disfigurement was associated with poor physical and mental outcomes, including poor adherence and one suicide; untreated depression was associated with poor adherence; acceptance of the new face occurred rapidly and without significant distress in all of the patients; fear of transplant rejection was present to some degree in all of the patients and did not substantially differ from other transplantation settings; media exposure may be disturbing but may also have had positive psychological effects on some of the patients. Mental health issues related to chronic rejection and re-transplantation remain to be explored.

Personality and breast cancer screening in women of the GAZEL cohort study.

The potential benefit of breast cancer screening is mitigated by the risk of false positives and overdiagnosis, thus advocating for a more personalized approach, based on the individual benefit-harm balance. Since personality might influence the women's appraisal of this balance, this prospective observational cohort study examined whether it could influence mammography use. A total of 2691 postmenopausal women of the GAZEL Cohort Study completed the Bortner Type A Rating Scale and the Buss and Durkee Hostility Inventory in 1993. Associations between personality scores and subsequent mammography use, self-reported through up to five triennial follow-up questionnaires, were estimated with Odds Ratio (OR) and 95% confidence interval (CI) with logistic mixed model regressions, adjusting for age, occupational grade, marital status, family history of breast cancer, age at menarche, age at first delivery, gynecological follow-up, hormone therapy use, and depressive symptoms. Individual propensity scores were used to weight the analyses to control for potential selection biases. More than 90% of the participants completed at least two follow-up questionnaires. Type A personality, but not hostility, was associated with mammography use in both univariate (crude OR [95% CI]: 1.62 [1.24-2.11], P < 0.001) and multivariate analyses (OR [95% CI]: 1.46 [1.13-1.90], P < 0.01). Type A personality traits (i.e., sense of time urgency, high job involvement, competitiveness) independently predicted mammography use among postmenopausal women. While paying more attention to the adherence of women with low levels of these traits, clinicians may help those with higher levels to better consider the risks of false positives and overdiagnosis.

Smoking and the Association Between Depressive Symptoms and Absolute Neutrophil Count in the Investigations Préventives et Cliniques Cohort Study.

OBJECTIVES: Depressive symptoms have been associated with chronic low-grade inflammation, including elevated neutrophil count. Smokers often have both high neutrophil count and depressive symptoms. Thus, smoking could explain the cross-sectional association between depressive symptoms and neutrophil count. METHODS: Total white blood cell count and subtypes, including absolute neutrophil, lymphocyte, monocyte, basophil, and eosinophil counts, were measured in 44,806 participants (28,534 men; mean [standard deviation] age = 38.9 [11.4] years), without a history of chronic disease or current medication. Depressive symptoms were assessed with the Questionnaire of Depression, Second Version, Abridged. Smoking status was self-reported and categorized in five classes. Sex, age, alcohol intake, self-rated health, body mass index, glycemia, physical activity, household composition, occupational status, and education were included as covariates. Associations were examined with general linear models and causal mediation analyses. RESULTS: After adjustment for all covariates except smoking, depressive symptoms were positively associated with neutrophil count only (ß = 5.83, standard error [SE] = 2.41, p = .014). After further adjustment for a semiquantitative measure of smoking, this association was no longer significant (ß = 2.40, SE = 2.36, p = .30). Causal mediation analyses revealed that smoking mediated the association (p < .001), accounting for 57% of its total variance. In contrast, depressive symptoms were negatively associated with lymphocyte count in fully adjusted model only (ß = -3.21, SE = 1.11, p = .004). CONCLUSIONS: Smoking may confound or mediate the association between depressive symptoms and neutrophil count. These results advocate for including an accurate measure of smoking in future studies addressing this association. When considering the link between depression and inflammation, one should not overlook the noxious effects of smoking.

Treating empty nose syndrome as a somatic symptom disorder.

Empty nose syndrome (ENS) is a rare complication of inferior turbinate resection, characterized by a paradoxical nasal obstruction sensation despite decreased nasal resistance. Here we report the case of a 37-year-old patient with ENS and severe functional impairment, who was diagnosed with a somatic symptom disorder and treated accordingly. Cognitive behavior therapy targeting dysfunctional beliefs and avoidance behaviors together with a treatment by venlafaxine resulted in dramatic functional improvement between month 2 and month 4. At month 6, the patient was displaying back-to-normal levels of functioning and was no longer seeking care for ENS. Treating ENS as a somatic symptom disorder might constitute a first-line, safe alternative to surgical treatment.

Hostility and the risk of peptic ulcer in the GAZEL cohort.

OBJECTIVE: Evidence for an association between hostility and peptic ulcer mainly relies on cross-sectional studies. Prospective studies are rare and have not used a validated measure of hostility. This prospective study aimed to examine the association between hostility and peptic ulcer in the large-scale French GAZEL cohort. METHOD: In 1993, 14,674 participants completed the Buss and Durkee Hostility Inventory. Participants were annually followed-up from 1994 to 2011. Diagnosis of peptic ulcer was self-reported. The association between hostility scores and ulcer incidence was measured by hazard ratios (HR) and 95% confidence intervals computed through Cox regression. RESULTS: Among 13,539 participants free of peptic ulcer history at baseline, 816 reported a peptic ulcer during a mean follow-up of 16.8 years. Adjusting for potential confounders, including smoking, occupational grade, and a proxy for nonsteroidal anti-inflammatory drug exposure, ulcer incidence was positively associated with total hostility (HR per SD: 1.23, confidence interval: 1.14-1.31), behavioral hostility (HR per SD: 1.13, confidence interval: 1.05-1.21), cognitive hostility (HR per SD: 1.26, confidence interval: 1.18-1.35), and irritability (HR per SD: 1.20, confidence interval: 1.12-1.29). The risk of peptic ulcer increased from the lowest to the highest quartile for all hostility measures (p for linear trend < .05). CONCLUSIONS: Hostility might be associated with an increased risk of peptic ulcer. Should these results be replicated, further studies would be needed to explore the underlying mechanisms.

Depression and the risk of cancer: a 15-year follow-up study of the GAZEL cohort.

Depression has long been hypothesized to be associated with cancer incidence. However, there is evidence for a positive publication bias in this field. In the present study, we examined the association between various measures of depression and cancer incidence at several sites. A total of 14,203 members of the French GAZEL (Gaz et Electricité) cohort (10,506 men, 3,697 women) were followed up for diagnoses of primary cancers from January 1, 1994, to December 31, 2009. All medically certified sickness absences for depression recorded between January 1, 1990, and December 31, 1993, were compiled. Depressive symptoms were self-reported in 1993, 1996, and 1999 with the Center for Epidemiologic Studies Depression Scale. During a mean follow-up period of 15.2 years, 1,119 participants received a cancer diagnosis, excluding nonmelanoma skin cancer and in situ neoplasms. Considering 6 cancer sites (prostate, breast, colorectal, smoking-related, lymphoid and hematopoietic tissues, other sites) and 4 measures of depression, we found 1 positive association and 1 negative association. Overall, there was no compelling evidence for an association between depression and cancer incidence. Such null results should be considered when addressing concerns of cancer patients and their relatives about the role of depression in cancer onset.

Impact of organizational culture on preventability assessment of selected adverse events in the ICU: evaluation of morbidity and mortality conferences.

PURPOSE: To determine whether organizational culture is associated with preventability assessment of reported adverse events (AE) in intensive care units (ICU). DESIGN: Blind review of time randomly distributed case notes written in the form of structured abstracts by the nurses who participated in recently implemented morbidity and mortality conferences from December 2006 to June 2010 in a 18-bed ICU in France. Ninety-five abstracts summarizing the discussions of 95 AE involving 95 patients were reviewed by two external blinded pairs (each comprised of one senior intensivist and one psychologist). METHODS: A score for each organizational culture style was determined, with the highest scorer being considered the dominant style present in the abstract. RESULTS: Reliability of the classification and quantification of culture traits between pairs was very good or good for 13 dimensions and moderate for two others. The two pairs deemed 32/95 and 43/95 of AE preventable (κ = 0.59). Concordance was very good (κ = 0.85) between the external pairs for evaluation of the dominant culture style. The Cochran-Armitage trend test indicated an increasing trend for change of the dominant organizational culture style over time: the team-satisfaction-oriented culture took a leading role (p = 0.02), while the people-security-oriented culture decreased dramatically (p < 0.001). The task-security-oriented culture was significantly associated with a preventable judgment, while the people-security-oriented culture was significantly associated with an unpreventable judgment (p < 0.001). CONCLUSIONS: This study demonstrated a strong relationship between preventability assessment of AE reported by caregivers and their organizational culture in the ICU.

Mortality associated with depression as compared with other severe mental disorders: a 20-year follow-up study of the GAZEL cohort.

Individuals with severe mental disorders (SMD) have an increased risk of mortality from somatic diseases. This study examined whether this risk is different in persons with depressive disorders compared to those with other SMD (i.e. schizophrenia and bipolar disorder). In 1989, 20,625 employees of the French national gas and electricity company (15,011 men and 5614 women, aged 35-50) agreed to participate in the GAZEL cohort study. Three diagnosis groups were created based on sick leave spells from 1978 onwards: 1) no SMD, 2) depressive disorders and 3) other SMD. Dates and causes of death were available from January 1, 1990 to December 31, 2010. The association of diagnosis groups with mortality was estimated with hazard ratios (HR) and 95% confidence intervals (CI) computed using Cox regression. During a mean follow-up of 19.8 years, 1544 participants died, including 1343 from a natural cause, of which 258 died from cardiovascular diseases. After adjustment for age, gender, occupational status, alcohol consumption, smoking and body-mass index, participants with a history of sickness absence for SMD had a greater risk of natural mortality (HR: 1.24, CI: 1.08-1.43), cardiovascular mortality (HR: 1.49, CI: 1.08-2.05) and non-cardiovascular natural mortality (HR: 1.19, CI: 1.02-1.39). Compared to depressive disorders, other SMD were associated with an increased risk of natural mortality (HR: 1.94, CI: 1.17-3.22) and cardiovascular mortality (HR: 3.58, CI: 1.53-8.39). Job security and systematic medical follow-up may fall short of preventing premature death among workers with sickness absence due to SMD.

Personality and the risk of cancer: a 16-year follow-up study of the GAZEL cohort.

OBJECTIVE: Large-scale prospective studies do not support an association between neuroticism and extroversion with cancer incidence. However, research on other personality constructs is inconclusive. This longitudinal study examined the associations between four personality measures, Type 1, "suppressed emotional expression"; Type 5, "rational/antiemotional"; hostility; and Type A with cancer incidence. METHODS: Personality measures were available for 13,768 members in the GAZEL cohort study (baseline assessment in 1993). Follow-up for diagnoses of primary cancers was obtained from January 1, 1994 to December 31, 2009. Associations between personality and cancer incidence were evaluated using Cox proportional hazards analyses and adjusted for potential confounders. RESULTS: During a median follow-up of 16.0 years (range, 9 days-16 years), 1139 participants were diagnosed as having a primary cancer. The mean duration between baseline and cancer diagnosis was 9.3 years. Type 1 personality was associated with a decreased risk of breast cancer (hazard ratio per standard deviation = 0.81, 95% confidence interval = 0.68-0.97, p = .02). Type 5 personality was not associated with prostate, breast, colorectal, or smoking-related cancers, but was associated with other cancers (hazard ratio per standard deviation = 1.17, 95% confidence interval = 1.04-1.31, p = .01). Hostility was associated with an increased risk of smoking-related cancers, which was explained by smoking habits, and Type A was not associated with any of the cancer endpoints. CONCLUSIONS: Several personality measures were prospectively associated with the incidence of selected cancers. These links may warrant further epidemiological studies and investigations about potential biobehavioral mechanisms.

Personality and hormone therapy use among postmenopausal women in the GAZEL cohort study.

OBJECTIVE: To examine with a prospective design the association of personality with hormone therapy (HT) use before and after the publication of the Women's Health Initiative (WHI) trial. DESIGN: Questionnaires were mailed to measure type A personality and hostility. Additional data from up to six mailed questionnaires every 3 years were used to determine the subsequent date of menopause and the use of HT. The association between personality and HT use was measured by the relative index of inequality computed through binary logistic regression. SETTING: The French GAZEL Cohort Study. PATIENT(S): Women (n = 1,803) who reached natural menopause during the study. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Hormone therapy use within 1 year after the date of menopause. RESULT(S): Hormone therapy use (916 users vs. 887 nonusers) was associated with type A personality (relative index of inequality = 1.88, 95% confidence interval = 1.35-2.63). This association remained significant after adjustment for all potential confounders (relative index of inequality = 1.84, 95% confidence interval = 1.23-2.74). There was no significant interaction between type A personality and the date of menopause as regards the WHI publication. CONCLUSION(S): Type A personality may be associated with HT use among postmenopausal women, regardless of other predictors, including vascular and breast cancer risk factors.

Depressive mood and subsequent cancer diagnosis in patients undergoing a colonoscopy.

BACKGROUND: In patients with clinical signs that may indicate a colorectal cancer, physicians may interpret the presence of a comorbid depressive mood as either increasing or decreasing the likelihood of cancer diagnosis. This study examined the association between depressive mood in candidates for a colonoscopy and subsequent diagnosis of cancer. METHODS: Ninety-four outpatients [35 men, mean age ± standard deviation (SD) = 56.2 ± 9.8 years, 59 women, mean age ± SD = 54.2 ± 12.9 years] were given the 13-item Beck depression inventory to assess depressive mood before undergoing a colonoscopy. Additional psychological, demographic, and clinical data were collected prior to the colonoscopy. RESULTS: The colonoscopy found a cancer in 18 patients (19.1%). Cancer patients were older (P = 0.015) and more likely to present with anemia (P < 0.001) and unexplained weight loss (P = 0.046). Depressive mood was associated with a subsequent diagnosis of cancer in women (P = 0.007), but not in men (P = 0.985). This association remained significant after adjustment for potential confounders in women (i.e., anemia and unexplained weight loss) (P = 0.014). CONCLUSIONS: In women with clinical signs that warrant a colonoscopy, comorbid depressive mood may be associated with an increased likelihood of colorectal cancer and should not delay the receipt of a guideline-based diagnosis procedure.

Low social support is associated with an increased risk of postoperative delirium.

STUDY OBJECTIVE: To examine the predictive value of social support in postoperative delirium. DESIGN: Prospective observational study. SETTING: Postoperative recovery room and orthopedic surgery department. PATIENTS: 106 consecutive patients undergoing a planned orthopedic surgery with general anesthesia. MEASUREMENTS: All patients completed questionnaires to assess depressive mood (the Beck Depression Inventory) and social support (Sarason's Social Support Questionnaire) during the preanesthesia visit. Postoperative delirium symptoms were assessed daily using the Memorial Delirium Assessment Scale. Demographic, clinical, and biological data, including anesthesia procedure, were recorded. MAIN RESULTS: Controlling for various potential confounders through multivariate binary logistic regression, postoperative delirium was independently predicted by satisfaction with social support, but neither by depressive mood nor the number of supportive persons. Other significant predictors were the preoperative use of benzodiazepines, age, and type of surgery. CONCLUSION: Patients who report low satisfaction with social support may present with a particular vulnerability to postoperative delirium, even after controlling for physical confounding variables and depressive mood.

Hostility may explain the association between depressive mood and mortality: evidence from the French GAZEL cohort study.

UNLABELLED: Depressive mood is associated with mortality. Because personality has been found to be associated with depression and mortality as well, we aimed to test whether depressive mood could predict mortality when adjusting for several measures of personality. METHODS: 20,625 employees of the French national gas and electricity companies gave consent to enter in the GAZEL cohort in 1989. Questionnaires were mailed in 1993 to assess depressive mood, type A behavior pattern, hostility, and the six personality types proposed by Grossarth-Maticek and Eysenck. Vital status and date of death were obtained annually for all participants. The association between psychological variables and mortality was measured by the Relative Index of Inequality (RII) computed through Cox regression. RESULTS: 14,356 members of the GAZEL cohort (10,916 men, mean age: 49 years; 3,965 women, mean age: 46 years) completed the depressive mood scale and at least one personality scale. During a mean follow-up of 14.8 years, 687 participants had died. Depressive mood predicted mortality, even after adjustment for age, sex, education level, body mass index, alcohol consumption, and smoking [RII (95% CI) = 1.56 (1.16-2.11)]. However, this association was dramatically reduced (RII reduction: 78.9%) after further adjustment for cognitive hostility (i.e. hostile thoughts) [RII (95% CI) = 1.12 (0.80-1.57)]. Cognitive hostility was the only personality measure remaining associated with mortality after adjustment for depressive mood [RII (95% CI) = 1.97 (1.39-2.77)]. CONCLUSIONS: Cognitive hostility may either confound or mediate the association between depressive mood and mortality.

Catatonia recognition and treatment.

BACKGROUND: Catatonic syndrome is no longer considered a subtype of schizophrenia but is more frequently associated with mood disorders (mania, melancholia, and psychotic depression) as well as general medical conditions (neurological disorders, drug-induced and toxic-induced conditions, metabolic conditions). A case of catatonia is reported which occurred after alcohol withdrawal. CASE REPORT: Catatonia occurred 48 hours after alcohol withdrawal in a 54-year-old woman who had stopped all her treatment (in the context of a type II bipolar disorder). A dramatic improvement of symptoms was observed after oral administration of zolpidem. CONCLUSIONS: This case seems to confirm that catatonia can represents a nonspecific response to stress factors. The withdrawal of multiple medications was already described as a basis for catatonia. Alcohol withdrawal could constitute an additional risk factor for catatonia. The zolpidem test is a useful diagnostic and therapeutic test.

[Resiliency supports: a possible tool for helping children when a parent suffers from cancer]. / Les tuteurs de résilience: un outil possible dans le soutien aux enfants dont un parent est atteint de cancer.

Contradictory results were published on the existence of children's distress when a parent suffers from cancer. On the other hand, the long term traumatic impact of the disease, and in particular of the loss of a parent, is more documented and consensual. The resiliency theory is based on the observation of people having a "favorable evolution" although they lived serious traumatic events. It questions the factors contributing to what we could describe as a "good adjustment" rather than the negative consequences of an event. Some authors suggested the founder role of a triple landmark offered by the parental figures to the child since its very young age for establishing a capacity to resiliency: the quality of interpersonal bonds, the reference to stated and respected rules and the attribution of a meaning and an orientation to one's own existence. The theory of resiliency offers some tracks for supporting the best the adaptive capacities of children and the whole family facing the cancer of a parent. According to this current of thought, supporting the parents in their role of parents seems one of the best ways, in first intention, to support the children themselves.

Does personality predict mortality? Results from the GAZEL French prospective cohort study.

BACKGROUND: Majority of studies on personality and physical health have focused on one or two isolated personality traits. We aim to test the independent association of 10 personality traits, from three major conceptual models, with all-cause and cause-specific mortality in the French GAZEL cohort. METHODS: A total of 14,445 participants, aged 39-54 in 1993, completed the personality questionnaires composed of the Bortner Type-A scale, the Buss-Durkee Hostility Inventory (for total, neurotic and reactive hostility) and the Grossarth-Maticek-Eysenck Personality Stress Inventory that assesses six personality types [cancer-prone, coronary heart disease (CHD)-prone, ambivalent, healthy, rational, anti-social]. The association between personality traits and mortality, during a mean follow-up of 12.7 years, was assessed using the Relative Index of Inequality (RII) in Cox regression. RESULTS: In models adjusted for age, sex, marital status and education, all-cause and cause-specific mortality were predicted by 'total hostility', its 'neurotic hostility' component as well as by 'CHD-prone', 'ambivalent' 'antisocial', and 'healthy' personality types. After mutually adjusting personality traits for each other, only high 'neurotic hostility' remained a robust predictor of excess mortality from all causes [RII = 2.62; 95% confidence interval (CI) = 1.68-4.09] and external causes (RII = 3.24; 95% CI = 1.03-10.18). 'CHD-prone' (RII = 2.23; 95% CI = 0.72-6.95) and 'anti-social' (RII = 2.13; 95% CI 0.61-6.58) personality types were associated with cardiovascular mortality and with mortality from external causes, respectively, but CIs were wider. Adjustment for potential behavioural mediators had only a modest effect on these associations. CONCLUSIONS: Neurotic hostility, CHD-prone personality and anti-social personality were all predictive of mortality outcomes. Further research is required to determine the precise mechanisms that contribute to these associations.

Relation of depressive mood to plasminogen activator inhibitor, tissue plasminogen activator, and fibrinogen levels in patients with versus without coronary heart disease.

The increased risk of coronary heart disease (CHD) associated with depression is well documented. We hypothesized that impaired fibrinolysis is involved in this link. To explore the association of depressive mood and/or vital exhaustion with various measurements of fibrinolysis activity, 231 men (40 to 65 years old; 123 without CHD and taking no medication and 108 with documented CHD), completed the Center of Epidemiologic Studies Depression Scale and the Maastricht Questionnaire for vital exhaustion. Using classic cut-off points (Center of Epidemiologic Studies Depression Scale score >or=17, Maastricht Questionnaire score >or=8), 6.5% and 9.8% of subjects without CHD and 38% and 48.1% of those with CHD were classified as depressed and exhausted, respectively. Patients with CHD were older, had a higher body mass index, and higher levels of total cholesterol, glucose, plasminogen activator inhibitor 1 (PAI-1), tissue plasminogen activator (t-PA) antigen, and fibrinogen; 47% were treated for hypertension. Depressed subjects had higher levels of PAI-1 activity (p = 0.006) and exhausted patients had higher levels of PAI-1 activity (p = 0.011) and fibrinogen (p = 0.009). After adjusting for clinical condition (with or without CHD), smoking, hypertension, triglyceride concentration, and body mass index, PAI-1 activity remained higher in depressed subjects (p = 0.03). This association persisted after further adjustment for vital exhaustion or for t-PA antigen and fibrinogen levels. t-PA antigen and fibrinogen levels were not associated with depressive mood in multivariate analyses. No fibrinolytic variable was associated with vital exhaustion in multivariate analyses. In conclusion, depressive mood, but not vital exhaustion, is associated with higher levels of PAI-1 activity, suggesting a possible impairment of fibrinolysis and indicating a potential additional mechanism by which depressive mood may act as a cardiovascular risk factor.

[Psychosocial distress and stressful life antecedents associated with smoking. A survey of subjects consulting a preventive health center]. / Souffrance psychosociale et antécédents biographiques traumatiques chez des fumeurs. Enquête auprès de consultants d'un Centre de prévention sanitaire et sociale.

BACKGROUND: The relationship between smoking and various socio-demographic or socio-economic factors, as well as the interactions between depressive mood and smoking are already known. However, the respective contribution of psychological factors and stressful life antecedents during childhood and adolescence warrants further specification. METHODS: 2315 consecutive subjects, aged 16 to 59, consulting for a free work-up in a preventive health centre, supported by the National French Health insurance system, were invited to fill out a series of questionnaires: the GHQ-28 and the LOT, respectively measuring psychosocial distress and dispositional optimism, as well as a questionnaire on socio-demographic, socio-economic and biographical data. RESULTS: 78.1% complete records could be analysed: the "smokers" group (n = 870, 48.1%) declared a current tobacco consumption of at least one cigarette/day. This group was characterized by a predominance of male subjects, older age, modest educational level, low income level and responded to socio-economic criteria of precariousness more frequently (p < 0.001, except for age: p = 0.006). Smoking was also associated with higher levels of psychosocial distress, as assessed by GHQ-28, especially for the depressive mood and anxiety items of the questionnaire (p < 0.001), and with lower levels of dispositional optimism (p < 0.01). As regards biographical data, smokers were characterized by a way of life marked by financial problems, reduced social contacts, and a higher frequency, before the age of 18, of divorce or separation of the parents (p = 0.002), frequent parental quarrels (p < 0.001) or separation from the parents (p < 0.001). The presence of a depressive mood at GHQ-28 as well as frequent parental quarrels remained independent risk factors for smoking in multiple logistic regression (odds ratio respectively equal to 1.61 and 1.34), after adjustment on gender, educational level and the notion of socio-economic precariousness. CONCLUSION: These results highlight the complementary role of socio-economic, psychological factors and certain stressful life antecedents among the determinants of smoking and should be taken into account for tailoring smoking cessation programs.

Educational level has a major impact on the representations of cholesterol: a study in 1579 hypercholesterolemic patients.

OBJECTIVE: To determine the specific features of representations of cholesterol and hypercholesterolemia according to the educational level (EL) and gender among hypercholesterolemic (HC) subjects. DESIGN: The knowledge, beliefs and personal opinions of 1579 hypercholesterolemic patients [58% males; 40% low EL; mean age 58.3 (SD = 11.5)], recruited by their general practitioners, were analyzed from the responses to a self-administered questionnaire. RESULTS: In comparison with women, and after adjusting for EL, men were less likely to know the acceptable total cholesterol level (OR = 0.80; P < 0.05), more likely to perceive hypercholesterolemia as not being a serious disorder (OR = 1.33; P < 0.05), mainly due to overweight (OR = 1.74; P < 0.001), modern (OR = 1.41; P < 0.01), and carefree lifestyle (OR = 1.80; P < 0.01), and less able to commit themselves to a therapeutic project (diet is only possible if shared by the spouse or family, OR = 1.25; P < 0.05). In comparison with subjects with a middle/high EL, and after adjusting for gender, the least educated subjects exhibited lower dietary knowledge (P < 0.001) and less right beliefs (the presence of cholesterol in blood is normal, OR = 0.48; P < 0.001), expressed the most misconceptions concerning hypercholesterolemia and its attendant risks (high cholesterol can induce cancer, OR = 1.63, P < 0.01, or rheumatism, OR = 3.64; P < 0.001; it is possible to perceive high cholesterol levels before seeing the results of blood tests, OR = 1.48; P < 0.001), exhibited lower self-efficacy (it is discouraging to know that heredity plays a role in a health problem, OR = 1.42; P < 0.001) and were the least convinced by and motivated for treatment (treatment may be limited in time, OR = 1.32; P < 0.05, dieting is impossible if one has an active lifestyle including eating out, OR = 1.64; P < 0.001). CONCLUSIONS: For distinctive reasons, male gender and low educational level, which are already recognized as cardiovascular risk factors, emerged from our study as limiting patient's personal involvement in the management of hypercholesterolemia. They attest to the need to support educational and informational messages aimed at alerting, convincing and motivating. To heighten the impact of such efforts, it would seem necessary to target specific messages to men and patients with low educational level.

[Depression and associated organic pathologies, a still under-estimated comorbidity. Results of the DIALOGUE study]. / Dépression et maladies organiques associées, une comorbidité encore sous-estimée. Résultat de l'enquête DIALOGUE.

INTRODUCTION: The field of comorbidity between organic pathologies and mood disorders remains insufficiently explored, whereas such comorbidities predict a more unfavorable outcome of both mood disorders and organic pathologies themselves. OBJECTIVE: The purpose of the Depression and organic diseases study (DIALOGUE) was to obtain in France a set of quantitative data on the prevalence of comorbidities between major depressive episodes (MDE) and associated chronic organic pathologies (ACOP), as well as on the diagnostic and therapeutic difficulties encountered in the management of such comorbidities in daily medical practice. METHODS: General practitioners (GP) and private or hospital psychiatrists were invited to collect several socio-demographic, clinical and therapeutic data on five consecutive patients corresponding to the inclusion criteria. Four groups of patients were set up: 2 082 patients followed up in primary care by their GP for a chronic somatic pathology (GPS group), as well as 2 017, 1 335 and 522 patients respectively followed up in primary care (PPD group), private (GPD group) or hospital psychiatry (HPD group) for a depression not already treated, or requiring modification of its pharmacological treatment (GPD, PPD and HPD group). RESULTS: Among the patients of the GPS group, 41% presented with an associated MDE and, among the depressed patients of the three other groups, respectively 47, 55 and 63% presented with an ACOP. MDE were rather old (more than six months of duration) and severe. However, only 20% of the MDE in the GPS group had a treatment in progress, while in 74% of these same cases the onset of MDE was retrospectively dated more than 2 months before the day of the inclusion in the study. The ACOP, whose functional impact was judged as more severe (cancer, HIV, neurological diseases, renal insufficiency, osteo-articular diseases, insulino-dependent diabetes and coronary heart disease) were more often considered as responsible for the concomitant MDE and more often followed up in psychiatric settings than the other pathologies. Among the overlap signs between the ACOP and the MDE, fatigue was cited first and embarrassed psychiatrists more than GPs, contrary to sleep disorders. In spite of the diagnostic difficulties related to the comorbidity and recognized by all the physicians, GPs seldom asked for the opinion of a psychiatrist (5%) and appealed less often than psychiatrists to the cognitive and affective signs specific of the depression (low self-esteem, anhedonia). CONCLUSION: The unrecognized frequency in the association between depression and organic pathologies pleads for closer cooperation between GPs and psychiatrists, as for continuous training not only of the GPs, but also the psychiatrists, in order to limit the observational biases and the therapeutic hesitations induced by these comorbidities.