Suicide mortality in people with mental disorders: a register-based study in north France.

INTRODUCTION: Suicide is very common among people with mental disorders. In addition, suicide mortality rates are stable in this group, while they are decreasing in the general population. METHODS: The vital statuses of adult inpatients admitted to French psychiatry departments in 2008-2009 were researched in death databases on 31 December 2013. Suicide probability was calculated using a Kaplan-Meier analysis, and standardized mortality ratios (SMRs) were calculated in relation to the population of the study area. RESULTS: Among the 13,979 patients included in the study, (7416 men and 6563 women; mean age 43.6 ± 14.6 years), 1454 died in total, among whom 286 died by suicide an average of 4.9 years after the date of their enrolment. The cumulative probability of suicide was 0.8% at 1 year, 1.3% at 2 years and 2.5% at 6 years. The SMR value, which was 1492 for the whole group of patients and was twice as high in women (2494) as in men (1220), decreased with age (from 2078 in patients aged 18-34 years to 1278 in patients aged 75 years or more). DISCUSSION: Our study confirms that suicide mortality is higher in inpatients admitted to French psychiatry units than in the general population and advocates specific prevention programmes for this group.

Autobiographical Memory Deficits in Alcohol-Dependent Patients with Short- and Long-Term Abstinence.

BACKGROUND: Autobiographical memory (AM) enables the storage and retrieval of life experiences that allow individuals to build their sense of identity. Several AM impairments have been described in patients with alcohol abuse disorders without assessing whether such deficits can be recovered. This cross-sectional study aimed to identify whether the semantic (SAM) and episodic (EAM) dimensions of AM are affected in individuals with alcohol dependence after short-term abstinence (STA) or long-term abstinence (LTA). A second aim of this study was to examine the factors that could disrupt the efficiency of semantic and episodic AM (the impact of depression severity, cognitive functions, recent or early traumatic events, and drinking history variables). METHODS: After clinical and cognitive evaluations (alcohol consumption, depression, anxiety, IQ, memory performance), AM was assessed with the Autobiographical Memory Interview in patients with recent (between 4 and 6 weeks) and longer (at least 6 months) abstinence. Participants were asked to retrieve the number and nature of traumatic or painful life experiences in recent or early life periods (using the Childhood Traumatic Events Scale). RESULTS: The 2 abstinent groups had lower global EAM and SAM scores than the control group. These scores were comparable for both abstinent groups. For childhood events, no significant differences were observed in SAM for both groups compared with control participants. For early adulthood and recent events, both STA and LTA groups had lower scores on both SAM and EAM. Moreover, there was a negative correlation between the length of substance consumption and SAM scores. CONCLUSIONS: This study highlighted a specific AM disorder in both episodic and semantic dimensions. These deficits remained after 6 months of abstinence. This AM impairment may be explained by compromised encoding and consolidation of memories during bouts of drinking.

Mortality of people suffering from mental illness: a study of a cohort of patients hospitalised in psychiatry in the north of France.

BACKGROUND: The mortality of people suffering from psychiatric illnesses is far higher than that of the general population, all categories of diagnosis combined; mortality statistics can be used as an index of quality of care. The aim of this study was to assess the all-cause mortality in psychiatric patients covering all diagnostic groups. METHODS: The living or deceased status of 4,417 patients of majority age hospitalised in a public mental health establishment between 2004 and 2007 were requested from French National Institute for Statistics and Economic Studies on 1st January 2011. The cause of death of those people who had died was obtained from French National Institute for Health and Medical Research and comparative standardized mortality ratios (SMR) were established from the population in a region of northern France of the same age in 2006. RESULTS: The study population was made up of 54% men and 46% women, median age 41 and 45 years old, respectively. Four hundred and seventy-three people died during the period studied. The SMR were 421 for men (95% CI 378-470) and 330 for women (95% CI 281-388). The highest SMRs were found in patients aged 35-54, with a 20-time higher mortality risk than the general population of the same age. CONCLUSION: Our study confirms the considerably higher mortality in psychiatric patients than in general population, particularly in mean age and mostly due to an unnatural cause.

[Temporary recommendation for use on off-label baclofen: viewpoint of Prescribers of the CAMTEA system]. / La « recommandation temporaire d'utilisation ¼ sur le baclofène : point de vue des prescripteurs du dispositif CAMTEA.

The use of high dose baclofen for alcohol-dependence emerged in France from 2008 based on empirical findings, and is still off-label. However, due to the rapid increase in this prescribing practice, the French health authorities have decided to frame it using an extraordinary regulatory measure named "temporary recommendation for use" (TRU). Baclofen prescribers from CAMTEA, a regional team-based off-label system for supervising baclofen prescribing, which was developed much prior to the TRU, discuss herein the pros and cons of this measure and the applicability of its different aspects in the daily clinical practice.

[Continued use of hypnotic initiated as part of antidepressant treatment]. / La poursuite de consommation d’'hypnotiques initiée lors d'’un traitement antidépresseur.

INTRODUCTION: Chronic hypnotic prescription is common, but not recommended. This study analysed whether hypnotic use at the beginning of antidepressant treatment could be the starting point for future hypnotic use. METHODS: Concomitant hypnotic and antidepressant prescriptions were retrieved from the National Health Insurance Fund for employees of the Nord-Pas-de-Calais database. Dispensing of hypnotics during the two quarters following discontinuation of antidepressant treatment was investigated. RESULTS: 8.9% of patients continued using hypnotics after having stopped antidepressants. Factors associated with this continued dispensing were female gender, age greater than or equal to 45 years, quarterly dispensing of hypnotics during antidepressant treatment, dispensing of three or more hypnotics per quarter during antidepressant treatment, and previous dispensing of opioid substitution therapy. CONCLUSION: A minority of patients continued using hypnotics after stopping antidepressant treatment initiated with hypnotics.

[Outpatient cannabis withdrawal programme]. / Sevrage ambulatoire du cannabis.

Cannabis is the most consumed illicit substance in France, and its use can lead to dependency. Lille university hospital, le Pari association, offers patients wanting to stop using cannabis a support therapy based on positive feedback led by nurses, as well as symptomatic treatment of anxiety and sleep disorders.

[Prescription of psychotropic medicines to pregnant women in Nord-Pas-de-Calais, France]. / La prescription de psychotropes durant la grossesse dans le Nord-Pas-de-Calais.

AIM: Prescription of psychotropic medicines carries risks to pregnancy. It is therefore appropriate to measure the prescription rate of these compounds in pregnant women. METHOD: We studied the prescription rate for psychotropic agents to pregnant women from the Cnamts medicines reimbursement data and we compared this to prescriptions in non-pregnant women in the same age group. RESULTS: There is a fall in the use of psychotropic agents in women during pregnancy compared to a non-pregnant population of the same age. Pregnant women receive 2.17 times less psychotropic agents. Nevertheless, approximately one out of every twenty women is prescribed a proprietary product with known risk to the neonate and four out of a thousand are prescribed a proprietary product which carries a risk of malformation during the first trimester. CONCLUSION: Medical practice takes account of embryo-fetal risk in prescribing psychotropic agents in general although more communication is needed about the risk of some compounds during pregnancy.

[Outpatient withdrawal programme: advanced practice in addictology]. / Sevrage ambulatoire: une expérience de la coopération en addictologie.

Advanced nursing practices are procedures enabling nurses to carry out, in a structured and predefined manner, tasks usually entrusted to doctors. Introduced in France by the Berland reports of 2003 and 2006, advanced nursing practices remain under-developed in the fields of psychiatry and addictology. In this context, Lille regional and university hospital has set up an outpatient programme for alcohol withdrawal, a scheme coordinated by a nurse, authorised to modifythe treatment dosage according to the patient's clinical state and who is supported by a network of caregivers during the period of medicalised withdrawal.

A case of de novo seizures following a probable interaction of high-dose baclofen with alcohol.

AIMS: Baclofen is a promising medication for the treatment of alcohol dependence, and the prescription of high-dose baclofen (HDB) is increasing within the medical community, especially for patients who are unresponsive to approved treatments. Although baclofen is considered to be quite safe at low doses, the possible interactions between HDB and alcohol have not been precisely studied. METHODS: We report the case of a 46-year-old patient without any history of neurological disorders who experienced two episodes of seizures after a short relapse of alcohol misuse while undergoing treatment with up to 240 mg/day of baclofen. RESULTS: Although both alcohol and baclofen may theoretically induce seizures individually, we discuss and largely rule out the likelihood that either of these two drugs was solely responsible for the patient's seizures. We hypothesize that the seizures resulted from an interaction between alcohol and HDB, and determined that this hypothesis is 'probable' with Horn's Drug Interaction Probability Scale. CONCLUSION: We encourage our colleagues who prescribe HDB to acquaint their patients with the possible enhanced risk of seizures, notably in persistence of alcohol abuse. Moreover, until data from a large study on the safety of HDB use by alcohol misusers are available, this treatment should be conducted under strict supervision and after having carefully evaluated the benefit-risk ratio.

[First analysis of the deployment of the ethical approach in the field of mental health in the Nord Pas-de-Calais region]. / Première analyse du déploiement de la démarche éthique dans le champ de la santé mentale en région Nord Pas-de-Calais.

For 3 years, the Regional Federation of Mental Health Research (F2RSM) has led a space ethics reflexion Department of mental health (ERESM) to federate structures that ethical institutions and mental health services have been creating in the Nord-Pas de Calais. This approach is, in many ways, revealing issues that involve the institutionalisation of ethical reflection in care facilities. In this article, after referring to the major developments in this field, we describe the conditions for the emergence of ethical bodies in the region. Through the choice of development and operation of the ethical reflexion department, we highlight a number of points of attention that illustrate the complex articulation between institutional expectations and concerns of professionals. The trajectory of the ERESM is thus revealed as a process of reflective learning open to all stakeholders, providers and users of mental health.

Impact of tryptophan metabolism on the vulnerability to alcohol-related blackouts and violent impulsive behaviours.

AIMS: We examined (1) the association of SLC6A4 genotypes and alcohol dependence (AD) in a sample of alcoholics; (2) the validity of lifetime occurrence of blacked-out violent impulsive behaviour (BOVIB) during binge drinking bouts as a criterion for subtyping AD patients and (3) a mechanistic hypothesis for BOVIB involving tryptophan-2,3-dioxygenase (TDO) activity. METHODS: Three common polymorphisms of the SLC6A4 gene (5-HTTLPR, A/G SNP of LPR region and VNTR in intron 2) were genotyped. An oral tryptophan (Trp) load (OTL) was administered to a sample of patients seeking help for AD. BOVIB history and psychological status were screened by BOVIB-Q, depression (BDI), anxiety (BAI, STAI) and personality (TCI) questionnaires. During the 7 h following Trp load, serum kynurenine (Kyn) and Trp were monitored. RESULTS: BOVIB+ patients showed significantly higher scores on depression, anxiety and character scales but no significant association was found between SLC6A4 polymorphisms and BOVIB. Patients with a history of BOVIB (BOVIB+ subgroup) differed from those exempt from such episodes (BOVIB- subgroup) for TDO activity response to OTL assessed by the Kyn:Trp ratio (P = 0.043) and the slope of concentration increase ratio (SCIR) of serum Kyn (P = 0.043). CONCLUSIONS: Put together, these findings support the validity of the BOVIB criterion to differentiate a sub-group of vulnerable AD subjects and suggest that OTL may help to concurrently define a specific endophenotype.

[A system of prescriptions without drug approval: example of baclofen]. / Un dispositif de prescriptions hors-AMM : exemple du baclofène.

Baclofen is an anti-spastic drug that acts as an agonist of GABA-B receptors. It also seems to decrease the appetence for alcohol (anti-craving effect), although this effect has not been certified by Authorities for drug approval in France (AMM). However, baclofen receives a great deal of demand by patients hoping to reduce their alcohol consumption. Nonetheless, the lack of AMM and the high doses of baclofen supposed to exert an anti-craving effect often discourage practitioners from prescribing this drug in current medical practice. Therefore, it is preferable for a drug like baclofen to be prescribed under specific regulations. As such, certain criteria similar to those required in clinical trials are necessary to protect patients as well as the prescribing doctors. The criteria that are proposed here are: the use of drugs without AMM approval as a last resort (all other treatments must have failed), the collegiate decision for the drug prescription, good knowledge of the potency of the drug as well as good record keeping of patients and proper supervision. The departments of addiction, pharmacology and pharmacovigilance of the University Hospital of Lille, France present here a medical process named "multidisciplinary consultations for resort treatments of addictions" (CAMTEA). This process is designed to meet all the above mentioned criteria and to allow the use of baclofen as an anti-craving drug in safest conditions. If this proves to be successful with baclofen, it is possible to extend the use of CAMTEA to other drugs without AMM approval in addictologic pathologies.

Mental disorders on admission to jail: A study of prevalence and a comparison with a community sample in the north of France.

BACKGROUND: The aim of the present study was to estimate prevalence rates of psychiatric and substance use disorders in male and female prisoners on admission to prison in the north of France and compare the frequency of these disorders to the general population. METHODS: This cross-sectional survey on Mental Health in the Prison Population (MHPP), conducted between March 2014 and April 2017, interviewed 653 randomly selected men and women who had recently been committed to the French general population prison system in the Nord and Pas-de-Calais departments. For each subject, the Mini International Neuropsychiatric Interview (MINI), a standardized psychiatric interview, was used to screen for psychiatric and substance use disorders. The prevalence rates were then compared with data from the Mental Health in the General Population (MHGP) survey, a general population survey that used the same assessment methodology as MHPP in the Nord and Pas-de-Calais departments. A control sample was taken from the MHGP survey with a ratio of one case (MHPP) to three controls (MHGP) matching on age and sex. RESULTS: The sample was primarily composed of French men, most of them single with low educational levels at the time of imprisonment. The mean age was 31.7 (standard deviation = 9.9; min = 18; max = 67). Most of the subjects included were first-time prisoners. The prevalence of affective disorders among newly incarcerated individuals was 31.2% with higher rates for major depressive disorder (27.2%). The prevalence of anxiety disorders was 44.4% with higher rates for generalized anxiety disorder (25.2%). The prevalence of psychotic syndromes was 6.9%. The prevalence of substance use disorders was 53.5% and a suicide risk was identified in 31.4% of the prisoners interviewed. Higher prevalence rates were found in the MHPP when compared with the MHGP for all psychiatric and substance use disorders assessed except for dysthymia and current isolated psychotic syndrome. CONCLUSIONS: Our study shows very high levels of prevalence for psychiatric and substance use disorders in recently committed French prisoners.

Inversion of melatonin circadian rhythm in chronic alcoholic patients during withdrawal: preliminary study on seven patients.

AIMS: The inversion of melatonin circadian rhythm secretion in some alcoholics during both intake and acute withdrawal has been widely reported. In the same way, what happens to this inversion when these patients are in long-term withdrawal is not known. To document this abnormality in alcoholics after withdrawal we investigated melatonin secretion observed during chronic alcoholization and after withdrawal. METHODS: We measured the urinary 6-sulfatoxymelatonin (6SM) (6SM/creatinine ratio), main metabolite of the hormone, in two fractions, one diurnal and the other nocturnal, in seven alcohol-dependent patients presenting with this abnormality during alcoholization at two times: in acute withdrawal phase (under benzodiazepines) and 15 days after beginning of withdrawal (free of any psychotropic treatment). RESULTS: Our results show that this reversed rhythm of melatonin secretion as seen by the diurnal excretion of 6SM (6SM/creatinine ratio) persists during acute withdrawal in more than half of the patients and is still present 15 days after withdrawal in three patients. CONCLUSION: It is remarkable that the inversion of the melatonin rhythms gets corrected in four out of seven patients after withdrawal. But, the circadian disorganization of melatonin secretion in three patients could underline a desynchronization in some alcoholic patients and may indicate more widespread circadian temporal structure disturbances in these patients.

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.

A case-comparison study of executive functions in alcohol-dependent adults with maternal history of alcoholism.

INTRODUCTION: As executive dysfunctions frequently accompany alcohol dependence, we suggest that reports of executive dysfunction in alcoholics are actually due, in some case to a maternal history of alcohol misuse (MHA+). A history of maternal alcohol dependence increases the risk for prenatal alcohol exposure to unborn children. These exposures likely contribute to executive dysfunction in adult alcoholics. To assess this problem, we propose a case-comparison study of alcohol-dependent subjects with and without a MHA. METHODS: Ten alcohol-dependent subjects, with a maternal history of alcoholism (MHA) and paternal history of alcoholism (PHA), were matched with 10 alcohol-dependent people with only a paternal history of alcoholism (PHA). Executive functions (cancellation, Stroop, and trail-making A and B tests) and the presence of a history of three mental disorders (attention deficit hyperactivity disorder, violent behavior while intoxicated, and suicidal behavior) were evaluated in both populations. RESULTS: Alcohol-dependent subjects with MHA showed a significant alteration in executive functions and significantly more disorders related to these functions than PHA subjects. The major measures of executive functioning deficit are duration on task accomplishment in all tests. Rates of ADHD and suicidality were found to be higher in MHA patients compared to the controls. CONCLUSION: A history of MHA, because of the high risk of PAE (in spite of the potential confounding factors such as environment) must be scrupulously documented when evaluating mental and cognitive disorders in a general population of alcoholics to ensure a better identification of these disorders. It would be helpful to replicate the study with more subjects.

[Influential factors in regular and intensive use of psychoactive drugs]. / Les facteurs qui influencent la consommation intensive et régulière de médicaments psychotropes.

The article attempts to construct a typology to the use of psychoactive drugs and the study of the various factors linked to their use, whether heavy or regular. The results draw on the exploitation of databases containing medicines presented for reimbursement by medical insurance in the Nord - Pas-de-Calais region. In 2007 and 2008, 20.7% of the insured population (764,650 people) benefited from reimbursements for this type of medication. Among the beneficiaries, about a third (30.5%) had an intense consummation. Age, the CMUs benefits and the fact that a person is or not followed by a psychiatrist are the most influential variables on the intensity and the regularity of intake. The observed regularity of the recourse to benzodiazepines does not conform with the current recommendations.

Combining brief contact interventions (BCI) into a decision-making algorithm to reduce suicide reattempt: the VigilanS study protocol.

INTRODUCTION: The early postattempt period is considered to be one of the most at-risk time windows for suicide reattempt or completion. Among the postcrisis prevention programmes developed to compensate for this risk, brief contact interventions (BCIs) have been proven to be efficient but not equally for each subpopulation of attempters. VigilanS is a region-wide programme that relies on an algorithmic system to tailor surveillance and BCI provisions to individuals discharged from the hospital after a suicide attempt. AIM: VigilanS' main objective is to reduce suicide and suicide reattempt rates both at the individual level (patients included in VigilanS) and at the populational level (inhabitants of the Nord-Pas-de-Calais region). METHODS AND ANALYSIS: At discharge, every attempter coming from a participating centre is given a crisis card with an emergency number to contact in case of distress. Patients are then systematically recontacted 6 months later. An additional 10-day call is also given if the index suicide attempt is not the first one. Depending on the clinical evaluation during the phone call, the call team may carry out proportionated crisis interventions. Personalised postcards are sent whenever patients are unreachable by phone or in distress. On the populational level, mean suicide and suicide attempt rates in Nord-Pas-de-Calais will be compared before and after the implementation of the programme. Here/there cross-sectional comparisons with a control region will test the spatial specificity of the observed fluctuations, while time-series analyses will be performed to corroborate the temporal plausibility of imputing these fluctuations to the implementation of the programme. On the individual level, patients entered in VigilanS will be prospectively compared with a matched control cohort by means of survival analyses (survival curve comparisons and Cox models). DISCUSSION: VigilanS interventional components fall under the ordinary law care regime, and the individuals' general rights as patients apply with no addendums or restrictions for their participation in the programme. The research section received authorisation from the Ethical Committee of Lille Nord-Ouest under the caption 'Study aimed at evaluating routine care' and is registered in 'Clinical Trials'. The French Ministry of Health plans to extend the experimentation to other regions and probe the relevance of this type of 'bottom-up' territorial prevention policy at the national level. TRIAL REGISTRATION NUMBER: NCT03134885.