Folates and post partum depression.

Hypofolatemia can cause psychiatric disturbances of a depressive nature. Pregnancy and delivery are often associated with hypofolatemia. This study was conducted to determine if hypofolatemia at day 3 post partum is a risk factor for baby blues or post partum depression. To study this hypothesis, 131 post partum women were followed prospectively for the 3 months immediately following delivery. 19% were found to have 'baby blues', as defined by a score greater than 20 on Pitt's scale (Pitt, 1968, J. Psychiatry 114, 1325-1335) and 12% had post partum depression as defined by a score greater than 7 on QD2A scale (Pichot et al., 1984, Rev. Psycholog. App. 34, 229-250, 323-340), within the three months post partum. No relationship was observed between the serum or erythrocyte folate levels on the third day following delivery and the maternal post partum depression scores. A statistically significant correlation between post partum depression and previous psychiatric disturbance was, however, observed.

Amisulpride has a superior benefit/risk profile to haloperidol in schizophrenia: results of a multicentre, double-blind study (the Amisulpride Study Group).

In a multicentre, double-blind, flexible-dose study, 199 patients with paranoid schizophrenia or schizophreniform disorders received haloperidol (10-30 mg/d) or amisulpride (400-1200 mg/d) for four months. More patients in the haloperidol group withdrew prematurely (44% vs 26%; P = 0.0077) due to a higher incidence of adverse events. Amisulpride was at least as effective as haloperidol in reducing the Brief Psychiatric Rating Scale (BPRS) total score (-27.3 vs -21.9) (non-inferiority test; P < 0.001). The PANSS positive score improved to a similar extent in both groups whilst improvement in the PANSS negative score was significantly greater with amisulpride (-10.5 vs -7.2; P = 0.01). The percentage of responders on the Clinical Global Impression scale was also significantly greater with amisulpride (71% vs 47%; P < 0.001). Both the Quality of Life Scale (QLS) and the Functional Status Questionnaire (FSQ) improved to a significantly greater extent under amisulpride. Haloperidol was associated with a greater incidence in extrapyramidal symptoms and with a greater increase in the Simpson-Angus score than was seen with amisulpride (0.32 vs 0.02; P < 0.001). In conclusion, amisulpride is globally superior to haloperidol in the treatment of acute exacerbations of schizophrenia and significantly improves patients' quality of life and social adjustment.

[Brief history of the development of valproate in bipolar disorders]. / Historique du développement du valproate dans les troubles bipolaires.

The anticonvulsant properties of N-dipropylacetic acid (valproic acid) were discovered in 1967 by Meunier and Carraz. It very soon became widely used in epilepsy, generally in the form of sodium valproate. Divalproate, an equimolar combination of valproic acid and sodium valproate has been available in the United States for this indication since 1983. The development of this drug for use in bipolar disorders occurred in two stages. Antimanic and prophylactic activity was demonstrated for valpromide, a primary amide of valproic acid (Lambert et al., 1968-71). The preliminary studies conducted by Lambert were not repeated outside France and it was only much later that the efficacy of derivatives of valproic acid in bipolar disorders was demonstrated in studies undertaken in Germany with sodium valproate (Enrich and Von Zerssen, 1980-85), and then in the USA with divalproate in the last decade. The majority of controlled studies were performed with divalproate and demonstrated the efficacy of this drug in monotherapy during manic episodes (Pope et al., 1991) (Bowden et al, 1994), and divalproate was approved by the FDA in 1995 in this indication. The results of the study by Bowden and the findings of other open studies suggest a wider spectrum of activity for divalproate than for lithium with a good efficacy profile in subtypes of mania in which the effects of lithium are mediocre: dysphoric mania, rapid cycling mania and forms of mania secondary to organic brain disease. The prospective studies by Puzynski and Klosiewicz (1984) and by Lambert and Venaud (1992) demonstrated the prophylactic activity of valpromide, with slightly greater efficacy being noted against manic episodes than against depressive episodes. The study by Bowden et al. (2000) shows that good efficacy of divalproate in acute manic episodes in a given patient may be predictive of efficacy of the drug in maintenance therapy. The field of bipolar disorders currently appears much wider and more heterogeneous than has long been held. Current therapeutic strategy is dominated by thymoregulators. In such long-term therapy where poor compliance constitutes a risk factor for treatment failure, use of valproate (valpromide, divalproate) has the twin advantage of being easy to manage and well tolerated in the long-term. During coadministration of thymoregulators, which is often necessary due to their limited individual efficacy, general consensus exists regarding the therapeutic value of combined divalproate and lithium.

[The importance of classifications in psychiatry]. / L'intérêt des classifications en psychiatrie.

The classifications currently used in psychiatry have different aims: to facilitate communication between researchers and clinicians at national and international levels through the use of a common language, or at least a clearly and precisely defined nomenclature; to provide a nosographical reference system which can be used in practice (diagnosis, prognosis, treatment); to optimize research by ensuring that sample cases are as homogeneous as possible; to facilitate statistical records for public health institutions. A classification is of practical interest only if it is reliable, valid and acceptable to all potential users. In recent decades, there has been a considerable systematic and coordinated effort to improve the methodological approach to classification and categorization in the field of psychiatry, including attempts to create operational definitions, field trials of inter-assessor reliability, attempts to validate the selected nosological categories by analysis of correlation between progression, treatment response, family history and additional examinations. The introduction of glossaries, and particularly of diagnostic criteria, marked a decisive step in this new approach. The key problem remains that of the validity of diagnostic criteria. Ideally, these should be based on demonstrable etiologic or pathogenic data, but such information is rarely available in psychiatry. Current classifications rely on the use of extremely diverse elements in differing degrees: descriptive criteria, evolutive criteria, etiopathogenic criteria, psychopathogenic criteria, etc. Certain syndrome-based classifications such as DSM III and its successors aim to be atheoretical and pragmatic. Others, such as ICD-10, while more eclectic than the different versions of DSM, follow suit by abandoning the terms "disease" and "illness" in favor of the more consensual "disorder". The legitimacy of classifications in the field of psychiatry has been fiercely contested, being variously dubbed "a reductive academic exercise of no relevance to patients", "a dehumanizing labelling system, and a potential source of social and political violence", "a destructive prognostic guide", and so on. Other critics point to various aspects of certain classifications: the abandonment of theoretical concepts, the arbitrary nature of certain categories, the selection of definitions and criteria, the privileged position systematically accorded to the notion of category over that of general dimension. Multiaxial systems such as those proposed in successive versions of DSM or the classifications used in child psychiatry go some way towards meeting these criticisms. They go beyond simple labelling and place the patient in an overall medicopsycho-social setting. Nosographical indicators do not constitute an obstacle to psychopathological understanding. No classifications are capable of satisfactorily fulfilling all needs, namely those of daily practice, research and health statistics. The has led to the development of specialized diagnostic criteria and instruments, as in research for example. It should also be noted in this context that different versions of ICD-10 exist for psychiatrists, general practitioners, researchers and healthcare managers. The greatest danger posed by classifications is the potential reification of hypothetical approaches, arbitrary categorization and the dulling of reflection, all of which have created a need for regular revisions underpinned by field trials.

[Current clinical aspects of obsessive disorders]. / Clinique et aspects actuels des troubles obsessionnels.

The clinical approach to obsessional troubles has barely evolved since the symptoms were first referenced throughout the 19th century. Recent developments in active therapeutics have led to studies on large series of patients. Thus, the various clinical and evolutive aspects, the borderline forms and associated pathologies (other anxiety troubles, depression and mental anorexy) have been delineated.

[The problems posed to the general practitioner by depression (author's transl)]. / Problèmes posés au médecin praticien par la dépression.

Given the high incidence of depression, it is necessary and desirable that as many cases as possible should be treated by general practitioners. However, general practitioners are on the whole ill-prepared to meet the needs of depressed patients. In the last few years a big effort has been made in certain countries to improve the psychiatric training of general practitioner and to enable him the better to detect and treat depression. Communication between psychiatrists and general practitioners is made difficult by the lack of a common language and terms used should be defined clearly. Some of the problems in practice are diagnostic in nature: detect of the depressive syndrome, of the minor or masked forms; differential diagnosis of depression and anxiety. The commonest problems in treatment are: selection of drug, monitoring of side-effects, duration of treatment. The general practitioner needs information also on such questions as: how to evaluate the risk of suicide; when to call in the specialist; how far to use supportive psychotherapy. Some types of depression are particularly likely to come to the general practitioner: depression masked by physical symptoms, depression associated with or secondary to physical disease, depression in the elderly.

[Organic illness and depression (author's transl)]. / Pathologie organique et dépression.

Depression constitutes a major health problem. Its prevalence in any one year is about 3 per cent of the general population. Most depressed patients are seen by general practitioners, and represent approximately 10 to 18 per cent of their patients. Depression should be present in about 20 per cent of the inpatients in general medicine departments. Depression and organic pathology are very often associated, thus leading to diagnosis mistakes and delays in medical care. Depressions masked by somatic symptoms frequently provoked such mistakes. Depressions occurring during and after medical illnesses, and more specifically chronic illnesses, are often completely neglected. These depressions hinder the patient's readaptation and impair his recovery although they would, in the majority of cases, be accessible to chemotherapeutic and/or psychotherapeutic treatment.

[Tyrer's Brief Scale for Anxiety used with outpatients. First validation in the French language]. / L'échelle brève d'anxiété de Tyrer en pratique extrahospitalière. Première validation en langue française.

The brief scale for anxiety of Tyrer is a subdivision of the comprehensive psychopathological scale. We studied a serie of 105 anxious outpatients treated for chronic or reactive anxiety, without depressive or psychotic symptoms. We confirm its sensitivity to change, prove its concurrent validity in regard to the Hamilton anxiety rating scale and demonstrate that the brief scale for anxiety is a reliable instrument to assess anxiety with outpatients. Nevertheless the assessment of its internal validity raises the question of the item's selection at the time of the elaboration of the rating scales according to the scale's purpose. Indeed, must we attempt to register all the symptoms of the anxious syndrome, with the risk of including less specific items? Or must we choose the most characteristic and specific items with the risk of obtaining a more reductionist inventory, but more reliable in a "transnosographic" perspective?

[An open study of Mianserin (author's transl)]. / Etude ouverte de la mainsérine.

The authors present a synthesis of 277 observations collected in France from open studies of mianserin. The product has shown positive results in 65 per cent of the patients considered, based on the global clinical judgement of the prescriber at the beginning and the end of a 28 days open study. The data from Hamilton's scale for depression and Beck's Inventory, even though concerning a smaller number of patients, seem to provide similar results. The improvement appears from the first week, and seems to concern the overall depressive mood, anxiety, psychomotor inhibition, and sleep. The evaluation of the respective results for each target-symptom is made difficult due to the lack of precise data concerning the associated psychotropic drugs. Tolerance has generally been good; there have only been five drop-outs as a result of unpleasant side effects.

[Assays of arylsulfatase activity in psychotic patients. Review of the literature and results of a study of 22 patients]. / Dosages de l'activité de l'arylsulfatase chez les malades psychotiques. Revue de la littérature et résultats d'une étude chez 22 patients.

After a clinical and biological description of arylsulfatase A and metachromatic leucodystrophy, we present the results of a study of leucocyte arylsulfatase A in a population of 22 adult psychotic inpatients. The patients, clinically defined, filled the criteria of DSM III of schizophrenic disorders. All of them were treated by neuroleptics. None of these 22 patients showed a level of arylsulfatase A different from the range of 27 healthy adult controls. These results differ from those of most precedent studies of arylsulfatase A in "psychiatric populations". Some explanations of this difference are suggested. The concept of "purely psychiatric" form of adult metachromatic leucodystrophy is discussed.

[Changes in urinary levels of MHPG, VMA and 5-HIAA and plasma tryptophan in post-partum blues. Initial results]. / Modification des taux de MHPG, VMA, 5-HIAA urinaires et de tryptophane plasmatique dans le "post-partum blue". Premiers résultats.

In post-partum depressive illness ("post-partum blue") we measured urinary MHPG, VMA, 5-HIAA and free and total Trp. VMA and especially MHPG reflect the brain noradrenaline metabolism. Trp is the precursor of 5-HT synthesis and 5-HIAA is the main urinary catabolite of 5-HT. The clinical evaluation consisted in self-evaluation scales: Pitt scale 1, 3 and 5 days after delivery, CESD scale of NIMH (depression) and BONIS scale (anxiety) at 6th day. Moreover a psychiatrist measured depression intensity on the MADRS scale and DSM III data. First results seem to indicate a decrease of free MHPG and VMA, an increase of 5-HIAA and no alteration of free and total Trp. These modifications could involve adrenergic and serotoninergic alterations in brain.

[Study of vigilance after ingestion of zopiclone in comparison with nitrazepam and placebo (author's transl)]. / Etude de la vigilance après prise de zopiclone en comparaison avec nitrazépam et placebo. Méthodologie de l'étude : questionnaires d'auto-évaluation et tests psychométriques.

Increasing importance is being given to the residual effects of hypnotics on the day following absorption; with zopiclone, a new hypnotic, we have studied vigilance 9, 12 and 15 hours after a single evening dose of 10 mg, on a double-blind basis in comparison with 10 mg of nitrazepam and a placebo. The assessment of vigilance is based on responses to self-rating questionnaires and psychometric tests. Twenty-one healthy subjects forming a homogeneous group as regards age, I.Q., and vigilance were included in this study. Each subject received the three products in random distributed order, with an interval of three months between each trial. The results of these tests reveal modifications which, particularly 9 hours after administration, reflect a modification in vigilance, appearing to be more marked with nitrazepam than with zopiclone. Thus, from the point of view of the residual effects of hypnotics on vigilance, it is possible to position the products tested in the following order: placebo -- zopiclone -- nitrazepam.

[Haloperidol decanoate. Results of an open-ended multicentric study in chronic psychotic states]. / Décanoate d'halopéridol. Résultats d'une étude ouverte multicentrique dans les états psychotiques chroniques.

UNLABELLED: An open multicentric study of 196 in-patients was carried out in 9 centres. After an initial stabilization (min. 15 days) with oral haloperidol, patients received haloperidol decanoate IM for at least 24 weeks (or a minimum of 9 injections). RESULTS: - esterification of haloperidol increased the duration of its efficacy (interval between 2 injections: average 4 weeks) without interfering with its therapeutic activity (global appreciation scale, BPRS at each injection and at the end of the treatment); - equivalent quantities of haloperidol injected at a time were 15 to 20 times those administered daily during the initial stabilisation period; - side-effects were not different with haloperidol decanoate as compared to those of the previous period (haloperidol).

[Plasma and saliva DST (dexamethasone suppression test) in depression. Clinical applications and kinetic approach]. / DST plasmatique et salivaire dans la dépression. Applications cliniques et approche cinétique.

Both plasmatic and salivary DST were simultaneously performed on a sample of 37 patients with a diagnosis of major depressive disorder (DMS III criteria): 22 primary depressions and 15 secondary depressions. Salivary DST showed a similar specificity but a decreased sensitivity in comparison with plasmatic DST. Essentially, the simultaneous use of both tests resulted in a better specificity for primary depression.

[Study of the relation of gynecologic and obstetric findings and psychological disorders of pregnancy and the puerperium]. / Etude des relations entre données gynéco-obstétricales et troubles psychiques de la grossesse et du post-partum.

The relationship between gynaecological and obstetrical parameters and psychological troubles in pregnancy and after delivery are a matter of much debate. This arises partly because of different methods of studying the conditions and because of epidemiological studies that have been carried out on this subject. This longitudinal prospective study has been carried out on 211 women who were delivered in the maternity department of Louis Mourier Hospital. The figure for anxiety (in the de Bonis scale of greater than or equal to 20) was 13 to 15% at different times in the pregnancy, of depression (in the CESd scale greater than or equal to 16) was between 11 and 14.5%. 34.5% of those women who had delivered suffered from "baby blues", while 20% had symptoms of depression (CESd greater than or equal to 16 in the first week post-partum) and 6% had a quite obvious syndrome of depression (MADRS greater than or equal to 20). Finally, 18 to 24.5% of women had a major episode of depression (according to the DSM III test) in the year following delivery. As far as risk factors were concerned there was a statistically significant correlation between anxiety and depression in pregnancy and induction of labour, as well as difficulties with the third stage of labour and with an Apgar score of less than 9 in the infant. There was poor correlation between "baby blues" and gynaecological and pathological changes except where vaginal delivery was not spontaneous and where large episiotomies were carried out. On the other hand, women who had pathological labours or cesareans or a general anaesthetic for the third stage had more troubles than others in the year following delivery. Finally, women who showed signs of anxiety or depression in pregnancy or had "baby blues" after delivery were less likely to be able to breast feed their children.

[Seasonal affective disorders, a new clinical category]. / Les troubles affectifs saisonniers, une nouvelle catégorie clinique.

Seasonal affective disorders have recently been individualized by American authors. According to these authors, this subgroup of affective diseases deserve to be regarded as a clinical category owing to its specific symptoms, its epidemiological features and its response to treatment. They are characterized by the triad: hypersomnia, hyperoxia, weight gain, associated with usual symptoms of depression. Moreover, contrary to the bipolar manic-depressive psychosis, they seem to predominate among women. Finally, phototherapy, the various protocols of which are discussed here, is said to be effective. The influence of latitude combined with the effectiveness of phototherapy has led to original pathogenic hypotheses, among which the presence of a chronobiological disorder (abnormality of the season-induced circadian rhythm), although attractive and supported by a strict clinical study, has yet to be demonstrated. Also hypothetical is the role played by melatonin: is this hormone the principal "mediator" or an epiphenomenon?

[Mental disorders in elderly hospitalized patients. Epidemiological study in an internal medicine department]. / Troubles mentaux chez les sujets âgés hospitalisés. Etude épidémiologique dans un service de médecine interne.

This epidemiological transversal study conducted on 100 patients older than 65 years hospitalized in the Internal Medicine department of a University hospital demonstrates the frequency of psychiatric pathology in these patients: dementia 19 percent; other psycho-organic disorders 17 percent; affective disorders 23 percent and other psychological disturbances 4 percent. Thus, 63 percent of this patient population had a mental disorder as defined by the DSM III criteria. These disorders are generally not or imperfectly identified by the internists in charge of these patients.

[Psychotic women and their children]. / Les femmes psychotiques et leurs enfants.

With desinstitutionalization, the social life of psychiatric patients and particularly that of psychotics has arisen in new terms over the past twenty years. In particular, relationships and sexuality of these patients are manifest realities to which few studies are devoted. 61 schizophrenic and 21 bipolar women (18-45 years of age, mean 34 in-or outpatients) were interviewed with a battery of instruments (PANSS, Carpenter's criteria of schizophrenia with deficit syndrome, axis V of DSM-III-R) and with a semi-structured questionnaire related to clinical data, sexuality, relationships, children and motherhood. Half of the schizophrenic women have an active sexual life, and children. The study provides information about the reproduction rate of schizophrenic women, the precocity of their pregnancies and the outcome of their children. The study also treats these women's ability to rear their children, their desire to have children and any hospitalizations during the perinatal period. These results, as well as those related to abortion and contraception, are discussed in the light of those of the bipolar control group.