Place of psychosocial rehabilitation in psychiatry of the elderly / Place de la réhabilitation psychosociale en psychiatrie de la personne âgée

Psychosocial rehabilitation (PSR) is a practice focused on recovery of the personal processes in which the elderly subject works to maintain his autonomy for as long as possible, and to remain in control of his life and his decisions. The belief that once old, the person loses his ability to act, is often linked to cognitive biases and can have negative impacts on recovery. Indeed, compared to adults, the elderly subject is doubly stigmatized, both by mental disorders and the consequences of aging. Thus, the geriatric population requires, in the recovery process, to take into account the specificities related to aging. Moreover, PSR must go beyond the control of symptoms and aim to improve the quality of life and well-being. We thus propose to describe in this article the RPS tools adapted to the psychiatry of the elderly subject.

La réhabilitation psychosociale (RPS) est une pratique axée sur le rétablissement des processus personnels dans lesquels le sujet âgé chemine pour maintenir son autonomie le plus longtemps possible, et rester maitre de sa vie et de ses décisions. La croyance qu'une fois âgée, la personne perd de sa capacité à agir, est souvent liée à des biais cognitifs et peut avoir des impacts négatifs sur le rétablissement. En effet, par rapport à l'adulte, le sujet âgé est doublement stigmatisé, à la fois par les troubles mentaux, et les conséquences du vieillissement. Ainsi, la population gériatrique nécessite, dans le processus de rétablissement, une prise en compte des spécificités liées au vieillissement. Par ailleurs, la RPS doit aller au-delà de la maîtrise des symptômes et viser l'amélioration de la qualité de vie et du bien-être. Nous proposons ainsi de décrire dans cet article les outils de RPS adaptés à la psychiatrie du sujet âgé.

PLAN-e-PSY, a mobile application to improve case management and patient's functioning in first episode psychosis: protocol for an open-label, multicentre, superiority, randomised controlled trial.

INTRODUCTION: The prognosis of first episode psychosis (FEP), which is a severe disorder, can be notably impaired by patients' disengagement from healthcare providers. Coordinated specialty care with case management is now considered as the gold standard in this population, but there are still challenges for engagement with subsequent functional impairments. Youth-friendly and patient-centred clinical approaches are sought to improve engagement in patients with FEP. Mobile applications are widely used by young people, including patients with FEP, and can increase the youth friendliness of clinical tools. We hypothesise that a co-designed mobile application used during case management can improve functioning in patients with FEP as compared with usual case management practices. METHODS AND ANALYSIS: A mobile case management application for planning and monitoring individualised care objectives will be co-designed with patients, caregivers and health professionals in a recovery-oriented approach. The application will be compared with usual case management practices in a multicentre, two-arm and parallel groups clinical trial. Patients will be recruited by specialised FEP teams. Impact on functioning will be assessed using the Personal and Social Performance Scale; the variation between baseline and 12 months in each group (control and active) will be the primary outcome. ETHICS AND DISSEMINATION: This study has been approved by the Inserm Institutional Review Board IRB00003888 (Comité d'évaluation éthique de l'INSERM, reference number 20-647). The results of the study will be published in a peer-reviewed journal and presented at national and international conferences. We will also communicate the results to patients and family representatives' associations. An optimised version of the application will be then disseminated through the French FEP network (Transition Network). TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT04657380.

Attention in schizophrenia: Impaired inhibitory control, faulty attentional resources, or both?

While the literature regarding the existence of difficulties in inhibition in schizophrenia is relatively consistent, it is not clear whether these difficulties reflect any specific deficit in an inhibitory control process or whether they are the result of deficits in the systems that regulate inhibitory control, such as attentional resources. This also raises the issue of attentional resources in schizophrenia, which offers a somewhat puzzling and sometimes contradictory picture. In this study, these issues were investigated by means of a paradigm in which the need for inhibitory control and the need for correct allocation of attentional resources varied parametrically. Twenty-six outpatients with a diagnosis of schizophrenia and 26 matched controls completed a visual search task during which distractors were presented and had to be inhibited. At the same time, they also completed an auditory target detection task of varying difficulty. The results show that the patients had difficulties both in inhibiting distractors and in correctly allocating attention to the two tasks. The results also show that these two difficulties were not related. This leads to the conclusion that schizophrenia involves both defective inhibitory control and faulty management of attentional resources, and that the former does not result from the latter. Furthermore, these effects seem to be neither dependent on processing speed, nor related to medication.

From Theory to PrACTice: A Cognitive Remediation Program Based on a Neuropsychological Model of Schizophrenia.

Cognitive dysfunction is one of the hallmark deficits of schizophrenia. A wide range of studies illustrate how it is strongly interconnected to clinical presentation and daily life functioning [see Ref. (1, 2)]. Hence, cognition is an important treatment target in schizophrenia. To address the challenge of cognitive enhancement in schizophrenia, a large number of cognitive remediation programs have been developed and evaluated over the past several decades. First, an overview of these programs is presented highlighting their specificity to cognitive deficit in schizophrenia using an integrated method. In this case, cognitive training focuses on enhancing several elementary cognitive functions considered as a prerequisite to social skills or vocational training modules. These programs are based on the neurodevelopmental hypothesis of schizophrenia. However, moderate improvement for patients who benefit from these therapies has been observed as described in Wykes et al. review (3). Next, neuropsychological models of schizophrenia are then presented. They highlight the critical role of the internally generated intentions in appropriate willful actions. The cognitive control mechanism deals with this ability. Interestingly, available cognitive remediation programs have not been influenced by these models. Hence, we propose another alternative to set up a specific cognitive remediation program for schizophrenia patients by targeting the cognitive control mechanism. We describe the PrACTice program that is in the process of being validated.