Management of alcohol-related liver disease: the French Association for the Study of the Liver and the French Alcohol Society clinical guidelines.

Excessive alcohol consumption is the leading cause of liver diseases in Western countries, especially in France. Alcohol-related liver disease (ARLD) is an extremely broad context and there remains much to accomplish in terms of identifying patients, improving prognosis and treatment, and standardising practices. The French Association for the Study of the Liver wished to organise guidelines together with the French Alcohol Society in order to summarise the best evidence available about several key clinical points in ARLD. These guidelines have been elaborated based on the level of evidence available in the literature and each recommendation has been analysed, discussed and voted by the panel of experts. They describe how patients with ARLD should be managed nowadays and discuss the main unsettled issues in the field.

Sugar intake and craving during alcohol withdrawal in alcohol use disorder inpatients.

To assess whether changes in sugar intake and craving occur during alcohol withdrawal in humans, we conducted a prospective, observational study in a university hospital addictions treatment center. Recruited patients had severe alcohol use disorder and were hospitalized for 7 days in the short-stay unit for alcohol withdrawal and then for 6 weeks in the rehabilitation unit. During the hospital stay, they had no access to alcohol but had full access to sweet products and beverages in a shop and vending machines located inside the hospital. Alcohol craving was assessed using a visual analogue scale on Days 1, 15, and 45. Sugar craving, sweet products stored by patients in their rooms, and weight were assessed on the same days. Thirty-five patients were included. Sugar craving increased in 14 patients during the hospital stay, whereas no change was observed in the remaining 21. Significant increases in both the amounts of sweet products stored in the patients' rooms (p < 0.02) and weight (p < 0.05) were observed only in the sugar craving group. During the same period, alcohol craving decreased significantly in all patients. Changes in tobacco smoking were not different according to the sugar craving status and therefore cannot explain the observed differences. In conclusion, increased intake and craving for sugar after alcohol withdrawal were observed in 40% of the patients included in our prospective study, and these results were similar to those of a study conducted in the alcohol post-dependent state model in rats.

Health-related quality of life in alcohol dependence: Similar cross-cultural impact beyond specific drinking habits.

This study explores sociocultural differences in alcohol-related impact on quality of life between France and United Kingdom. We included 38 alcohol-dependent patients in France and United Kingdom in 10 focus groups. We used a text-mining approach. Three classes of each corpus regarded identical themes across the countries: (a) core impact on quality of life, (b) drinking habits, (c) sources of help. Core impact was similar between the two countries. Main differences were in drinking habits and referral to sources of help. Despite differences in drinking habits, the domains of life impacted by alcohol were non-country specific.

Alcohol consumption, drinker identity, and quality of life among students: why there cannot be one prevention strategy for all.

INTRODUCTION: The objective for this study was to combine drinking characteristics and two subjective measures, drinker identity and alcohol-related quality of life, i.e., negative impact of alcohol on quality of life, to determine relevant profiles for indicated prevention programs. In particular, we hypothesized that different profiles of students with high level of alcohol consumption exist when exploring subjectivity. METHODS: We performed an online survey among 16,930 students. We collected sociodemographics and environmental data, including alcohol-related quality of life, drinker identity, and drinking characteristics. We performed a hierarchical clustering on principal components. We described all variables in each cluster and explored between clusters differences by Kruskal-Wallis tests. RESULTS: We identified five clusters as regarding drinker identity, drinking characteristics, and alcohol-related quality of life. Among these five clusters, three clusters presented high drinking characteristics. A very vulnerable cluster showed high level of alcohol consumption, impact on quality of life and on academic results, and strong drinker identity. An egodystonic cluster showed high level of consumption, mild impact on quality of life and on academic results, but low drinker identity. A cluster seemed short-term super-adapted in heavy drinking environment, showing high level of alcohol consumption and drinker identity, but low impact on quality of life and on academic results (all between clusters p values < 0.001 with Kruskal-Wallis tests). CONCLUSION: The subjective experience of students from these clusters was significantly different (p value < 0.001), and could explain some inadequacy of certain prevention strategies, considering binge drinker student as a homogeneous group. Prospective studies are needed to explore changes over time of these clusters.

The Efficacy of Three Modalities of Internet-Based Psychotherapy for Non-Treatment-Seeking Online Problem Gamblers: A Randomized Controlled Trial.

BACKGROUND: Internet-based interventions targeted at the most at-risk gamblers could reduce the treatment gap for addictive disorders. Currently, no clinical trial has included non-treatment-seeking patients who have been recruited directly in their gambling environment. This study was the first exclusively Internet-based randomized controlled trial among non-help-seeking problem gamblers with naturalistic recruitment in their gambling environment. OBJECTIVE: The aim of this study was to assess the efficacy of three modalities of Internet-based psychotherapies with or without guidance, compared to a control condition, among problem gamblers who play online poker. METHODS: All active poker gamblers on the Winamax website were systematically offered screening. All problem poker gamblers identified with a Problem Gambling Severity Index (PGSI) score of ≥ 5 were eligible to be included in the trial. Problem gamblers were randomized into four groups: (1) waiting list (control group), (2) personalized normalized feedback on their gambling status by email, (3) an email containing a self-help book to be downloaded with a Cognitive Behavioral Therapy (CBT) program without guidance, and (4) the same CBT program emailed weekly by a trained psychologist with personalized guidance. Efficacy was assessed based on the change in PGSI between baseline and 6 weeks (end of treatment) or 12 weeks (maintenance) and supported by player account-based gambling data automatically collected at the three time points. RESULTS: All groups met high attrition rates (83%), but the group with guidance had a significantly higher dropout rate than the other three groups, including the control group. Although all groups showed some improvement, with a mean decrease of 1.35 on the PGSI, no significant difference in efficacy between the groups was observed. One-third of the problem gamblers fell below the problem gambling threshold at 6 weeks. CONCLUSIONS: Guidance could have aversively affected problem gamblers who had not sought help. Despite the lack of significant difference in efficacy between groups, this naturalistic trial provides a basis for the development of future Internet-based trials in individuals with gambling disorders. Comorbidities, natural course of illness, and intrinsic motivation seem to be critical issues to consider in future designs. TRIAL REGISTRATION: ANSM 2013-A00794-41.

Pharmacotherapy for smoking cessation: pharmacological principles and clinical practice.

Strategies for assisting smoking cessation include behavioural counselling to enhance motivation and to support attempts to quit and pharmacological intervention to reduce nicotine reinforcement and withdrawal from nicotine. Three drugs are currently used as first line pharmacotherapy for smoking cessation, nicotine replacement therapy, bupropion and varenicline. Compared with placebo, the drug effect varies from 2.27 (95% CI 2.02, 2.55) for varenicline, 1.69 (95% CI 1.53, 1.85) for bupropion and 1.60 (95% CI 1.53, 1.68) for any form of nicotine replacement therapy. Despite some controversy regarding the safety of bupropion and varenicline, regulatory agencies consider these drugs as having a favourable benefit/risk profile. However, given the high rate of psychiatric comorbidity in dependent smokers, practitioners should closely monitor patients for neuropsychiatric symptoms. Second-line pharmacotherapies include nortriptyline and clonidine. This review also offers an overview of pipeline developments and issues related to smoking cessation in special populations such as persons with psychiatric comorbidity and pregnant and adolescent smokers.

Inhibition/activation in bipolar disorder: validation of the Multidimensional Assessment of Thymic States scale (MAThyS).

BACKGROUND: One of the major issues in clinical practice is the accurate differential diagnosis between mixed states and depression, often leading to inappropriate prescriptions of antidepressants in mixed states, and as a consequence, increasing the risk of manic switch and suicide. In order to better define the spectrum of mixed states, it may be useful to develop a dimensional approach. In this context, the MAThyS (Multidimensional Assessment of Thymic States) scale was built to assess activation/inhibition levels in all bipolar mood episodes, and to determine whether a clinical description in terms of activation/inhibition can help better define bipolar states with which both manic and depressive symptoms are associated. The aim of this paper is the validation of the MAThyS scale in 141 bipolar patients in acute states (manic, hypomanic, mixed, or depressive). METHODS: The validation of the MAThyS scale was the primary outcome of this 24-week, phase III, open-label, olanzapine single-arm clinical trial. Principal component, factorial analysis, and Cronbach's coefficient calculation (internal consistency) were performed. Concurrent validity (correlations with 17-item Hamilton Depression Rating Scale [HAMD-17], Hamilton Anxiety Rating Scale [HAMA], and Young Mania Rating Scale [YMRS]) and responsiveness to the clinical intervention were assessed (change in MAThyS scale and effect size) at 6 and 24 weeks. RESULTS: Scree plot of eigenvalues identified a 2-dimension structure ("activation/inhibition level" and "emotional component"). Psychometric properties were good: Cronbach's coefficient was >0.9. Concurrent validity was good with low correlation (-0.19) with the HAMA scale and a higher correlation at baseline with the YMRS (0.72) and HAMD-17(-0.43). As expected, the activation state was predominant in manic, hypomanic, and mixed states while inhibition was predominant in depressive states. MAThyS score improvement was observed (effect size: -0.3 at 6 and 24 weeks). CONCLUSIONS: The MAThyS demonstrated good psychometric properties. The MAThyS scale may help clinicians to better discriminate and follow bipolar episodes, especially the broad spectrum of mixed episodes.

[Current therapeutic strategies for tobacco dependence]. / Stratégies thérapeutiques contre la dépendance tabagique.

Smoking remains the first preventable cause of premature death worldwide. Despite the knowledge of adverse consequences of smoking, many smokers have difficulties to quit for good. This is due to the addictive nature of tobacco, at least as strong as the one of illicit drugs. The mechanisms of nicotine dependence are very similar to those of other addictive behaviors, and are based on disequilibrium of the meso-cortico-limbic reward system. The withdrawal syndrome responds well to nicotine replacement therapy, bupropion, and varenicline. Recent guidelines stress the responsibility of all health care professional to address the smoking problem of every patient through the 5 A model: Ask - Advise - Assess - Assist - Arrange.

[From nicotine dependence to addictology]. / De la tabacologie à l'addictologie.

The concept of addiction has developed in France since the beginning of the 2000s. It has justified by common clinical aspects, high level of co-morbidities between addictions to psychoactive drugs, common cognitive and behavioral mechanisms, the impact of comparable psychological and genetic factors, the same neurobiological mechanisms and the same therapy options in many cases. Although some specificities remain in smoking management: absence of intoxication and abuse diagnosis in DSM-IV, less consensual politics of harm reduction, and own pharmacotherapy solutions. Despite what is commonly thought, tobacco is the most addictive amongst all psycho-active-substances in Western countries.

Development and Psychometric Properties of a New Patient-Reported Outcome Instrument of Health-Related Quality of Life Specific to Patients with Gambling Disorder: The Gambling Quality of Life Scale (GQoLS).

BACKGROUND: Impairment or distress caused by gambling disorder can be subjectively assessed via quality of life. The aim of this study was to develop a new patient-reported outcome instrument to explore the health-related quality of life (HRQoL) in gambling disorders, the Gambling quality-of-life scale (GQoLS), and to document its psychometric properties. METHODS: A previous qualitative study had been conducted using focus groups of problem gamblers to identify areas of HRQoL impacted by gambling. The seven domains identified served as the basis for the hypothetical structure of GQoLS. Draft items were generated from the patient's speeches to illustrate each of these domains. Cognitive debriefing interviews were realized to obtain a final hypothetical GQoLS. A validation study was then carried out to determine the final version of GQoLS and its psychometric properties (structural validity, construct validity, internal consistency). RESULTS: The final GQoLS was composed of 21 items, with a total mean score of 38.3 (±13.6). Structural validity found a major dimension and four other minor dimensions. The five dimensions were: "emotion", "lifestyle", "loneliness", "taboo" and "preoccupation". GQoLS was moderately to strongly correlated with PGSI and EQ-5D visual analogic scale. Cronbach's alpha coefficient was 0.92. CONCLUSION: GQoLS is the first HRQoL instrument specific to patients with a gambling disorder and developed from the patient's perspective. GQoLS presents good psychometric properties. GQoLS can be used in clinical research to demonstrate the effectiveness of an intervention on outcomes that are relevant from the patient's perspective.

Pictograms to aid laypeople in identifying the addictiveness of gambling products (PictoGRRed study).

The structural addictive characteristics of gambling products are important targets for prevention, but can be unintuitive to laypeople. In the PictoGRRed (Pictograms for Gambling Risk Reduction) study, we aimed to develop pictograms that illustrate the main addictive characteristics of gambling products and to assess their impact on identifying the addictiveness of gambling products by laypeople. We conducted a three-step study: (1) use of a Delphi consensus method among 56 experts from 13 countries to reach a consensus on the 10 structural addictive characteristics of gambling products to be illustrated by pictograms and their associated definitions, (2) development of 10 pictograms and their definitions, and (3) study in the general population to assess the impact of exposure to the pictograms and their definitions (n = 900). French-speaking experts from the panel assessed the addictiveness of gambling products (n = 25), in which the mean of expert's ratings was considered as the true value. Participants were randomly provided with the pictograms and their definitions, or with a standard slogan, or with neither (control group). We considered the control group as representing the baseline ability of laypeople to assess the addictiveness of gambling products. Each group and the French-speaking experts rated the addictiveness of 14 gambling products. The judgment criterion was the intraclass coefficients (ICCs) between the mean ratings of each group and the experts, reflecting the level of agreement between each group and the experts. Exposure to the pictograms and their definition doubled the ability of laypeople to assess the addictiveness of gambling products compared with that of the group that read a slogan or the control group (ICC = 0.28 vs. 0.14 (Slogan) and 0.14 (Control)). Laypeople have limited awareness of the addictive characteristics of gambling products. The pictograms developed herein represent an innovative tool for universally empowering prevention and for selective prevention.

Suicidal attempts in bipolar disorder: results from an observational study (EMBLEM).

OBJECTIVES: To compare patients with and without a history of suicidal attempts in a large cohort of patients with bipolar disorder and to identify variables that are associated with suicidal behavior. METHODS: European Mania in Bipolar Longitudinal Evaluation of Medication (EMBLEM) is a two-year, prospective, observational study that enrolled 3,684 adult patients with bipolar disorder and initiated or changed oral treatment for an acute manic/mixed episode. Of those, 2,416 patients were eligible for the two-year follow-up. Only baseline characteristics were studied in the present study, included sociodemographic data, psychiatric history and comorbidities, history of suicide attempts, history of substance use problems, compliance with treatment, inpatient admissions, and functional status. Symptom severity was assessed using the Clinical Global Impression-Bipolar Disorder (CGI-BP) scale, the Young Mania Rating Scale (YMRS), and the 5-item Hamilton Depression Rating Scale (HAMD-5). A logistic regression model identified baseline variables independently associated with a history of suicidal behavior. RESULTS: Of the 2,219 patients who provided data on their lifetime history of suicide attempts, 663 (29.9%) had a history of suicidal behavior (at least one attempt). Baseline factors associated with a history of suicidal behavior included female gender, a history of alcohol abuse, a history of substance abuse, young age at first treatment for a mood episode, longer disease duration, greater depressive symptom severity (HAMD-5 total score), current benzodiazepine use, higher overall symptom severity (CGI-BP: mania and overall score), and poor compliance. CONCLUSIONS: These factors may be considered as potential characteristics to identify subjects at risk for suicidal behavior throughout the course of bipolar disorder.

[Current strategies for treatment of alcohol problems]. / Stratégies actuelles de prise en charge des troubles de l'alcoolisation.

Amongst validated psychological treatments, brief intervention appears to be the best suited for primary care. It aims at increasing motivation for change after a screening for an alcohol use disorder. The first therapeutic step for an alcohol-dependent patient aiming at abstinence is alcohol detoxification. At this stage, benzodiazepines should be briefly prescribed if the patient manifests clinically significant withdrawal symptoms. The next step is relapse prevention, for which only three medications are currently validated in France, acamprosate, naltrexone, and disulfiram.

Burden and Help-Seeking Behaviors Linked to Problem Gambling and Gaming: Observational Quantitative and Qualitative Analysis.

BACKGROUND: Models based on the uniqueness of addiction processes between behavioral addictions are highly contentious, and the inclusion of gaming disorder in the addiction nosography remains controversial. An exploratory approach could clarify a hypothesized common and subjectively identifiable process in addictive behaviors and the necessarily different expressions of the disorder due to behavior specificities, in particular the sociocultural characteristics and profiles of users. OBJECTIVE: The aim of this study was to describe the nature of contacts to a help service by exploring commonality and specificities of burden and help-seeking for problem gambling or gaming. METHODS: This was an observational quantitative-qualitative study. We included all contacts (ie, online questions and contacts by phone or chat when the helper completed a summary) to a helpline for gamers, gamblers, and relatives over a 7-year period. We constituted a text corpus with online questions and summaries of contacts by phone or chat. We collected basic sociodemographic data, including the device used to contact the service (phone or internet), contacting the service for oneself ("user") or being a relative of a user and type of relative, gambling (yes/no), gaming (yes/no), and age and sex of the gambler/gamer. We describe the corpus descriptively and report the computerized qualitative analysis of online questions, chat, and summary of phone calls. We performed a descendant hierarchical analysis on the data. RESULTS: A total of 14,564 contacts were made to the helpline, including 10,017 users and 4547 relatives. The corpus was composed of six classes: (1) gaming specificities, (2) shared psychological distress and negative emotions, (3) the procedure for being banned from gambling, (4) the provided help, (5) gambling specificities, and (6) financial problems. CONCLUSIONS: Negative emotions and shared distress linked to gambling and gaming support current scientific consensus that these behaviors can produce psychological distress in se; however, meaningful differences were observed in core symptoms of addiction between gamers and gamblers, beyond specificities related to the behavior itself: loss of control was elicited in the class corresponding to gambling specificities and not by gamers and their relatives.

Mental Burden of Hospital Workers During the COVID-19 Crisis: A Quanti-Qualitative Analysis.

Context: This study is a quanti-qualitative analysis of all contacts to a helpline service for hospital workers during the COVID-19 crisis. Our aim was to describe the nature of mental burden in hospital workers and factors subjectively associated to this burden from the workers' perspective. Methods: We included all 50 contacts from 25 different workers and 10 different professions over the course of 1 month. We described the corpus and reported the computerized qualitative analysis of summary of contacts. We performed a descendant hierarchical analysis and analyzed specificities of classes of age with a correspondence factor analysis. Results: The corpus was composed of three classes: (1) distress specific to the COVID-19 situation, (2) help provided, and (3) pre-existing psychological vulnerability. Factors subjectively responsible for mental distress were: (a) the contamination risk, (b) confinement, and (c) the rapidly evolving situation and changing instructions. Lack of "COVID-free time" seemed to increase negative emotions. Reassignment to a high viral density unit was a stressor, especially in older workers. Young workers mentioned pre-existing vulnerability more than others. Fear of death was shared by all classes of age, regardless of the objective risk of contamination. Discussion: Hospital workers experience mental distress factors both in common with the general population and specific to the hospital environment. Preserving and organizing support for the mental health of all hospital workers is a critical challenge, including those with poorly recognized professions. Leads for institutions to avoid additional stressors for hospital workers are presented. Young workers with pre-existing vulnerability seem particularly impacted.

Study protocol for an online randomised controlled trial among non-treatment seeking problem gamblers: training inhibition in online problem gambling (TRAIN-online) trial.

INTRODUCTION: Development of fully internet-based programs could provide a new avenue to improve access to healthcare for problem gamblers. In this project, we aim to assess the efficacy of a web-based cognitive intervention targeting inhibitory control among problem gamblers, using a randomised controlled design. As impaired inhibitory control is involved in self-regulation difficulties in behavioural addictions, it represents a particularly relevant cognitive process to target for an online psychological intervention. METHODS AND ANALYSIS: This will be a single-blinded, randomised, comparative therapeutic web-based, controlled trial. Up to 200 non-treatment seeking adult problem gamblers with a Problem Gambling Severity Index-recent (PGSI-recent) score ≥5 will be included. The intervention will be a computerised cognitive training program targeting inhibitory skills. The comparator, an active control, will be a computerised neutral sensorial program. Both programs will be carried out under similar conditions: biweekly online training for 6 weeks and optional telephone support will be offered to patients for debriefing. The main objective of the study is to assess the clinical efficacy of the online cognitive training program at 6 weeks, measured with the PGSI-recent. The secondary objectives are to assess the efficacy on the gambling behaviour assessed by the account-based gambling data, on the self-reported gambling practice, and on the inhibition performance at the neuropsychological level at 6, 14 and 52 weeks. We will also assess the acceptability of this program and the preferred level of guidance. Data analysis will be in intention-to-treat. ETHICS AND DISSEMINATION: This randomized controlled trial will be executed in compliance with the Helsinki Declaration, and was approved by the local ethics boards (Comité de Protection des Personnes) in October 2017. The findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03673800.