[Advanced directives in psychiatry: A review of the qualitative literature, a state-of-the-art and viewpoints]. / Les directives anticipées en psychiatrie : revue de la littérature qualitative, état des lieux et perspectives.

BACKGROUND: Advance Directives are written documents, which are used for people to notify their preference for a future situation when they are unable to give their consent. In psychiatry, psychiatric advance directives (PADs) can be used for patients with chronic psychotic disorders such as schizophrenia, or a bipolar disorder. PADs give the patient an opportunity to state wishes in advance about his/her treatment when he/she is in an acute state of illness. PADs were initially developed as a way for patients to defend themselves against the power of the psychiatrists, but are likely to become a useful tool in psychiatric care. PADs may contain information about medication, non pharmaceutical devices, and the name of a proxy decision maker. The main objective is to reduce the number of compulsory hospitalisations. OBJECTIVE: This article is a qualitative review which carries out a state-of-the-art on the use of PADs for people with chronic psychotic disorders and defines suggestions to include this intervention in the French psychiatric context. METHOD: We used the keywords psychiatric advance directives, crisis card, Ulysse directives, joint crisis plan (JCP) in the MEDLINE database to propose a qualitative review. We selected original clinical studies about the use of PADs for people with psychotic disorders. RESULTS: We included 36 articles. The qualitative analysis identified seven main themes: different types of PADs, effectiveness of PADs, practical use of PADs, patient's views, clinician's views, economical aspects, and legal aspects. The content of the PADs is consistent with psychiatric standard care in nearly all cases, regarding medical instructions, pre-emergency interventions, non-hospital alternatives and non-medical personal care. Patients use their PADs to describe prodromal symptoms of relapse and to suggest a treatment and a hospitalisation in advance. PADs are not used to refuse all treatments. Patients show a strong interest in creating a directive and a high level of satisfaction when using it. They feel they have more control over their mental health problem and are more respected and valued as a person. Thirty-six to fifty-three percent of clinicians had positive opinions regarding PADs. They valued the increase of the patient's autonomy and the prevention of relapse, but were concerned about difficulties for accessing the documents, and about the lack of training of the medical teams. Clinicians also feared the pressure of relatives or partners on treatment decisions. The qualitative analysis revealed the specific benefit of the JCP, a particular type of PADs negotiated with the medical team, on the reduction of the general number of admissions. We can identify practical problems such as the lack of accessibility to PADs in emergency situations, and the clinician's reluctance to use PADs. The only economical evaluation showed a non-significant decrease in total costs. DISCUSSION: PADs are used in a few countries, although their benefits in terms of patient's perceptions and compulsory admissions are promising. The JCP proposes a specific clinical approach based on therapeutic alliance. Its creation also involves the clinician, family members and a neutral mediator in a negotiated process. The JCP is likely to be the most efficient PAD model in reducing compulsory admissions. The use of the JCP appears to be relevant in the context of the new French legislation, establishing outpatient commitment orders and could be an effective way to improve the relationships with patients.

[Polymyalgia rheumatic and chronic myelomonocytic leukemia]. / Pseudo-polyarthrite rhizomélique satellite d'une leucémie myélomonocytaire chronique.

INTRODUCTION: Myelodysplasia (MDS) can occur as systemic manifestations such as connective tissue diseases or vasculitis. Rheumatological manifestations are also described in such context. Herein, we report the observation of a patient with chronic myelomonocytic leukemia (CMML) who developed systemic manifestations: polymyalgia rheumatica and pericarditis. CASE REPORT: A 78-year-old patient was referred for the exploration of two months history of inflammatory shoulder pain associated with biological inflammatory syndrome. He presented with asthenia, anorexia and loss of 5kg in one month. He had a three years follow-up for a CMML without any specific treatment. All of the explorations carried out showed a typical polymyalgia rheumatica. A pericardial effusion requiring emergency drainage was synchronously diagnosed. All the symptoms occurred during a worsening of his hematological disease. The rheumatological manifestation was favorable after a short corticosteroid therapy and pericarditis did not recur after 2 years of follow-up. CONCLUSION: It should be necessary to screen patients for MDS in a context of systemic manifestation, especially in elderly patients with an abnormal blood count (cytopenia, macrocytosis and monocytosis).

Galanin receptor 2 overexpressing mice display an antidepressive-like phenotype: possible involvement of the subiculum.

The behavioral phenotype of a transgenic mouse overexpressing a galanin receptor 2 (GalR2)-enhanced, green fluorescent protein (EGFP)-construct under the platelet-derived growth factor-B promoter, and of controls, was assessed in various behavioral tests, such as the Porsolt forced swim test, as well as the open field, elevated plus maze and passive avoidance tests. In addition, the distribution of GalR2-EGFP expressing cell bodies and processes was studied in the brain of these mice using histochemical methods. Three age groups of the transgenic mice demonstrated decreased levels of immobility in the forced swim test, indicative of antidepressive-like behavior and/or increased stress resistance. Anxiety-like behaviors, measured in two different tests, did not differ between the GalR2-overexpressing and the wild-type mice, nor did motor activity levels, emotional learning or memory behaviors. High levels of GalR2 mRNA and protein expression were observed in the presubiculum, subiculum, cingulate cortex, retrosplenial granular and agranular cortices, subregions of prefrontal cortex, and the olfactory bulb, regions which are directly or indirectly implicated in depression-like behavior. These results may contribute to the understanding of the pathophysiology of major depressive disorder and the role of GalR2 in the regulation of mood, and suggest a potential therapeutic effect by targeting the GalR2 for treatment of depressive disorders.