[Association between the violence in the community and the aggressive behaviors of psychotics during their hospitalizations]. / Relation entre la violence intra-hospitalière des patients avec psychoses et la violence dans la communauté.

BACKGROUND: Violence is a common issue in psychiatry and has multiple determiners. The aim of this study is to assess the psychotic inpatients' violence in association with the violence of the neighborhood from which the patients are drawn and to estimate the impact of this environmental factor with regard to other factors. METHOD: A prospective multicenter study was led in nine French cities. Eligible patients were psychotic involuntary patients hospitalized in the cities' psychiatric wards. During their treatments, any kind of aggressive behavior by the patients has been reported by the Overt Aggression Scale (OAS). RESULTS: From June 2010 to May 2011, 95 patients have been included. Seventy-nine per cent of the patients were violent during their hospitalizations. In a bivariate analysis, inpatient violence was significantly associated with different factors: male gender, patient violence history, substance abuse, manic or mixed disorder, the symptoms severity measured by the BPRS, the insight degree and the city crime rate. In a multivariate analysis, the only significant factors associated with the patients' violence were substance abuse, the symptoms severity and the crime rates from the different patients' cities. CONCLUSION: These results suggest that violence within the psychotic patients' neighborhood could represent a risk of violence during their treatments.

[Drawing up guidelines for the attendance of physical health of patients with severe mental illness]. / Elaboration de recommandations pour le suivi somatique des patients atteints de pathologie mentale sévère.

INTRODUCTION: Having a mental illness has been and remains even now, a strong barrier to effective medical care. Most mental illness, such as schizophrenia, bipolar disorder, and depression are associated with undue medical morbidity and mortality. It represents a major health problem, with a 15 to 30 year shorter lifetime compared with the general population. METHODS: Based these facts, a workshop was convened by a panel of specialists: psychiatrists, endocrinologists, cardiologists, internists, and pharmacologists from some French hospitals to review the information relating to the comorbidity and mortality among the patients with severe mental illness, the risks with antipsychotic treatment for the development of metabolic disorders and finally cardiovascular disease. The French experts strongly agreed on these points: that the patients with severe mental illness have a higher rate of preventable risk factors such as smoking, addiction, poor diet, lack of exercise; the recognition and management of morbidity are made more difficult by barriers related to patients, the illness, the attitudes of medical practitioners, and the structure of healthcare delivery services; and improved detection and treatment of comorbidity medical illness in people with severe mental illness will have significant benefits for their psychosocial functioning and overall quality of life. GUIDELINES FOR INITIATING ANTIPSYCHOTIC THERAPY: Based on these elements, the French experts propose guidelines for practising psychiatrists when initiating and maintaining therapy with antipsychotic compounds. The aim of the guidelines is practical and concerns the detection of medical illness at the first episode of mental illness, management of comorbidity with other specialists, family practitioner and follow-up with some key points. The guidelines are divided into two major parts. The first part provides: a review of mortality and comorbidity of patients with severe mental illness: the increased morbidity and mortality are primarily due to premature cardiovascular disease (myocardial infarction, stroke...).The cardiovascular events are strongly linked to non modifiable risk factors such as age, gender, personal and/or family history, but also to crucial modifiable risk factors, such as overweight and obesity, dyslipidemia, diabetes, hypertension and smoking. Although these classical risk factors exist in the general population, epidemiological studies suggest that patients with severe mental illness have an increased prevalence of these risk factors. The causes of increased metabolic and cardiovascular risk in this population are strongly related to poverty and limited access to medical care, but also to the use of psychotropic medication. A review of major published consensus guidelines for metabolic monitoring of patients treated with antipsychotic medication that have recommended stringent monitoring of metabolic status and cardiovascular risk factors in psychiatric patients receiving antipsychotic drugs. There have been six attempts, all published between 2004 and 2005: Mount Sinai, Australia, ADA-APA, Belgium, United Kingdom, Canada. Each guideline had specific, somewhat discordant, recommendations about which patients and drugs should be monitored. However, there was agreement on the importance of baseline monitoring and follow-up for the first three to four months of treatment, with subsequent ongoing reevaluation. There was agreement on the utility of the following tests and measures: weight and height, waist circumference, blood pressure, fasting plasma glucose, fasting lipid profile. In the second part, the French experts propose guidelines for practising psychiatrists when initiating and maintaining therapy with antipsychotic drugs: the first goal is identification of risk factors for development of metabolic and cardiovascular disorders: non modifiable risk factors: these include: increasing age, gender (increased rates of obesity, diabetes and metabolic syndrome are observed in female patients treated with antipsychotic drugs), personal and family history of obesity, diabetes, heart disease, ethnicity as we know that there are increased rates of diabetes, metabolic syndrome and coronary heart disease in patients of non European ethnicity, especially among South Asian, Hispanic, and Native American people. Modifiable risk factors: these include: obesity, visceral obesity, smoking, physical inactivity, and bad diet habits. Then the expert's panel focussed on all the components of the initial visit such as: family and medical history; baseline weight and BMI should be measured for all patients. Body mass index can be calculated by dividing weight (in kilograms) by height (in meters) squared; visceral obesity measured by waist circumference; blood pressure; fasting plasma glucose; fasting lipid profiles. These are the basic measures and laboratory examinations to do when initiating an antipsychotic treatment. ECG: several of the antipsychotic medications, typical and atypical, have been shown to prolong the QTc interval on the ECG. Prolongation of the QTc interval is of potential concern since the patient may be at risk for wave burst arrhythmia, a potentially serious ventricular arrhythmia. A QTc interval greater than 500 ms places the patient at a significantly increased risk for serious arrhythmia. QTc prolongation has been reported with varying incidence and degrees of severity. The atypical antipsychotics can also cause other cardiovascular adverse effects with, for example, orthostatic hypotension. Risk factors for cardiovascular adverse effects with antipsychotics include: known cardiovascular disease, electrolyte disorders, such as hypokaliemia, hypomagnesaemia, genetic characteristics, increasing age, female gender, autonomic dysfunction, high doses of antipsychotics, the use of interacting drugs, and psychiatric illness itself. In any patient with pre-existing cardiac disease, a pre-treatment ECG with routine follow-up is recommended. CONCLUDING REMARKS: Patients on antipsychotic drugs should undergo regular testing of blood sugar, lipid profile, as well as body weight, waist circumference and blood pressure, with recommended time intervals between measures. Clinicians should track the effects of treatment on physical and biological parameters, and should facilitate access to appropriate medical care. In order to prevent or limit possible side effects, information must be given to the patient and his family on the cardiovascular and metabolic risks. The cost-effectiveness of implementing these recommendations is considerable: the costs of laboratory tests and additional equipment costs (such as scales, tape measures, and blood pressure devices) are modest. The issue of responsibility for monitoring for metabolic abnormalities is much debated. However, with the prescription of antipsychotic drugs comes the responsibility for monitoring potential drug-induced metabolic abnormalities. The onset of metabolic disorders will imply specific treatments. A coordinated action of psychiatrists, general practitioners, endocrinologists, cardiologists, nurses, dieticians, and of the family is certainly a key determinant to ensure the optimal care of these patients.

[Is the suicidal risk assessment scale RSD of predictive value?]. / L'échelle d'évaluation du risque suicidaire RSD possède-t-elle une valeur prédictive?

INTRODUCTION: A part (60% to 70%) of those who are going to act out their suicide consult a doctor the month before. Studies have shown the need to improve the practitioner's capacity to diagnose depression. The assessment of the suicidal risk is crucial. The search for suicidal risk factors helps to define the populations at risk. However, it doesn't provide information concerning the possibility of acting out in the short term. And how does one react when faced with those who do not present any of the risk factors? Psychometric instruments attempt to help the therapist in his/her reasoning. SUICIDAL RISK ASSESSMENT: Among them, the suicidal risk assessment scale RSD should be mentioned. Its objective is to estimate the seriousness of the suicidal risk, with 11 levels. It is built around a possible will to commit suicide rather than a single assessment of the frequency of suicidal ideas. Its construction in hierarchical order permits the progressive assessment of the suicidal risk, in the form of a semi-structured interview. Hence, the suicidal risk assessment scale RSD looks for the existence of death wishes (levels 1-2), of suicide ideations and its frequency (levels 3-4-5), and of a passive desire to die (level 6). Level 7 shows the onset of a decision making process, except that the patient is still inhibited by various important factors in his/her life. More often, the fear of inflicting immense suffering to his/her loved ones or for religious beliefs, is found. From level 8, determination has made way to hesitation. An active death wish exists, and although the plan remains undefined, the act is decided on. At level 9 the methods of application are developed and a plan is established. The ultimate level exists when there is a start in the preparation of the act of suicide (level 10). This hierarchical order has been confirmed by some epidemiological studies. METHOD: The inclusion of the suicidal risk assessment scale RSD in a double-blind, placebo-controlled study, which tested the efficacy of fluvoxamine in reducing the risk of recurrence of depression over 18 months, appears of particular interest. In this multicentre study, patients of both sexes were included, aged between 18 and 70 years, presenting a major depressive episode with a MADRS equal to a minimum of 25, and having had a minimum of two episodes of major depression within the last five years. RESULTS: The resulting analysis carried out on 103 patients showed a satisfactory concurrent validity between the suicidal risk assessment scale RSD and the items "suicide" of the MADRS (rho=0.79; p=0.0001) and the Hamilton Depression Scale (rho=0.70; p=0.0001), and fairly satisfactory concurrent validity with the depression degree assessed by the MADRS overall score (rho=0.40; p=0.0001). The short-term follow-up under treatment revealed enhanced sensitivity of the RSD versus the MADRS. The improvement in suicidal risk, assessed by the RSD, was faster than the improvement in depression, which is interesting from a clinical point of view. The medium-term follow-up tested the predictive validity of RSD and confirmed a greater level of suicidal risk from a score of 7 on the RSD, with the death by suicide of 2 subjects among the 15 who exhibited a score between 7 and 10 on the RSD on inclusion. On the other hand, no acting out, no attempted suicides, and no suicides were noted in the group of 88 subjects whose RSD was lower or equal to 6 on inclusion (p=0.02 using Fisher's exact test). CONCLUSION: Thus, the RSD appears of interest, from a clinical point of view, by providing a -diagnostic, or a scientific approach.

How does gatekeeper training improve suicide prevention for elderly people in nursing homes? A controlled study in 24 centres.

BACKGROUND: The death rate due to suicide in elderly people is particularly high. As part of suicide selective prevention measures for at-risk populations, the WHO recommends training "gatekeepers". METHODS: In order to assess the impact of gatekeeper training for members of staff, we carried out a controlled quasi-experimental study over the course of one year, comparing 12 nursing homes where at least 30% of the staff had undergone gatekeeper training with 12 nursing homes without trained staff. We collected data about the residents considered to be suicidal, their management further to being identified, as well as measures taken at nursing home level to prevent suicide. RESULTS: The two nursing home groups did not present significantly different characteristics. In the nursing homes with trained staff, the staff were deemed to be better prepared to approach suicidal individuals. The detection of suicidal residents relied more on the whole staff and less on the psychologist alone when compared to nursing homes without trained staff. A significantly larger number of measures were taken to manage suicidal residents in the trained nursing homes. Suicidal residents were more frequently referred to the psychologist. Trained nursing homes put in place significantly more suicide prevention measures at an institutional level. CONCLUSIONS: Having trained gatekeepers has an impact not only for the trained individuals but also for the whole institution where they work, both in terms of managing suicidal residents and routine suicide prevention measures.

[Emotional processes in schizophrenia: investigation of the evaluative component]. / Processus émotionnel dans la schizophrénie: étude de la composante d'évaluation.

Schizophrenia is a disease that constitutes a particularly relevant way to investigate emotional processing. Indeed, major clinical signs of emotional disturbance (eg, anhedonia) suggest that some emotional mechanisms are defective in patients with schizophrenia. Evaluation can be considered as a fundamental component of the emotional system (28) and the first aim of the present study was to test the polarity hypothesis according to which different mechanisms are involved in the evaluation of positive vs negative emotional events. The second aim was to disentangle a -paradox emerging from the schizophrenia literature. On one hand, the tendency that schizophrenic patients have to under-evaluate the level of unpleasantness of negative stimuli suggests a deficit in the evaluation of negative events. For instance, it was proposed that patients with schizophrenia show a major deficit in the recognition of negative emotions, but a preserved recognition of positive emotions. On the other hand, the fact that anhedonia constitutes a critical cli-nical feature of schizophrenia suggests a deficit in the eva-luation of positive events. For instance, Crespo-Facorro et al. showed that patients with schizophrenia had a tendency to under-evaluate the level of pleasantness of positive stimuli but correctly evaluated the level of unpleasantness of negative stimuli. Given the importance of the social component in the analysis of deficits in patients with schizophrenia, we hypothesized that the variation of this component in stimuli used in the literature could explain the apparently inconsistent results described above. For example, the Bell et al. study used social stimuli whereas the Crespo-Facorro et al. study used non-social stimuli. Therefore, in our study, we have decided to manipulate the social component of stimuli. Another research issue of the present experiment was to study the explicit and/or implicit mode of processing of eva-luation in schizophrenic patients. In general, the experimental logic was to expect interaction effects between the factors polarity (negative vs positive) and participants (schizophrenic patients vs controls). Moreover, given the potential importance of the social component, a three-way interaction of the factors polarity, participants, and social component was expected. Finally, the experimental paradigm allowed us to search for dissociations in the context of both explicit and implicit evaluation. Stimuli used were negative and positive emotional pictures from the International Affective Picture System. Stimuli were chosen so that the mean valence -ratings of negative and positive pictures were at the same distance from neutrality. The factor arousal was controlled so that negative and positive pictures had equivalent mean arousal ratings. The social component factor was operatio-nalized by selecting pictures that either depicted or not a social scene. A fundamental criterion was that all social pictures were depicting at least one human being (eg, a wedding or a funeral), whereas non-social pictures never depicted any human being (eg, animals and landscapes). An upper and a lower border, that were either identical or different, were added to each picture. In a first experiment (the "implicit-task experiment"), patients with schizophrenia and matched controls were requested to decide whether the two borders surrounding the pictures were identical or different. Asking participants to process the borders was an experimental ruse to test if emotional processing takes place even when it is not task-relevant, and therefore if it is implicit. In a second experiment (the "explicit-task experiment"), the same participants were requested to evaluate whether the pictures were pleasant or unpleasant. Analyses of variance (ANOVA) were computed on response time and number of correct responses for both tasks. An important result was the observation of the expected three-way interaction effect of the factors polarity, participants, and social component on response time in the explicit task F(1, 19)=4.8, p<0.05. Critically, we observed that, for non-social stimuli, the interaction effect of the factors participants and polarity on response time was significant in the explicit task, F(1, 8)=4.9, p<0.05. These results are consistent with the polarity hypothesis and suggest a deficit in the processing of non-social positive stimuli in patients with schizophrenia. The expected three-way interaction effect was also observed on the number of correct responses in the explicit task F(1, 19)=5, p<0.04. For this task, we critically observed that, for social stimuli, the interaction effect of the factors participants and polarity on the number of correct responses was significant F(1, 19)=8.4, p<0.04. These results are also consistent with the polarity hypothesis and suggest a deficit in the processing of social negative stimuli in patients with schizophrenia. Moreover, let us notice that a comparison of the performances of the two groups revealed that patients made significantly more errors than controls for the evaluation of non-social positive stimuli, F(1, 19)=10,5, p<0.001, but not for the evaluation of non-social negative stimuli, F<1. In the implicit-task experiment, the analysis revealed that patients had a tendency to make more errors in the judgment of borders configuration for negative than for positive stimuli, whereas control participants showed the opposite tendency F(1, 19)=5.7, p<0.03, for the interaction of the factors polarity and participants. This result is consistent with the idea that distinct cognitive mechanisms are involved in the evaluation of positive vs negative emotional events even in the context of implicit processing. In conclusion, results obtained support the hypothesis according to which different cognitive mechanisms are involved in the evaluation of positive vs negative emotional events. Moreover, results suggest that patients with schizophrenia show a deficit in hedonic judgment of social negative and non-social positive stimuli. The later result indicates that the paradox described above becomes clearer whenever the social component of emotional stimuli happens to be taken into account. Results suggest that the polarity and the social component of events evaluated by patients with schizophrenia are critical parameters that should be considered in forthcoming studies that investigate affect disorders in schizophrenia.

[Management of suicidal adolescents: a clinical audit in 76 hospitals]. / L'audit clinique appliqué à la prise en charge hospitalière des jeunes suicidants: bilan d'une expérience auprès de 76 établissements.

We describe the implementation and results of a clinical audit of the management of suicidal adolescents in hospital that was carried out as part of the French national suicide prevention programme. The ANAES definition of a clinical audit is: "an assessment method using defined criteria that compares care practices with accepted standards and measures the quality of these practices and the results of care with a view to improving them". Standards for the audit were derived from the clinical practice guidelines published by ANAES (French National Agency for Accreditation and Evaluation in Health) in November 1998. They comprised 15 criteria covering ressources available and procedures implemented: patient management in hospital (9 criteria), contacts made with the patient's environment outside hospital (2 criteria) and preparation for discharge from hospital (4 criteria). Participation in the audit was voluntary. Overall, 76 hospitals from the 10 regions of France with a suicide prevention programme took part in the audit and made 1,554 observations. The number of observations per hospital ranged from 1 to 42. Compliance with the criteria was > 80 % for 5 criteria, 50-80 % for 3 criteria, and < 50 % for 7 criteria. A total of 26 hospitals, proposed a structured improvement plan, ie, scheduled, ordered and ranked measures with a definition of responsibilities and follow-up. Of these 26 hospitals, 15 had implemented the three ANAES recommendations (setting up a working group for the project, using a grid to analyse results, drafting a structured report) whereas only 5 of the 50 hospitals that did not come up with an improvement plan had done so. An operational outcome thus seems related to compliance with the audit method. Three years after the audit was set up, 17 hospitals took part in a second round. Improvements were noted for 12 criteria, mainly for those giving poor results in the first round. However, these improvements concerned few hospitals (eg just 4 hospitals for the criterion with the worst result in the first round). A worsening of compliance was noted for 3 criteria. In conclusion, hospitals were found to comply with guidelines relating to the management of suicidal adolescents in hospital. However, compliance with guidelines relating to making contact with the patient's environment outside hospital and preparing for discharge was less good. Although the hospitals taking part in the audit endorsed our method, our experience showed that, to be effective, clinical audits need methodological support and a well-defined time schedule.

Promoting quality improvement in French healthcare organisations: design and impact of a compendium of models and tools.

Relevant and user friendly information should be provided to professionals who wish to promote quality improvement in healthcare organisations (HCOs). In response to requests from French HCOs, we designed a compendium of methods and tools for use in quality improvement. Its contents were based on a critical review of the literature, face-to-face interviews with three industrial/business experts in quality, the views of 13 healthcare professionals knowledgeable in quality issues, and comments from over 40 potential users of the compendium. Overall, 14 methods and 20 tools relevant and applicable to the healthcare sector were identified. They were classified according to their main thrust, explained in detail, illustrated with specific cases from the literature or from personal experience, and published as a loose leaf compendium. The compendium was posted on the worldwide web and presented to healthcare managers in September 2000. It has become one of the most popular ANAES publications (approximately 5400 downloads over the first 6 months), partly because all French HCOs are legally bound to undergo accreditation which has been set up and is being implemented by ANAES.

Increased serum levels of neuron-specific enolase in epileptic patients and after electroconvulsive therapy--a preliminary report.

Serum neuron-specific enolase (NSE) levels were studied by an enzymo-immunoassay method in 2 groups of patients: a group of epileptic patients, and a group of patients with refractory major depression after electroconvulsive therapy (ECT). In patients without organic neurological disease (n = 274) the mean serum NSE level (+/- S.D.) was 8.4 +/- 3.4 micrograms/l. No correlation with sex or age was observed. No significant difference was observed between epileptic patients without seizure or major electroencephalogram (EEG) abnormality, and a reference group. Significant increases were observed in 32 samples collected from patients with interictal EEG without spikes and waves before the 7th day after a seizure, in whom mean NSE was 21.5 +/- 9.4 micrograms/l, and in 26 samples from 4 patients without seizures but with spikes and waves in the interictal EEG, whose mean NSE was 20.6 +/- 11.5 micrograms/l. The increases of serum NSE levels in epileptic patients seem therefore to be linked to seizures and/or to EEG abnormalities. The consequences of these observations for the survey of epileptic patients, and for the diagnosis of cerebral tumors (mainly neuroblastoma) or for monitoring treatment after surgical resection, are discussed. In only 1 patient out of 6, an increase in serum NSE levels was observed with a peak about 12 h after ECT. No significant correlation with the ECT features (length of seizures, one- or two-sided electrodes) was observed.

Fluvoxamine prevents recurrence of depression: results of a long-term, double-blind, placebo-controlled study.

This double-blind placebo-controlled study specifically tested the efficacy of fluvoxamine, at a dose of 100 mg a day, in reducing the risk of new episodes of depression. Out of 436 patients treated openly with fluvoxamine 283 patients fulfilled stringent criteria to define responders at 6 weeks. A total of 204 patients maintained their remission throughout a continuation treatment period of 18 weeks and then entered the prophylactic study. They were randomly assigned to receive either fluvoxamine 100 mg a day or placebo for 1 year. There were significantly fewer recurrences of new episodes of depression in the fluvoxamine group compared with the placebo group (p < 0.001). The significant advantage for fluvoxamine was also seen in the Kaplan-Meier analysis of time to recurrence (p < 0.001). The clear-cut efficacy of 100 mg of fluvoxamine and the good tolerability and side-effect profile demonstrated in this study support the view that fluvoxamine is particularly suitable for maintenance or prophylactic treatment.

Relationship between symptoms rated with the Positive and Negative Syndrome Scale and brain measures in schizophrenia.

The Positive and Negative Syndrome Scale (PANSS) was used to rate clinical symptoms in 42 inpatients with schizophrenia before they were examined by computed tomography. Significantly higher mean size of lateral and third ventricles, and higher mean cortical atrophy were found in schizophrenic patients compared with healthy control subjects. Ventricular enlargement and cortical atrophy were significantly related to low scores on the Composite subscale of the PANSS. Positive correlations were observed mainly with negative items such as blunted affect, emotional withdrawal, difficulties in abstract thinking, passive-apathetic social withdrawal, and lack of spontaneity of conversation. Additional positive correlations were observed with two items from the General Psychopathology subscale (mannerisms and disorientation). Inverse correlations were found with most positive items. These results suggest a relationship between brain structural abnormalities and the symptomatology of schizophrenia recorded with PANSS.

No season-of-birth effect in schizophrenic patients from a tropical island in the Southern Hemisphere.

The distribution of birth rates was examined in 668 schizophrenic patients born in Réunion, a tropical French island in the Southern Hemisphere, and compared with that in the general local population. We failed to observe a significant season-of-birth effect, either in the total sample of schizophrenic patients or in subgroups categorized by gender, age, or family history of schizophrenia. Seasonal factors do not appear to affect the yearly distribution of births among schizophrenic patients on Réunion Island. It is nevertheless possible that environmental factors which are seasonal in countries with more contrasting climates have a continuous effect, throughout the whole year, in subtropical areas. Conversely, these findings provide some evidence against the hypothesis that there is an age-incidence artifact in seasonal studies from countries in the Northern Hemisphere.

Schizophrenic patients: physical health and access to somatic care.

This study concerns the state of physical health and the availability of somatic care for 3,470 adult patients diagnosed as schizophrenic according to the research criteria established by the International Classification of Diseases (ICD-10 F20) and treated in public institutions. These institutions volunteered to participate in the study, whereas the patients were selected at random. Data concerning demographic characteristics, physical health, and access to somatic care are compared to that of a public health survey of a sample of the French population. The present study allows the estimation of ratios for a large number of diseases and of some risk factors among the target group. Heavy smokers and overweight individuals are more numerous among schizophrenics. Pathologies such as epilepsy, diabetes and AIDS infection are overrepresented. Patients' access to somatic care is more prevalent than that of the general population overall, similar to that of the less qualified workers or unemployed group. In this study, gender does not appear to allow prediction of care use for schizophrenics in contrast to the general population.

[Are new data collection systems needed to achieve public health and research goals for the prevention of suicide?]. / Les questions de santé publique et de recherche qui se posent dans le domaine de la prévention du suicide justifient-elles de nouveaux recueils de données?

Evaluation of suicide prevention programs, both on the local and national level, is a methodological challenge. In September 2000, France initiated a nation program for suicide prevention. But, as was noted in the Prémutan report and more recently the FNORS report, very few of the hundreds of preventive measures taken annually are evaluated. In addition to this assessment challenge, new data, particularly concerning the different phases of the suicide process, are needed to design new programs, define their objectives with precision, and assure their implementation. For example, if the objective is to improve prevention in men aged 25-54 years who suffer from a state of depression, alcohol abuse, impulsive personality disorders, and life events implicating loss, the necessary information is currently unavailable or sparse. The lack of data and research in this domain can be grouped into several categories: lack of proper definition and quantification of the objectives; insufficient study of the mechanisms by which prevention measures are effective: lack of monitoring tools providing information on the rate of implementation of planned actions. These arguments demonstrate the need for collecting new information to develop a dynamic prevention program. Such data collection should be synchronized, conducted by a wide range of actors, and concern multiple actions. Without a coherent information system, it is doubtful the current impetus for the prevention of suicide can be sustained.

[Depressive disorders. Sociodemographic factors predicting therapeutic response]. / Dépression. Facteurs prédictifs socio-démographiques dans la réponse thérapeutique.

The choice of an antidepressant according to the possible course of depression is a fundamental step in the treatment approach. Socio-demographic factors are considered in order to predict the outcome of depression receiving an adequate treatment. Only a few studies deal with this topic, probably because of the role the same factors play in the occurrence of depression. The influence of age, sex, marital status, socio-economic level and life events on compliance with treatment is considered as well as main clinical issues such as treatment resistance, risk of chronicity and of suicide. Generally speaking, socio-demographic factors do not constitute a major parameter when selecting an antidepressant. They are useful to identify patients at risk requiring special therapeutic measures. The poor prognosis of depression in males after 65 has must be emphatized, as well as the negative influence of life events occurring during the course of endogenous depression. Conversely, a decrease in the number of life events or a life event experiencing a new start in life, play an important role in the improvement of depression according to Brown. Those factors remain in the background of the pathological process and of its evolution, acting indirectly, with a poor association power. Moreover, most of those predictors have been determined a posteriori.

[The psychiatrist's point of view on the treatment of morbid obesity by gastroplasty]. / Le point de vue du psychiatre sur le traitement de l'obésité morbide par gastroplastie.

The surgical treatment of pathological obesity has been rapidly developing in France over recent years. The growing demand for operation raises a number of questions concerning the indications and the factors predictive of success. Patients are increasingly referred for a psychiatrist's or psychologist's opinion in order to detect psychiatric contraindications and to select patients who are able to comply with their weight reduction programme with the help of the operation and who are able to obtain a lasting improvement in their quality of life. The author starts by describing the explicit demand formulated by candidates for gastroplasty, characterized by a high degree of information and motivation. In view of the uncertainties concerning the right advice to be given to this population, an open prospective study was conducted among 109 gastroplasty candidates. Evaluation of somatic and psychological parameters was performed before the operation and at 6 months, 1 year, 2 years and 5 years. The preliminary results are based on 98 operated patients. The mean BMI (Body Mass Index) decreased from an initial value of 42.08 +/- 0.7 kg/m2 to 29.96 +/- 6.68 kg/m2 at one year. The frequency of vomiting decreased with successive evaluations, but nevertheless constituted the major disadvantage of the operation. Evaluation of depression scores, using the MADRS (Montgomery and Asberg Depression Rating Scale), did not reveal any depressogenic effect of gastroplasty. The other assessment instruments (visual analogue scales and Subjective Quality of Life Profile) indicated a favourable change in numerous dimensions of quality of life. Although it is too early to define any predictive criteria, the author proposes a list of empirical criteria in line with those reported in the literature and defines the role of psychiatrists before and after the operation.

[Lithium levels in biological media and treatment surveillance]. / Dosages du lithium dans les milieux biologiques et surveillance du traitement.

The authors present their collection procedures and the results concerning plasma, red blood cell or urinary lithium levels. They point out the interest of determination of red blood cell lithium for the prevention of toxical effects and the control of treatment in lithium intoxications. Clearance determination methodologies are also discussed.

[Retrospective comparative study of treatment with delayed-action neuroleptics and neuroleptics administrated orally in long-term psychosis]. / Etude rétrospective comparative des traitements neuroleptiques d'action prolongée et des traitements neuroleptiques par voie orale dans les psychoses au long cours.

Through a retrospective study, we have tried to compare the indication spectrum and efficacy of depot neuroleptics versus oral neuroleptics on two hundred patients suffering from long term psychosis. For each group, we selected one hundred patients who met the following requirements: the minimal duration of chemotherapy was of 3 years, the patients were aged 16 to 60. Patients receiving depot neuroleptics, although their original prognosis were worse than those of patients receiving oral neuroleptics, obtained the same good results concerning most semiological, chemotherapeutic and institutional criteria. However, good results for patients receiving depot neuroleptics must be qualified because of a more important number of chronic and defect states and a lack of autonomy.

[Daily profiles of melatonin, cortisol and gonadotropins in 8 adolescents with anorexia nervosa]. / Profils journaliers de la mélatonine, du cortisol et des gonadotrophines chez 8 adolescentes porteuses d'une anorexie mentale.

From a biological study of 8 patients with anorexia nervosa and an analysis of the daily profiles of gonadotropins, cortisol and melatonin, the authors discuss the possible relationship between anorexia nervosa and affective disorders. At the initial phase of the illness, plasmatic levels of FSH, LH and oestradiol were very low. 24-hour plasma cortisol values were comparable with those of a depressive population; when weight loss was equal to or higher than 25% of the initial weight, there was no suppression by dexamethasone. The daily profile of melatonin was maintained, with melatonin plasma levels significatively higher than in a control group of depressed patients.

[Analysis of 94 dexamethasone tests in a population of patients manifesting depressive symptomatology within the framework of a manic-depressive psychosis or other psychotic state]. / Analyse de 94 tests à la dexaméthasone dans une population de patients présentant une sémiologie dépressive dans le cadre d'une psychose maniaco-dépressive ou d'un autre état psychotique.

The authors report a study of 94 dexamethasone-suppression-tests conducted in a group of 29 patients with either a manic-depressive psychosis (n = 14) or a depressive symptomatology associated or not with a chronic psychotic disorder. 1 mg of dexamethasone was given orally at 11 p.m. and plasma cortisol levels were determined the following day at 4 p.m. The same day, a MADS was calculated. These tests were repeated every month for each patient independently of the clinical state. 9 patients received between 4 and 11 tests. A non suppression (cortisol plasma levels greater than or equal to 140 nmol/l) was observed in 27% of the tests. A comparable percentage was obtained in the whole group of patients and in the manic-depressive psychosis group. A good correlation appeared between plasma cortisol level at 4 p.m. and score for MADS. The study of the validity of the test shows a sensibility of 50% and a specificity of 85%. These results are similar with those presented in the literature.