[Violence towards people with severe mental disorders: a review of the literature and of related concepts]. / La violence envers les personnes atteintes de troubles mentaux : revue de la littérature et des notions connexes.

BACKGROUND: People with severe mental disorders tend to be seen as authors rather than as victims of violence, while mental illness is associated with violence and danger. French policy focuses on individuals with mental illness as authors of violence, to the detriment of evidence-based public health regarding such individuals when they are victims. METHODS: This article reviews knowledge concerning violence towards people with severe psychiatric disorders, clarifies what is meant by violence and raises the question of the need for local and national studies. The first part compares definitions and operationalisation of main variables, sampling, methods and results of studies published since 1990 on violence towards adults with severe psychiatric disorders. The second part draws on qualitative studies to clarify conceptual problems that arose in the review. RESULTS: Rates of victimisation for individuals with severe psychiatric disorders are shown to be high and far greater than those for the general population, despite the heterogeneity of studies in terms of sample characteristics, measures, methods and analyses. Certain types of factors - clinical, treatment, contextual - raise the probability of becoming a victim, as does the fact of having already been the author or the victim of a misdemeanour or crime. However, the cross-sectional designs used in these studies and the frequency of traumatic antecedents among psychiatric patients make it difficult to know whether violence precedes mental illness or vice-versa. CONCLUSION: The relationship between life conditions and victimisation among people with severe psychiatric disorders points to areas in which public health can already intervene. But geographical variation in results may require more local and national studies. The relationship between author and victim and between violence, discrimination and stigma requires more research.

[New tools for preventing and evaluating risk practices for hepatitis C transmission among injection drug users: some reflections on injection rooms and the measurement of risk-taking behaviors]. / Quels nouveaux outils pour prévenir et évaluer les pratiques à risque chez les injecteurs de drogue face au VHC? Réflexions sur les salles d'injection et les outils de mesure des prises de risques.

Injection rooms should be able to contribute to the prevention of the risks of transmission of hepatitis C (HCV) among intravenous drug users (IDUs). However, these services have yet to be set up and tested in France. This article presents a literature review of injection rooms and explores possible ways of evaluating the effects of this type of service on risks for HCV. Given the difficulties of estimating the service's impact on the incidence of HCV, evaluations could target injection-related risk taking behaviors. The second part of the article addresses the issue of risk taking practices and presents a new research tool able to explore out-of-the-ordinary situations involving risk-taking. Tested on a population of IDUs in Marseille, this tool detects forms of risk-taking and contexts in which injection is performed, which are always missed by the usual measures of risk practices. It could therefore be added to these measures and be useful for evaluating injection rooms.

Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial.

OBJECTIVES: This study tested a psychiatric rehabilitation approach for organizing and delivering services to street-dwelling persons with severe mental illness. METHODS: Street-dwelling persons with severe mental illness were randomly assigned to the experimental program (called Choices) or to standard treatment in New York City. We assessed study participants at baseline and at 6-month intervals over 24 months, using measures of service use, quality of life, health, mental health, and social psychological status. The average deviation from baseline summary statistic was employed to assess change. RESULTS: Compared with persons in standard treatment (n = 77), members of the experimental group (n = 91) were more likely to attend a day program (53% vs 27%), had less difficulty in meeting their basic needs, spent less time on the streets (55% vs 28% reduction), and spent more time in community housing (21% vs 9% increase). They showed greater improvement in life satisfaction and experienced a greater reduction in psychiatric symptoms. CONCLUSIONS: With an appropriate service model, it is possible to engage disaffiliated populations, expand their use of human services, and improve their housing conditions, quality of life, and mental health status.

Social and emotional problems in children with neurofibromatosis type 1: evidence and proposed interventions.

OBJECTIVE: To describe social and emotional problems in children and adolescents with neurofibromatosis type 1 (NF1) and propose interventions. Our hypothesis is that children with NF1 will have significantly more social and emotional problems, compared with their unaffected siblings and children in the general population. STUDY DESIGN: Forty-three children with NF1 and 22 unaffected siblings (ages 5 to 18 years) were assessed with a standardized test completed by parents and teachers (the Child Behavior Checklist). RESULTS: As with other aspects of NF1, there was variable expressivity. However, when rated by parents, children with NF1 had significantly more problems in comparison with test norms or unaffected siblings on 7 of 8 scales: Social Problems, Attention Problems, Anxiety/Depression, Withdrawal, Thought Problems, Somatic Complaints, and Aggressive Behavior. Children with NF1 also scored lower than unaffected siblings on measures assessing sports and other activities. Teachers reported fewer differences. CONCLUSIONS: We propose interventions in the form of information for parents; early screening and treatment for speech, motor, and cognitive problems; and an increased level of intervention to prevent and treat psychologic problems, including systematic screening with standardized tests.

Thoracic tumors in children with neurofibromatosis-1.

Thoracic tumors have been infrequently reported as a complication of neurofibromatosis-1 (NF1). To determine the prevalence and clinical features of thoracic tumors seen in children with NF1, we reviewed medical records and imaging studies for a group of 260 pediatric patients with NF1 followed in a multidisciplinary NF Center. Extrapleural thoracic tumors were seen in nine patients with NF1, corresponding to a prevalence of 3.5% in this hospital-based series of patients. Pathological studies of the tumors demonstrated plexiform neurofibroma in four cases and neurofibrosarcoma in one case. The remaining four cases were suspected to be plexiform neurofibroma based on clinical features but have not been confirmed histologically. Three patients presented with symptoms of chest pain, syncope, or wheezing; six patients were asymptomatic at the time of diagnosis of the tumors. Physical findings frequently found in patients with thoracic tumors were scoliosis (especially focal scoliosis) and visible plexiform neurofibromas of the neck. We conclude that NF1 patients presenting with any of these signs and symptoms should be screened for thoracic tumors with chest X-ray and magnetic resonance imaging as needed. It is unknown whether screening asymptomatic NF1 patients with chest X-rays on a regular basis will result in an improved outcome.

Ullrich-Turner syndrome and neurofibromatosis-1.

There is a well-known association between neurofibromatosis-1 (NF1) and Noonan syndrome-like manifestations, including short stature, short broad neck, and hypertelorism. These anomalies are thought to be due to variable expression of the NF1 gene. We report on two girls with NF1 who were found to have the Ullrich-Turner syndrome. Case 1, a 12-year-old white girl, was followed in a Neurofibromatosis Clinic because of multiple café-au-lait spots and a family history of NF1 in her mother and sister. On examination, she had short stature, hypertelorism, and short neck with low posterior hairline. Karyotype was 86% 46,XY/14% 45,X. Case 2, the first child of a woman with NF1, presented at birth with lymphedema of hands and feet and a short broad neck. Karyotype was 45,X. At age 23 months she was short, had epicanthic folds, hypertelorism, narrow palate, right simian crease, 19 café-au-lait spots, and axillary freckling. We conclude that chromosome studies should be performed in girls with NF1 who have short stature and Noonan- or Ullrich-Turner-like findings. Dilemmas raised by the dual diagnoses of NF1 and Ullrich-Turner syndrome include potential risks of growth hormone therapy and estrogen replacement therapy.

[Assessment of needs and evaluation of interventions in mental health. Current approach]. / Estimation des besoins et évaluation des interventions en santé mentale. Nouvelles approaches.

For needs assessment research to contribute to mental health program planning and evaluation, the term "need" requires better conceptualization and operationalization. Recent advances in this area are reviewed. The two major American contributions focus on "true prevalence" of need, but rely heavily on simplistic definitions. The major British methodology, developed on treated samples, operationalizes "need" as multidimensional and dynamic. However, its feasibility as a methodology in general populations remains to be demonstrated. Findings from recent mental health consumer preference surveys suggest that a multi-partite approach might be most productive for planning and evaluation.

Managed cases, drop-ins, drop-outs, and other by-products of mental health care.

The assertive case management (ACT) study by Bond and colleagues illustrates the problems of evaluating new mental health service modalities applied to multi-dimensional problems. Both characteristics of large urban areas and increasing consumer self-awareness affect implementation of random assignment and follow-up studies. In the study reviewed here, possible lack of fit between study subjects and the control condition, a drop-in center, may have contributed to a high attrition rate. As most of the controls never received the treatment, neither ACT nor the drop-in center were adequately tested. And without explication of how the control condition relates to other peer-oriented interventions, study findings cannot be generalized to self-help. The authors' conclusions concerning self-help are therefore not supported by their findings.

The paradoxes of reform: reevaluating Italy's mental health law of 1978.

Recent data on Italy's mental health law of 1978 delineate a more complex picture of deinstitutionalization than that suggested by the first wave of enthusiastic writings on the law's implementation. In violation of the law's original intent, many Italian regions depend heavily on newly established hospital-based units, while development of community services has been uneven. Factors affecting implementation include both ambiguous and unenforceable provisions in the law and unwillingness at the national and local levels to fund necessary community alternatives. Recent proposals to "reform the reform" may move Italian psychiatry even further away from the legacy of successful deinstitutionalization in cities such as Trieste and Arezzo.

Breaking the circuit of social control: lessons in public psychiatry from Italy and Franco Basaglia.

Much public discourse in the United States and in Canada acknowledges the dismal failure of the policy to 'deinstitutionalize' mental patients and to return them to some semblance of community living. The American Psychiatric Association has recently called for a reassessment of institutional alternatives--a call for a return to the asylum--in response to the needs of the new population of so-called homeless mentally ill. Here we contrast the failures of North American deinstitutionalization with the relative successes achieved in those regions of Italy where deinstitutionalization was grounded in a grassroots alternative psychiatry movement and professional and political coalition, Psichiatria Democratica. Democratic psychiatry challenged both the medical and the legal justifications for the segregative control of the 'mentally ill': madness as disease, and the constant over-prediction of the dangerousness of the mental patient. In addition, the movement challenged traditional cultural stereotypes about the meanings of madness, and was successful in gaining broad-based community support from political parties, labor unions, student groups, and artist collectives that were enlisted in the task of reintegrating the ex-mental patient. The Italian experiment, although flawed and riddled with its own inconsistencies and contradictions, offers evidence that deinstitutionalization can work without recreating in the community setting the same exclusionary logic that was the foundation of the asylum system.