Effectiveness of a French Program to Prevent Suicide Reattempt (VigilanS).

AIM: Brief contact interventions (such as letters, green cards, telephone calls or postcards) for reducing suicide reattempt (SR) and suicide have been evaluated since the 1980s, but results have been inconsistent. VigilanS is one of these programs that has benefited patients hospitalized for suicide attempt (SA) after discharge in 2 departments of northern France since 2015. The purpose of this study is to demonstrate its effectiveness in reducing SR. METHODS: Patients exposed to VigilanS in 2016 were recruited from the medical administrative database of the program, and the nonexposed patients from a database of the medico-surgical ward outside the scope of the program. First, a Cox model was used to compare the probability of SR during the 12-month follow-up period between the 2 groups. Second, a propensity score using the variables sex, age, source, SA history and SA method was used to match the VigilanS-exposed and the nonexposed patients. A Cox model propensity score adjusted analysis was reiterated on the matched data. RESULTS: The exposed and nonexposed groups included 3,068 and 3,694 individuals, respectively. In the bivariate analyses, the cumulative probability of SR at 12 months was significantly lower in the exposed group (6.0%, 95% confidence interval (CI): 5.5-6.5%) than in the nonexposed group (16.8%, 95% CI: 15.9-17.7%; p < 0.001). In the Cox model, the hazard ratio of SR was 0.38 in the exposed patients (95% CI: 0.36-0.40, p < 0.001). After matching, the cumulative probability of SR at 12 months was 5.2% in exposed versus 22.2% in nonexposed patients (p < 0.001). In the propensity score-adjusted Cox model, the hazard ratio of SR in the exposed patients was 0.19 (95% CI: 0.14-0.24, p < 0.001). CONCLUSION: The results suggest the effectiveness of this real-life program for reducing SR. However, VigilanS only benefits a portion of the patients hospitalized for SA and therefore could be extended.

[An example of post-discharge monitoring after a suicide attempt: VigilanS]. / Un exemple de système de veille post-hospitalière des suicidants : VigilanS.

BACKGROUND: Attempted suicide is a major risk factor of further re-attempts and death. Self-harm behaviors are related to multiple causes explaining why it is ineffective to have a single and simple strategy to offer after the clinical assessment in reducing morbidity and mortality. Furthermore, treatment adherence is known to be especially poor in a context where social connection seems compromised and a source of pain. Effective interventions can be divided into two categories: intensive intervention programs (care at home, supported by a series of brief psychotherapy interventions) and case management programs that rely on a "stay in contact" dimension. These programs, initiated by Jerome Motto and its short letters may consist of: (1) sending letters or postcards after discharge of the ER; (2) giving a crisis card that offers a crisis telephone line and a crisis unit for hospitalization if needed, and; (3) placing a phone call at some time distance after the discharge. The aim is to enhance a "connectedness feeling" with the patient. These different strategies have proven to be even more effective in some specific subgroups, highlighting the heterogeneity of this population. Each modality of contact was well accepted and generated a positive involvement of the patients. METHOD: It led to the idea of combining these different strategies in an algorithm built on the specificity of identified subgroups. A randomized controlled trial, named ALGOS was carried out in France to test this algorithm in 2011. The algorithm consisted of: (1) delivering a crisis card for first attempters; (2) giving a phone call for re-attempters to re-assess their situation between the 10th and 21st day after their discharge, and to propose a new intervention if needed, and; (3) in case of an unsuccessful call or a refusal of proposed care, sending personalized postcards for 6 months. All of this was supported with shared information to the general practitioner of the patient. This study was further adapted to routine care in 2015 in the northern departments of France, Nord and Pas-de-Calais (4.3 million people), taking the name of VigilanS. The inclusion consists of sending a form for every patient assessed after a suicide attempt in the two departments to the medical staff of VigilanS in order to provide information about the patient and the context of his suicide attempt. The algorithm has been modified in giving the crisis card to all the patients whether it is a first attempt or not. An information letter, explaining the aim of the monitoring is also given to the patient, and to his general practitioner. The calling staff is composed of 4 nurses and 4 psychologists, all trained in suicidal crisis management. They use a phone platform located in the Emergency Medical Assistance Service (SAMU) of the Nord department on a halftime basis and manage the incoming calls from the patients as well as the outgoing calls towards the patients, their relatives and their medical contacts. A set of 4 postcards (1 per month) can be sent if needed in case of an inconclusive or a failed phone call. CONCLUSION: Built on a monitoring philosophy, VigilanS has further developed a real crisis case management dimension requiring enough time to insure an effective medical supervision and strong networking abilities. A specific time is also needed to take care of all the technical aspects of the organization. This program expertise, designed by Northern departments to prevent suicide, can be shared with other French or even foreign territories.

[First trends of change in mortality by suicide in Nord-Pas-de-Calais since VigilanS]. / « Premières analyses de mortalité par suicide en Nord-Pas-de-Calais depuis l'implantation de VigilanS ¼.

INTRODUCTION: In terms of suicide prevention, population-based prevention devices often struggle to demonstrate an effect in terms of reducing suicidal acts of suicide, often focusing on the evolution of the number of suicide attempts, on time too short to statistically interpret changes in mortality. The consolidated figures for mortality in France are provided by the CepiDC with a delay of approximately three years. We therefore had to try to work with an approximation of the phenomenon, and we tested the proxy value of the enumeration of corpses, body examinations and medico-legal autopsies for suicide by the forensic doctors of the Nord-Pas-de-Calais region in France. In parallel, we conducted a comprehensive mortality study for 2016 in the VigilanS cohort. METHOD: By measuring the evolution of the number of body lifts for suicide by the Department of Forensic Medicine of the region, for the 3 years before VigilanS (2012-2014) compared to the 3 years since VigilanS (2015-2017). The deaths of patients of the VigilanS cohort were identified by calling the city halls of birth and domicile of all patients integrating the device in 2016. The cause of death was then characterized by contact of the attending physician. RESULTS: We observe an average decrease in suicide mortality of 9.9% (-12% for men, +0.3% for women). The exhaustive analysis of suicide mortality in the VigilanS cohort in 2016 found 19 deaths, of which 14 by suicide, or 0.4% of patients. This observed mortality rate in the VigilanS cohort in 2016 is significantly below the expected threshold in the literature (1 to 2% in the year following TS). CONCLUSION: It seems possible to reach the 2020 target for a 10% decrease in suicidal behavior in industrialized countries by 2020. The VigilanS device could therefore be protective in terms of suicide mortality.

[Changes in the number of suicide attempts in the NPC region since the start of VigilanS: First estimates]. / Évolutions du nombre de tentatives de suicide dans le Nord-PasdeCalais depuis l'implantation de VigilanS : premières estimations.

BACKGROUND: The implementation of a surveillance program after a suicide attempt (SA) is a very innovative step in the evolution of our system of care. It was interesting to know if we observe a decline in suicide attempts in the region, in particular of recurrences of SA. METHOD: We measured the evolution of the number of suicide attempts before and after implantation of VigilanS, using two types of analysis: a first from the national medical information systems in Medicine-Surgery-Obstetrics (PMSI-MCO) and a second from the collection of the ER stays for SA in the hospitals involved in the VigilanS program. RESULTS: In 2014 (year before start of VigilanS), a total of 10 119 ER stays for SA was observed (5626 women and4463 men); in 2017, the total was 9.230 stays for SA (5047 women and 3 839 men), representing a decrease of 13.5%. The reduction was balanced between men (-14%) and women (-10%). Based on the figures of PMSI, we see an acceleration of the reduction of stay for SA in the Nord-Pas-de-Calais after 2014 (-16% instead of -6%), instead of the two Picardy departments the most comparable which show a degradation of the phenomenon (+13%), and opposed to the Department of the Oise which shows a stable maintenance of the current decline (-12%). CONCLUSION: These two indicators are imperfect, but evolution over three years since the implementation of VigilanS goes in the same direction. We find a uncoupling of a hospital stay in connection with a SA. The intensity of this decline seems correlated to the penetrance of the program.

["VigilanSeu.r.se": A new profession?] / « VigilanSeu.r.se ¼ : un nouveau métier ?

In January 2015, in accordance with decades of scientific work based on maintaining contact, was born an innovative device for suicide prevention: VigilanS. To ensure this link, the choice was made to build a team with an equal number of nurses and psychologists, all located within the medical regulation. Nowadays, they are named "VigilanSeur": an original entity that highlights the emergence of this new profession, at the crossroads of several disciplines.

[First stage in identifying traumatic profil inpatients hospitalised in psychiatry in Martinique]. / Premières identifications d'un profil traumatique chez des patients hospitalisés en psychiatrie en Martinique.

The population hospitalised in psychiatry seems more exposed to traumatic events than the French general population, with particularly more sexual aggressions. The aim of this study is to describe the population hospitalised in psychiatry and more precisely the traumatic history of these patients, their comorbidities (mental diseases and addictions), and socio economical level. This descriptive, cross sectional and retrospective study took place in the Crisis Center in the University Hospital in Martinique (French West Indies), from February to July 2013. A socio-demographic information, the Mini International Neuropsychiatric Interview 5.0, the Trauma History Questionnaire and the Impact Events Scale-Revised were realised with 49 of the 143 patients admitted during this period (34.3%). In this population, we found a mean of 6.5 (standart-deviation=4.2) different types of traumatic event, with 38.8% patients reporting a natural disaster, and 38.8% declaring at least one sexual aggression. In the 25 patients suffering from post-traumatic stress disorder, 66.7% underwent a sexual aggression, significatively during childhood (before 10 years old, P=0.01), and during adolescence (between 10 to 18 years old, P=0.01). These results underline the importance of a systematic screening of the traumatic profile: the characteristics of the traumatic events and its clinical impact.

[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.

[Alpha-interferon and mental disorders]. / Interféron alpha et troubles psychiatriques.

UNLABELLED: The interferon alpha stands as a reference both in oncology and virology. But its efficiency is limited by frequent somatic as well as neuropsychic side effects. As a matter of fact, the reduction or the ending of a chemotherapy treatment come chiefly from the psychiatric complications caused by the use of interferon. For about 30% of patients, various psychic disorders are noticed: personality disorders, mood disorders, anxiety states, suicidal tendencies, manic and psychotic symptoms. We thus propose a review which shall be completed by a discussion on wether the interferon is responsible or not of the appearance of the described mental disorders. We shall conclude with a synthesis of the proposed practical management when confronted with such disorders. Psychiatric complications under interferon-Alpha. The appearance of psychiatric complications caused by interferon has been the subject of many publications. They have also raised the question of the toxicity mechanism which is still misunderstood today. This toxicity appears to be dose-dependent with variations depending on the daily dose given, the mode of administration, the combination with other chemotherapy treatments, the concomitance with a cerebral radiotherapy or a medical history of psychiatric disorders. Most of these effects occur after three weeks of treatment but non specific neuropsychic symptoms can be observed earlier. Non specific symptoms. They appear early but are difficult to detect, though they bring together a whole lot of clinical signs: asthenia, irritability, psychomotor slowdown, depressive mood or even a real "subsyndromic" depressive syndrome, anorexia, decline of the libido, concentration and attention problems, dizzy spells and headaches. Some authors have described intense and fluctuating of personality, mixing anxiety, irritability and disorder of drive control. Depression. Depression is the most frequently found psychiatric pathology in studies but the real frequency of clear cases of depressive problems is difficult to determine through lack of serious studies. So the incidence of depressive disorders usually varies from 5 to 15%. The depressive syndrome can settle as soon as the first week treatment, with a peak in the frequency during the first and third months. The seriousness and the incidence of this syndrome seem to be dose-dependent. The gravity of this complication lies in the suicidal risk, a risk all the more dreadful since there is not any identified risk factor. Suicides and suicidal behaviours. Serious complications, because they act directly on the vital prognosis. However fortunately, suicidal behaviours only represent a minority within all the side effects attributed to the interferon-alpha. These actions fit into three main clinical dimensions: complication of a severe depressive syndrome, confusional context and disorder of the impulses control. In practical terms, prevention proves to be difficult without identified predictive factors. Nevertheless, some authors point out the importance of aggravating comorbid disorders like alcoholism or the coinfection by the HIV. Manic syndrome. The appearance of a manic state under a chemotherapy treatment seems to be rare, given that there have been only a dozen cases published around the world. But these observations are interesting as far as both the study of imputability and the understanding of the toxicity mechanisms are concerned. Most of the cases deal with patients without a family or personal history of psychiatric disorders, and whose symptomatology disappears with the end of the treatment, which is an argument in favour of the imputation of the interferon in the appearance of manic disorders. In addition, some authors introduce the notion of tertiary mania: the appearance of an autoimmune hypothyroidism in relation with interferon and leading to athymic elation. Eventually, the appearance of manic problems at the end of the treatment makes it possible to speculate about the physiopathological mechanisms that are at issue. Anxiety disorders. These disorders are not much described: they generally are already existing disorders (like phobic or obsessive compulsive disorders), reactivated or aggravated by the interferon-alpha molecule. Adaptation disorders. It deals with adaptation disorders along with anxious temper coming at the beginning of the treatment. These problems are more concerned with the announcement of the diagnosis and its seriousness than with the toxicity of the interferon-alpha molecule. Psychotic states. There are less papers on the prevalence of psychotic disorders during the treatment, or at the end of it. But they can be found in both viral and malignant pathologies. A large retrospective study has shown ten cases of psychotic disorders and that in the absence of history of psychiatry or of a HIV co-infection. In every case the psychiatric aspect is stopped by the ending of the treatment or by an appropriated treatment. Usually, the few cases of paranoïd delusion described in papers seem to appear between one and three months of treatment, with patients having a history of psychiatric disorders. Aggravation of pre-existing mental disorders. Numerous authors have reported the recurrence of addictive behaviours (alcohol or other psychoactive matter) by weaned patients. Imputability to interferon-alpha in psychiatric disorders. It is difficult to draw the relationship between the chemotherapy with the interferon-alpha treatment and neuropsychiatric complications because there is a lack in specific studies. Nevertheless, it seems to be causal relations between the prescription of interferon and the appearance of psychic disorders. As a matter of fact, even if there is neither predictive criterion nor diagnosis of clinical type (set apart a dose effect), it is clear that there are diagnostic criteria of chronological kind: delay of appearance and disappearance of side effects compatible with the kinetics of the molecule and test of positive reintroduction. The imputability is thus most likely towards, given the reported clinical observations and signs of direct cerebral toxicity described for interferon: induction of neurophysiological changes among healthy volunteers, reversible EEG impairments the second week of treatment, direct vascular and neurological toxicity. Eventually, authors have shown that the psychiatric morbidity could be more important among patients under treatment than in a control group. In conclusion, the imputability of interferon appears to be very likely, more particularly in the appearance of mood disorders, mainly depressive ones, of manic syndromes and of certain psychotic episodes. MANAGEMENT: The most numerous therapeutic propositions naturally concern the depressive syndromes, because of their high frequency. In a recent article, the authors have detailed the pharmacological criteria of the ideal molecule: limited hepatic metabolism, low rate of proteinic fixation, long half-life and absence of active metabolite. So they advise not to prescribe imipraminic molecules and recommend the use of some SRI in first intention: citalopram and sertraline mainly, paroxetine to avoid given its pharmacological features that do not seem adapted. Only the minalcipram seems to show all the theoretical advantages described above. If there is an indication in the introduction of an anxiolytic medication, we shall prefer a benzodiazepine with short half-life like loxazepam and alprazolam. Besides, all the publications point out the importance of a specific clinical observation during the treatment as well as in the six months following its end. The agreement must bear full medical costs, above all including psychotherapic and social aspects. The proposed treatments for the other disorders are conventional: haloperidol and lithium for bipolar disorders, fluvoxamine for obsessive compulsive disorders and neuroleptics for psychotic disorders. CONCLUSION: The appearance of neuropsychiatric side effects during a chemotherapy using the interferon-alpha molecule is a frequent complication, the consequences of which can prove tragic: involvement of the vital prognosis, family and professional relation disturbances, compliance problems, risks of psychiatric morbidity at short and middle terms.... In spite of the absence of rigorous controlled studies, the imputability to the interferon of the appearance of psychological disorders appears very likely. So the role of the psychiatrist seems to be determining in the follow-up care of these patients who must be considered at high risk to develop a psychiatric pathology. The agreement to bear medical costs has to be made in narrow collaboration with clinical practitioners and must be part of a clinical continuity, from the pre-therapeutical evaluation to the remote follow-up care. Finally, it seems important to implement controlled studies, resting on a great diagnostic and methodological rigour, in order to clarify the toxicity mechanisms of interferon and to optimise the agreement to bear medical cost for the patients.