Long-term follow-up of pallidal Deep Brain Stimulation in teenagers with refractory Tourette syndrome and comorbid psychiatric disorders: About three cases.

OBJECTIVES: Tourette syndrome (TS) is a complex neuropsychiatric disorder associated with comorbid psychiatric disorders. Peak of tic severity typically occurs in early adolescence and impacts quality of life. Since 1999, promising therapeutic effects of Deep Brain Stimulation (DBS) have been reported in tic reduction for adults with refractory TS. The aim of the study was to assess the long-term risk-benefit ratio of pallidal DBS for young patients with refractory TS and severe comorbid psychiatric disorders. METHODS: We retrospectively assessed the long-term clinical outcomes of three adolescents who underwent pallidal DBS for the treatment of refractory TS. RESULTS: The mean duration of follow-up was 52 months in our case series. We observed that motor tics decreased with posteroventral GPi DBS in all patients, without reaching a continuous significance over the long-term follow-up. Self-reported social inclusion was globally improved, despite lack of efficacy of DBS on comorbid conditions. CONCLUSIONS: These findings suggest a long-term therapeutic benefit of early DBS intervention for highly socially impaired young patients suffering from intractable TS with severe comorbid psychiatric conditions. Further studies are needed to determine the most effective targets of DBS on both tics and comorbid psychiatric profile of TS.

[Appropriate medication prescribing in older people]. / Bon usage des médicaments chez le sujet âgé.

Drug-induced adverse effects are one of the main avoidable causes of hospitalization in older people. Numerous lists of potentially inappropriate medications for older people have been published, as national and international guidelines for appropriate prescribing in numerous diseases and for different age categories. The present review describes the general rules for an appropriate prescribing in older people and summarizes, for the main conditions encountered in older people, medications that are too often under-prescribed, the precautions of use of the main drugs that induce adverse effects, and drugs for which the benefit to risk ratio is unfavourable in older people. All these data are assembled in educational tables designed to be printed in a practical pocket format and used in daily practice by prescribers, whether physicians, surgeons or pharmacists.

[The clinic of apathy in schizophrenia: a critical review of the issue]. / L'apathie dans la schizophrénie: une revue clinique et critique de la question.

INTRODUCTION: Today the concept of apathy is subject to many questions. This psychological state is present and predominant in different disorders such as neurodegenerative and psychiatric diseases or neurological acquired disorders. Apathy is a part of the clinical vocabulary, however, we can note that in the literature there remains confusion in its definition, and we can find an amalgam with other clinical symptoms. OBJECTIVES: The aim of this review is to provide a clarification of the concept of apathy in clinical practice in schizophrenia as well as to highlight the gaps that exist. LITERATURE FINDINGS: Apathy belongs to the negative symptoms of schizophrenia. For its understanding, it is necessary to define apathy as a multidimensional syndrome (cognitive, emotional, and behavioral) manifesting as a quantitative reduction of voluntary behaviors directed toward one or several goals. However, at present, we are witnessing a reductionist and simplistic conception of the syndrome of apathy and this especially in the Anglo-Saxon literature. Several authors reduce apathy to its behavioral component, so in other words, to avolition/amotivation. Avolition refers to a loss of self-initiated and spontaneous behaviors. In this definition only observable behavior is taken into account and not the underlying mechanisms (cognitive and emotional). In order to understand the syndrome of apathy, it is necessary to have a holistic and multidimensional outlook. Some authors have proposed diagnostic criteria for apathy by taking into account the different dimensions of apathy. Moreover not only is apathy confused with avolition, but it is also still difficult to distinguish it from depression. Apathy and depression share common clinical signs (i.e. loss of interest), but they also have distinct clinical signs (lack of motivation for apathy, and suicidal ideation for depression). Authors have shown that the presence of one symptom (apathy or depression) does not predict the presence of the other. An apathetic patient does not have to be necessarily in a depressive state and vice versa. However, to our knowledge, there is no data capable of distinguishing depression from apathy in schizophrenia, and knowing what is the part of one and the other when the patient has both symptoms. In addition, we can see that the confusion that persists between those two symptoms also stems from assessment tools. Indeed, some assessment tools such as the Montgomery and Asberg Depression Rating Scale (MARDS) have an apathy subscale. Therefore, this scale does not only evaluate depression. Regarding the assessment of apathy in schizophrenia, there are specific and nonspecific tools. Nonspecific tools define apathy differently. For this reason, authors have proposed to measure apathy by using analytic factors of negative symptoms. In this case, apathy is going to be assessed by the factor "motivation/pleasure" including anhedonia, asociality and avolition. This factor will provide the possibility of a better assessment of apathy. Concerning specific scales (like AES), there are gaps such as a lack of standardization in the execution and the quotation. Furthermore, no scale takes into account the factors causing apathy. CONCLUSION: Knowing the reasons for apathy is necessary because this syndrome is frequent in schizophrenia, and it is found in the different phases of this disease (prodromal, first episode psychosis, and chronic). In addition, apathy has significant functional consequences on the patient's quality of life, as well as on his or her global functioning. Indeed, apathy impacts on his or her social and professional life. Patients with schizophrenia have a loss of autonomy, less employment and social withdrawal. Consequently, interest in its drug or treatment it is obvious. However, drug and non-drug treatments are not specific to apathy and therefore little effective on this syndrome. Implications to stimulate future research are presented.

[Evolution of the concept of apathy: the need for a multifactorial approach in schizophrenia]. / Évolution du concept d'apathie: nécessité d'une approche multifactorielle dans la schizophrénie.

BACKGROUND: Schizophrenia is a chronic and severe mental illness that affects over 1% of the population, characterized by multiple symptom dimensions. One of this class of symptoms, "negative symptoms", have received more attention over the last few years. Negative symptoms, including among others blunted affect, withdrawal or apathy, are particularly important for recovery and are associated with negative functional outcomes, such as inability to get an employment and conduct normal daily living activities. While positive symptoms are usually treated by antipsychotic drugs, negative symptoms are usually persistent, which indicates the need for better treatment. The aim of this article is to highlight recent scientific progress on apathy and to explore current multidimensional approaches of this concept in schizophrenia. Apathy is a symptom frequently encountered in schizophrenia and in many neurological disorders. Therefore, it can be regarded as a transnosographic symptom. LITERATURE FINDINGS: A long time considered as a loss of motivation (psychological concept hard to define), recent descriptive and etiological models have proposed to consider apathy as a multidimensional phenomenon. Marin et al., have proposed a model of apathy in reference to the motivation concept. Marin et al.'s apathy model is composed of three dimensions: firstly, cognitive dimension, secondly, sensory-motor dimension and thirdly, affective dimension. These authors propose to differentiate "apathy syndrome" from "apathy symptom". "Apathy syndrome" resulting from a lack of motivation whereas "apathy symptom" results from cognitive and/or emotional/affective disorders. In addition, Marin et al. propose that apathy syndrome corresponds to the "lack of motivation" not attributable to diminished level of consciousness, cognitive impairment or emotional distress. Following this proposal, Levy and Dubois propose to define apathy as a quantitative reduction of self-generated, voluntary and purposeful behaviors. It is therefore observable and can be quantified. Levy and Dubois have proposed an apathy model considering: firstly, apathy as a syndrome related to reduction in goal-directed behaviors; secondly, anatomically, apathy can be secondary to dysfunctions or lesions of the prefrontal cortex. Since the prefrontal cortex is functionally and anatomically heterogeneous, subtypes of apathy occur in diseases affecting the basal ganglia, because these diseases disrupt associative and limbic pathways from/to the prefrontal cortex; thirdly, from a pathophysiological point of view, apathy may be explained by the impact of lesions or dysfunctions of the basal ganglia, because these lesions or dysfunctions lead to a loss of temporal and spatial focalization, both of which result in a diminished extraction of the relevant signal within the frontal cortex, thereby inhibiting the capacity of the frontal cortex to select, initiate, maintain and shift programs of action.

[Toxoplasma gondii: a potential role in the genesis of psychiatric disorders]. / Toxoplasma gondii : un rôle potentiel dans la genèse de troubles psychiatriques. Une revue systématique de la littérature.

INTRODUCTION: Toxoplasma gondii is the most common protozoan parasite in developed nations. Up to 43% of the French population may be infected, depending on eating habits and exposure to cats, and almost one third of the world human's population may be infected. Two types of infection have been described: a congenital form and an acquired form. Although the medical profession treats these latent cases as asymptomatic and clinically unimportant, results of animal studies and recent studies of personality profiles, behavior, and psychomotor performance have led to reconsider this assumption. PRECLINICAL DATA: Among rats: parasite cysts are more abundant in amygdalar structures than those found in other regions of the brain. Infection does not influence locomotion, anxiety, hippocampal-dependent learning, fear conditioning (or its extinction) and neophobia in rats. Rats' natural predator is the cat, which is also T. gondii's reservoir. Naturally, rats have an aversion to cat urine, but the parasite suppresses this aversion in rats, thus influencing the infection cycle. Tachyzoites may invade different types of nervous cells, such as neurons, astrocytes and microglial cells in the brain, and Purkinje cells in cerebellum. Intracellular tachyzoites manipulate several signs for transduction mechanisms involved in apoptosis, antimicrobial effectors functions, and immune cell maturation. Dopamine levels are 14% higher in mice with chronic infections. These neurochemical changes may be factors contributing to mental and motor abnormalities that accompany or follow toxoplasmosis in rodents and possibly in humans. Moreover, the antipsychotic haloperidol and the mood stabilizer valproic acid most effectively inhibit Toxoplasma growth in vitro with synergistic activity. CLINICAL DATA: The effects of the parasite are not due to the manipulation in an evolutionary sense but merely due to neuropathological or neuroimmunological effects of the parasite's presence. Toxoplasmosis and schizophrenia: epidemiological studies point to a role for toxoplasmosis in schizophrenia's etiology, probably during pregnancy and early life, this association being congruent with studies in animal models indicating that animal exposures of the developing brain to infectious agents or immune modulating agents can be associated with behavioral changes that do not appear until the animal reaches full maturity. Psychiatric patients have increased rates of toxoplasmic antibodies, the differences between cases and controls being greatest in individuals who are assayed near the time of the onset of their symptoms. The increase of dopamine in the brain of infected subjects can represent the missing link between toxoplasmosis and schizophrenia. Toxoplasmosis and Obsessive Compulsive Disorder (OCD): the seropositivity rate for anti-T. gondii IgG antibodies among OCD patients is found to be significantly higher than the rate in healthy volunteers. Infection of basal ganglia may be implicated in the pathogenesis of OCD among Toxoplasma seropositive subjects. Toxoplasmosis and personality: infected men appear to be more dogmatic, less confident, more jealous, more cautious, less impulsive and more orderly than others. Conversely, infected women seem warmest, more conscientious, more insecure, more sanctimonious and more persistent than others. It is possible that differences in the level of testosterone may be responsible for the observed behavioral differences between Toxoplasma-infected and Toxoplasma-free subjects. CONCLUSION: In the future two major avenues for research seem essential. On one hand, prospective studies and research efforts must still be carried out to understand the mechanisms by which the parasite induces these psychiatric disorders. On the other hand, it has not yet been demonstrated that patients with positive toxoplasmic serology may better respond to haloperidol's or valproic acid's antiparasitic activity. These results may appear as a major issue in the drug's prescribing choices and explain variability in response to the treatment of patients with schizophrenia that is not explained by the genetic polymorphism.

[Adjustment disorders with anxiety. Clinical and psychometric characteristics in patients consulting a general practitioner]. / Le trouble de l'adaptation avec anxiété. Caractéristiques cliniques et psychométriques chez des patients consultant en médecine générale.

BACKGROUND: The DSM-IV and ICD-10 descriptions of adjustment disorders are broadly similar. Their main features are the following: the symptoms arise in response to a stressful event; the onset of symptoms is within 3 months (DSM-IV) or 1 month (ICD-10) of exposure to the stressor; the symptoms must be clinically significant, in that they are distressing and in excess of what would be expected by exposure to the stressor and/or there is significant impairment in social or occupational functioning (the latter is mandatory in ICD-10); the symptoms are not due to another axis I disorder (or bereavement in DSM-IV); the symptoms resolve within 6 months, once the stressor or its consequences are removed. Adjustment disorders are divided into subgroups based on the dominant symptoms of anxiety, depression or behaviour. Adjustment disorder with anxiety (ADA) is a very common diagnosis in primary care, liaison and general psychiatry services but we still lack data about its specificity as a clinical entity. Current classifications fail to provide guidance on distinguishing these disorders from normal adaptive reactions to stress. METHOD: Ninety-seven patients with ADA according DSM-IV were recruited in this primary care study and compared with 30 control subjects matched for age and sex. The diagnosis was made according to the MINI questionnaire completed with a standardized research of stressful events and an assessment of anxiety symptoms using different scales: the Hamilton Anxiety rating Scale (HAM-A), the Hospital Anxiety and Depression scale (HAD), The Penn-State Worry Questionnaire (PSWQ), the Positive and Negative Emotionality scale, 31 items (EPN-31 scale) and the State-Trait Anxiety Inventory (STAI-S). RESULTS: Life events in relation to work were the most frequent (43%). In terms of symptomatology, results showed that ADA is associated with a level of anxiety close to those obtained in other anxiety disorders, particularly GAD, in relation to general symptoms (physical and somatic) as well as anxious rumination and negative emotions. CONCLUSION: Further research is needed to better understand the disorder and clarify its frontiers, which still remain a controversial issue with regard to the homeostatic response to stress and other types of anxiety disorders. The results of our study suggest that this sub syndromic entity should be recognized and adequately treated, especially in general practice where it is very common.

Baseline anxiety effect on outcome of SSRI treatment in patients with severe depression: escitalopram vs paroxetine.

OBJECTIVE: To investigate if treatment outcome for severely depressed patients depends on their baseline level of anxiety. RESEARCH DESIGN AND METHODS: Patients with a primary diagnosis of severe major depressive disorder (n = 459) were randomised to 24 weeks of double-blind treatment with escitalopram (20 mg) or paroxetine (40 mg). Post hoc analyses of efficacy in patients with a baseline HAM-A total score < or =20 (n = 171) or >20 (n = 280) were based on analysis of covariance (ANCOVA) (ITT, LOCF). RESULTS: At week 24, the mean change from baseline in MADRS total scores was -24.2 for escitalopram-treated patients (n = 141) and -21.5 for paroxetine-treated patients (n = 139) (p < 0.05) in high baseline anxiety patients and the mean change from baseline in HAM-A total score was -17.4 (escitalopram) and -15.1 (paroxetine) (p < 0.05). When examining the proportion of complete remitters (CGI-S = 1) after 24 weeks of treatment, there was an increasing treatment difference as a function of baseline HAM-A total score in favour of escitalopram (ITT, LOCF). There was no treatment difference in the low baseline anxiety group. Significantly more patients (p < 0.01) withdrew from the paroxetine group (31%) than from the escitalopram group (17%), partly as the result of significantly more withdrawals due to AEs (p < 0.05). Incidence of AEs and withdrawals were not related to baseline anxiety and there were no significant differences in the incidence of individual AEs with escitalopram compared to paroxetine. LIMITATIONS: The post hoc nature of these analyses, the absence of placebo control group, and the requirement that patients should be suffering from severe depression, limit the generalisability of the results. CONCLUSION: Patients with severe depression together with comorbid anxiety symptoms responded significantly better to treatment with escitalopram 20 mg compared with paroxetine 40 mg. Contrary to paroxetine, escitalopram maintained its efficacy with increasing baseline anxiety levels.

[Prevalence of psychiatric disorders in French general practice using the patient health questionnaire: comparison with GP case-recognition and psychotropic medication prescription]. / Prévalence des troubles psychiatriques en médecine générale selon le patient health questionnaire: adéquation avec la détection par le médecin et le traitement prescrit.

INTRODUCTION: Psychiatric disorders, mainly depression and anxiety, are frequently encountered in primary care and are a major cause of distress and disability. Nearly half of cases go unnoticed and among those that are recognised, many do not receive adequate treatment. In France, there is limited research concerning the prevalence, detection and management of these conditions in primary care. OBJECTIVES: To estimate the prevalence of psychiatric disorders, overall and for the main psychiatric diagnostic categories, encountered in primary care; to describe general practitioners' (GPs') case identification rate; to examine psychotropic medication prescription according to diagnosis, in a regionally representative sample of GP attenders. METHODS: GP practicing standard general practice in an urban area of the city of Montpellier and a nearby semi-rural region were recruited to participate. The response rate was 32.8% (n=41). Five additional GP almost exclusively offering homeopathy and acupuncture were recruited nonrandomly for convenience purposes. In each GP surgery, consecutive patients entering the waiting room were invited by a research assistant to participate until 25 patients per GP were recruited. Each participant completed self-report questionnaires in the waiting time, including the patient health questionnaire (PHQ), which yields provisional DSM-IV diagnoses. The GP completed a brief questionnaire during the consultation, giving his/her rating of the severity of any psychiatric disorder present and action taken. RESULTS: The patient response rate was 89.8%. In all, 14.9% of patients reached DSM-IV criteria for major depression or anxiety disorder on the PHQ (9.1% for major depression, 7.5% for panic disorder; 6% for other anxiety disorders). For the subthreshold categories, 7.4% met criteria for other depressive disorders, 11.8% for somatoform disorders and 10.9% for probable alcohol abuse or dependence. 66.3% of patients with DSM-IV diagnoses of major depression or anxiety disorder were identified by the GP as having a psychiatric disorder. The identification rate was 51% for all depressive disorders, anxiety and somatoform disorders. Of patients receiving a prescription for anxiolytic or antidepressant medication on the survey day, 80% were classified as cases of psychiatric disorder by the GP. Only 48.8% met criteria for major depression or anxiety disorder on the PHQ. CONCLUSION: This study highlights the frequency of psychiatric disorders in a regional study of French general practice. Overall, prevalence rates were similar to those found elsewhere, except for probable alcohol abuse and dependence, which was considerably higher than in the USA PHQ validation study. As in other countries, GP identified roughly half of psychiatric cases. Furthermore, half of patients treated by anxiolytic or antidepressant medication did not meet the diagnostic criteria on the survey day for which these medications have mainly shown their efficacy. This confirms the French paradox of one of the highest psychotropic medication consumption rates in Europe despite many cases of depression remaining untreated. The PHQ could be a rapid and acceptable diagnostic aid tool for French general practice but first needs to be validated against the diagnosis of mental health professionals in this setting.

[Learning potential and cognitive remediation in schizophrenia]. / Potentiel d'apprentissage et revalidation cognitive dans la schizophrénie.

BACKGROUND: Many studies have stressed the importance of neurocognitive deficits in schizophrenia that represent a core feature of the pathology. Cognitive dysfunctions are present in 80% of schizophrenic patients, including deficits in attention, memory, speed processing and executive functioning, with well-known functional consequences on daily life, social functioning and rehabilitation outcome. Recent studies have stressed that cognitive deficits, rather than the positive or negative symptoms of schizophrenia, predict poor performance in basic activities of daily living. If it is possible to reduce psychotic symptoms and to prevent relapses with antipsychotic medication, it is not yet possible to have the same convincing impact on cognitive or functional impairments. Cognitive remediation is a new psychological treatment which has proved its efficacy in reducing cognitive deficits. A growing literature on cognitive rehabilitation suggests possibilities that in schizophrenia, specific techniques are able to enhance an individual's cognitive functioning. LITERATURE FINDINGS: Presently, two distinct and complementary cognitive remediation methods have been developed: the compensatory and the restorative approaches: (A) restorative approaches attempt to improve function by recruiting relatively intact cognitive processes to fill the role of those impaired, or by using prosthetic aids to compensate for the loss of function; (B) in contrast, in the restorative approach cognitive deficits are targeted directly through repeated practice training. However, results concerning cognitive remediation remain inconsistent. It is clear that not all individuals with schizophrenia display cognitive impairment, and even among those who do, the specific pattern of cognitive functioning varies. Moreover, traditional neurocognitive assessment, with a single or static administration of cognitive measures, provides moderately good prediction of skills acquisition in schizophrenia. Among other factors such as motivation, awareness of having a disease and acuteness of symptomatology, some studies have exposed that a cognitive variable, learning potential could mediate in part the effectiveness of cognitive remediation. DISCUSSION: The concept of learning potential is used to explain some of the observed variability in cognitive functioning. Learning potential is the ability to attain and utilize cognitive skills after cognitive training: it is assessed by individual variation in performance across three consecutive administrations of the Wisconsin Card Sorting Test (WCST): a pretest with standard instruction procedures, a training phase with expanded instruction and a post test with only standard instruction. Three learner subtypes can be identified: "learners" who perform poorly at the pretest but improve performance during the post-test, "non-retainers" who perform poorly at pre-test and do not improve at post-testing and "high achievers" who perform well in the initial pretest and maintain their good performance across the other two administrations. The assessment of learning potential could predict, with other psychological measures such as insight and motivation, the most effective neurocognitive rehabilitation program for an individual patient, and could help the clinician to optimize patient outcome through appropriate individual management. CONCLUSION: Indeed, learning potential could represent a good cognitive predictor and indicator for rehabilitation in schizophrenia for clinicians and should be used in cognitive assessment practice. However, the individuals most likely to benefit from cognitive remediation, and whether changes in cognitive function translate into functional improvements, are as yet unclear.

[Schizophrenic patients' length of stay: mental health care implication and medicoeconomic consequences]. / Durées d'hospitalisation des patients souffrant de schizophrénie: implication des systèmes de soin et conséquences médicoéconomiques.

A striking reduction in hospital beds can be seen as the defining characteristic of mental health services in many western countries during the last 30 years. The politic of shortening hospital stays for persons with psychosis has been questioned by a number of authors. Studies of patients returning to the community compared to those remaining in institutions show not only better quality of life and larger friendship networks, but also reductions in dependence on pharmacotherapies and lower mortality rates. An interesting comparison between three contrasting mental care systems in Holland, Italy and Australia concluded not surprisingly that hospital stays are shortest where community care is more developed, although long term hospitalization will always be required for a small number of very severe patients. The general conclusion was that shorter stays work best if and only if there is high quality community care which comes into play immediately on discharge. The central issue appears to be that the beneficial effects of short stays are modulated by conditions of discharge. That is, in the absence of a planned discharge policy, patients appear to be better off staying longer, in order that a structured rehabilitation plan may be put in place. The process of deinstitutionalisation has been driven by a variety of forces. One is to reduce costs, since hospital inpatient costs are very high. Generally, between one- and two-thirds of the total health care cost of schizophrenia is for hospitalization, even in countries that have already substantially reduced their inpatient provision. Recent years have seen a trend toward mental health services provided from community-based settings for defined catchment areas. The development of these services has a heavy cost, with the opening of replacement accommodation and other community facilities and large teams. While few patients or clinicians would contest today that a return to normal community life is preferable to institutionalization, the adoption of shorter hospital stays was not an evidence-based policy and no adequate evaluation study was ever put in place to predict the social, clinical and economic consequences of this widespread practice.

[Schizophrenic patients' length of stay: clinical factors of variability and consequences]. / Durées d'hospitalisation des patients souffrant de schizophrénie : facteurs cliniques de variations et leurs conséquences.

BACKGROUND: Schizophrenia is characterized by profound disruption in cognition and emotion, affecting the most fundamental human attributes: language, thought, perception, affect and sense of self. The clinical picture is further complicated by the multiple secondary consequences of the disorder; notably disrupted education, unemployment, impoverished social relationships, isolation, legal difficulties, family stress and substance abuse. Not surprisingly, the disorder is also associated with suicidal behaviour. The management of schizophrenia is thus extremely difficult with high rates of relapse, treatment refusal and poor treatment outcome. In Europe and the United States there has been a general trend towards decreasing the former long duration of hospital care in favour of short-term pharmacological stabilization in the hospital setting, followed by longer multidisciplinary follow-up within the community. This change reflects, on the one hand, the evolution in aetiological conceptions towards a predominantly neurobiological model of the disorder, with complex social consequences and also social and economic constraints. The clinical consequences of these changes were not, however, evaluated prior to the implementation of these changes. LITERATURE FINDINGS: Several studies have shown a clear relationship between reductions in duration of stay and increases in readmission rates and suggest that the development of community services may not in fact significantly improve clinical outcome, and may also possibly increase relapse rates due to the instability of the clinical condition at first discharge. There has been some unsettling evidence to suggest that shortening hospital stays may not be a general panacea. Authors reported in 1999 that deinstitutionalization policies in Denmark had led to premature discharge and subsequently a 100% increase in suicide, a doubling of the rates of criminal acts committed by psychotic patients, and increases of 80 to 100% in acute admission rates. A large follow-up study of psychotic patients in the USA found that hospital stays of less than 14 days were significantly associated with increased suicide risk; on the other hand, shortening hospital stays appears to be linked to higher rates of care satisfaction. CONCLUSION: Indeed, studies of patients returning to the community compared to those remaining in institutions show not only better quality of life and larger friendship networks, but also reductions in dependence on pharmacotherapy and lower mortality rates. The essential question of whether shortened hospital care may lead to premature discharge or, on the other hand, decreased patient dependency and social deviance, has not been adequately addressed.

[Lack of insight in schizophrenia: a review. Part I: theoretical concept, clinical aspects and Amador's model]. / La conscience des troubles (insight) dans la schizophrénie : une revue critique. Partie I : insight et schizophrénie, caractéristiques cliniques de l'insight.

INTRODUCTION: Schizophrenia is the psychiatric disorder in which the awareness of pathology (or insight) is most frequently altered. LITERATURE FINDINGS: A review of the literature shows that between 50 and 80% of patients with schizophrenia do not believe they have a disorder. Studies published on this subject over the two last decades stressed the specificity of this phenomenon in schizophrenic patients, taking into account both its prevalence and its clinical consequences comparatively to other mental disorders. If in bipolar disorders a lack of insight is linked with the intensity and acuteness of symptomatology, there is only a limited relationship between these factors in schizophrenia, thus making lack of insight a trait rather than a state-related symptom. DISCUSSION: Though defined for a very long time as a dichotomic phenomenon, the recent interest on insight in psychosis and the development of assessment tools for its evaluation have made it possible to underline its multifactorial and dynamic characteristics. Although lack of insight related to pathologies may vary across time in bipolar disorders, the results of clinical studies suggest that this phenomenon remains stable in schizophrenia. CONCEPTUAL PROPOSALS: In this review, we will reconsider the evolution of this concept in psychiatry and its definition. The clinical characteristics, which are specifically associated with the lack of insight in schizophrenia will be outlined. We will describe more specifically the model of Amador and Strauss and their assessment tool: the Scale to Assess Unawareness of Mental Disorder (SUMD). This model developed since the 1990s takes into account the time-related evolution of insight, and can be applied both to bipolar and psychotic disorders. ASSESSMENT TOOLS: The SUMD has six general items and four subscales. The general items estimate the three most widely used definitions of insight: awareness of having a mental disorder, awareness of the achieved effects of medication and awareness of the social consequences of having a mental disorder, and include assessment of both current and past-time periods. Four other subscales, each composed of 17 items, assess awareness and attribution of specific current and retrospective symptoms as well as deficits associated with severe mental disorders. Insight, thus, appears as a multidimensional and continuous phenomenon, since patients' awareness may apply only to part of their symptoms and vary over time. In this article, we will review existing scales assessing insight in schizophrenia. The deficiency of available scales validated in French limits the number of scientific publications concerning this important aspect of the clinical evaluation of schizophrenic patients. THERAPEUTICAL ASPECTS: Finally, interventions to improve insight in patients with schizophrenia are presented. Recent studies have shown cognitive behavioural therapy (CBT) to be of benefit in the treatment of poor insight in schizophrenia. CONCLUSION: Evidence suggests that early diagnosis and treatment of schizophrenia leads to better prognosis. An important suggestion from theses studies may be that psychosocial therapy needs to focus on explanations that are in tune with the culture, rather than focus on diagnostic labels.

[Lack of insight in schizophrenia: a review]. / La conscience des troubles (insight) dans la schizophrénie : une revue critique Partie II : modèles explicatifs et hypothèses psychopathologiques.

BACKGROUND: Relative to other psychiatric disorders, patients with schizophrenia are often unaware of the consequences of their disease and their need for treatment. These deficits in awareness referred in general in the English literature as "poor insight", have been the focus of many clinical studies over recent years. This phenomenon, which is considered as fundamental in clinical evaluations of schizophrenia, should be understood as a multidimensional process rather than a dichotomic phenomenon, as is presently the case. The links between insight deficits and responses to vocational rehabilitation efforts represent a major interest in research, including those related to medication compliance and clinical outcome. To conduct such studies, various evaluation tools have been developed, enabling the assessment of insight, of its time-course and of its components in psychosis and schizophrenia spectrum disorders. LITERATURE FINDINGS: The Scale to Assess Unawareness of illness in Mental Disorders (SUMD) developed by Amador and Strauss appears to be the most frequently used scale for the evaluation of awareness of the disorder in schizophrenia. Although the model proposed by Amador and Strauss is considered as the privileged model in the multidimensional approach of insight, it corresponds only to a phenomenological analysis of this concept. In the second part of this article, we thus review the current models attempting to explain the lack of insight in schizophrenia. Four current explanatory models of lack of insight will be described as follows: resulting either from adaptation or defence mechanisms to environmental stressors, resulting from cognitive bias of data processing, resulting from neuropsychological functional deficits and resulting from metacognitive deficits. DISCUSSION: Several hypotheses concerning these deficits arise from clinical studies. Although coping, and defence mechanisms to the consequences and stigmatization of the disease were hardly studied, the fact that poor insight does not appear related to the severity of symptomatology or to the emotional state of the patients argue against this hypothesis. Conversely, a considerable body of literature emphasized how unawareness may result from cognitive deficits. Research in neuropsychology and cognitive psychology has provided consistent results concerning the link between deficit in executive functions, frontal lobe dysfunction and poor insight. Recent studies on bias in cognitive information treatment and social cognition theories currently open new prospects.

[Pharmacological treatment of generalized anxiety disorders: rationale and limitations]. / Le traitement pharmacologique de l'anxiété généralisée: utilisation rationnelle et limitations.

The rational use of pharmacological treatment in generalized anxiety disorders is still a matter of debate due to the uncertainties concerning the nature, diagnostic criteria and target-symptoms of this frequent and potentially invalidating disorder. If benzodiazepines may still be prescribed for a limited amount of time (i.e. 6 to 12 weeks) due to the fluctuating nature of generalized anxiety, the chronic evolution of this disorder in most patients often justifies the long-term prescription of serotoninergic (5-HT) or dual-action (5HT-NA) antidepressants and sometimes of 5HT-la partial agonists like buspirone. Imipramine, a tricyclic antidepressant was the first to demonstrate its efficacy in carefully selected patients; however, due to the side-effects of this molecule recent guidelines based on controlled clinical trials, suggest to use either serotonergic antidepressants (SSRIs) or venlafaxine as a first-line treatment of generalized anxiety disorders. Because of its pharmacological profile buspirone remains however a useful option in patients with cognitive or addictive problems, especially alcoholics. If most SSRIs have demonstrated efficacy over placebo, head to head comparisons remain limited except for escitalopram which appear better tolerated than paroxétine in this indication. More recently, an anticonvulsant, pregabaline also demonstrated its efficacy in several clinical trials but the symptomatic profile of generalized anxiety patients likely to respond to this GABA analog compared to other psychotropic treatments remain to be established. The traditional use of other psychotropic agents such as hydroxyzine, an H1 histaminergic receptor antagonist, is only supported by limited scientific data; this is also the case of sedative typical antipsychotics which benefit/risk ratio should be carefully evaluated before being prescribed to generalized anxiety patients resistant to other psychotropic agents. However, the possible use of atypical antipsychotics with a better tolerance profile than the typical ones in this indication is presently under investigation in several countries. At last it is important to realize that most clinical trials in this field only include patients with non-comorbid generalized anxiety and that their conclusion may not always be generalizable to most psychiatric patients who are usually characterized by a high rate of comorbidity. In this population the indication of specific pharmacological treatments should rely on a careful evaluation of the patients drug treatment history, of the duration, evolution and functional consequences of their symptoms and of the nature of their possible comorbidity. The treatment of resistant generalized anxiety disorders remains a question for future research but the use of imipramine or sedative antipsychotics could be an option when other treatments have failed to induce any improvement.

A comparative study of the efficacy of long-term treatment with escitalopram and paroxetine in severely depressed patients.

OBJECTIVE: This randomised, double-blind, fixed-dose study evaluated the efficacy of escitalopram and paroxetine in the long-term treatment of severely depressed patients with major depressive disorder (MDD). RESEARCH DESIGN AND METHODS: Patients with a primary diagnosis of MDD and baseline Montgomery-Asberg Depression Rating Scale (MADRS) >or= 30 were randomised to 24 weeks of double-blind treatment with fixed doses of either escitalopram (20 mg) (n = 232) or paroxetine (40 mg) (n = 227). The primary analysis of efficacy was an analysis of covariance (ANCOVA) of change from baseline to endpoint (Week 24) in MADRS total score (last observation carried forward, LOCF). MAIN OUTCOME MEASURES; RESULTS: At endpoint (24 weeks), the mean change from baseline in MADRS total score was -25.2 for patients treated with escitalopram (n = 228) and -23.1 for patients with paroxetine (n = 223), resulting in a difference of 2.1 points (p < 0.05). The difference in the change in the MADRS total score (LOCF) was significantly in favour of escitalopram from Week 8 onwards. The proportion of remitters (MADRS or= 35), there was a difference of 3.4 points at endpoint in the MADRS total score in favour of escitalopram (p < 0.05). The overall withdrawal rate for patients treated with escitalopram (19%) was significantly lower than with paroxetine (32%) (p < 0.01). The withdrawal rate due to adverse events was significantly lower for escitalopram (8%) compared to paroxetine (16%) (p < 0.05). There were no significant differences in the incidence of individual adverse events during treatment. CONCLUSION: Escitalopram is significantly more effective than paroxetine in the long-term treatment of severely depressed patients.

Psychiatric morbidity, disability and service use amongst primary care attenders in France.

Attenders (n = 124, response rate 84%) of five GPs in Montpellier completed questionnaires on health (reason for visit, cause of problem, GHQ-12), disability (WHODAS II) and service use (CSRI). For each patient, the GP filled in a brief form including a rating of severity of physical and psychological illness. Overall 30.6% of patients were classified as GHQ cases indicating probable non-psychotic psychiatric morbidity and 58.9% were rated as having a physical illness by the GP. Patients with psychiatric morbidity showed as high levels of disability as those with a physical illness, with however a greater number of domains of life affected. They also had a greatly increased number of disability days and used services to a greater extent than those without psychiatric morbidity, these links being stronger than with physical illness. Use of the WHODAS II and the CSRI has not been previously reported in France. This study shows that they could be useful instruments for depicting disability and service use in general practice. The findings from this initial study indicate the need for greater research in primary care focusing on accurate detection and treatment of patients so that disability and excess service use associated with psychiatric morbidity might be reduced.

Prevalence of DSM-IV psychiatric disorder in the French elderly population.

BACKGROUND: France has high rates of psychotropic drug consumption and suicide in the elderly population, but it has not yet been possible to determine whether this is due to exceptionally high morbidity rates. AIMS: To describe the first longitudinal population study of psychiatric disorder undertaken in France, and to estimate current and lifetime prevalences and age of onset of psychiatric disorder. METHOD: A study group of 1873 non-institutionalised persons aged 65 years and over was randomly recruited from the Montpellier district electoral rolls. The Mini International Neuropsychiatric Interview was used to assess current and lifetime symptoms. Cases identified by the application of DSM-IV criteria were re-examined by a clinical panel. RESULTS: Forty-six per cent of the study population had experienced a mental disorder in their lifetime, and 3.7% had made a suicide attempt. Lifetime prevalence of major depression was 26.5% and 30% for anxiety disorders. Current prevalence rates were 14.2% for anxiety disorders, 10.7% for phobia, 3% for major depression and 1.7% for psychosis. CONCLUSIONS: Results show very high rates of lifetime but not current major depression. Rates of current phobia and suicidal ideation in the very elderly are also high compared with other studies. The rates reported are likely to be underestimates.

[Impact of psychiatric disturbances on the outcome of coronary bypass surgery]. / Impact des troubles psychiques sur les suites d'un pontage coronaire.

The influence of anxiety and depression on the development and prognosis of coronary disease seems to be well established but there are few studies of the effects of these disturbances on the postoperative outcome of coronary surgery. The object of this review of the literature was to present recent data on this subject and to suggest therapeutic strategies for patients referred for coronary bypass surgery to improve their quality of life and even cardiovascular prognosis.