Association between benzodiazepine receptor agonist use and mortality in patients hospitalised for COVID-19: a multicentre observational study.

AIMS: To examine the association between benzodiazepine receptor agonist (BZRA) use and mortality in patients hospitalised for coronavirus disease 2019 (COVID-19). METHODS: A multicentre observational study was performed at Greater Paris University hospitals. The sample involved 14 381 patients hospitalised for COVID-19. A total of 686 (4.8%) inpatients received a BZRA at hospital admission at a mean daily diazepam-equivalent dose of 19.7 mg (standard deviation (s.d.) = 25.4). The study baseline was the date of admission, and the primary endpoint was death. We compared this endpoint between patients who received BZRAs and those who did not in time-to-event analyses adjusted for sociodemographic characteristics, medical comorbidities and other medications. The primary analysis was a Cox regression model with inverse probability weighting (IPW). RESULTS: Over a mean follow-up of 14.5 days (s.d. = 18.1), the primary endpoint occurred in 186 patients (27.1%) who received BZRAs and in 1134 patients (8.3%) who did not. There was a significant association between BZRA use and increased mortality both in the crude analysis (hazard ratio (HR) = 3.20; 95% confidence interval (CI) = 2.74-3.74; p < 0.01) and in the IPW analysis (HR = 1.61; 95% CI = 1.31-1.98, p < 0.01), with a significant dose-dependent relationship (HR = 1.55; 95% CI = 1.08-2.22; p = 0.02). This association remained significant in sensitivity analyses. Exploratory analyses indicate that most BZRAs may be associated with an increased mortality among patients hospitalised for COVID-19, except for diazepam, which may be associated with a reduced mortality compared with any other BZRA treatment. CONCLUSIONS: BZRA use may be associated with an increased mortality among patients hospitalised for COVID-19, suggesting the potential benefit of decreasing dose or tapering off gradually these medications when possible.

Does substance use explain social differences in terms of depression? Findings from the Constances cohort.

BACKGROUND: The role of alcohol, tobacco and cannabis use in social differences in terms of depression is poorly understood. METHOD: We have applied mediation and moderated-mediation models stratified by gender to a population-based sample (N = 37,192) of French men and women from the Constances cohort with baseline and follow-up measures of depressive states. We have examined whether socioeconomic status (SES, measured by education and income) differences in the prevalence of depressive states may be explained by both differences in prevalence of substance use according to SES (mediating effects) and differential effects of substance use on depressive state according to SES (moderating effects). RESULTS: In the mediation models, substance use only explained 5.3% and 2.4% of the association between low education and depressive state in men and women respectively, and was not a significant mediator for income. Moderated mediation models showed robust moderation effects of education and income in both men and women. The association of tobacco use with depressive symptoms, which was the only substance for which a mediation effect remained and for which the moderation effect of SES was the strongest, was significantly higher in participants with low SES. LIMITATIONS: The partially cross-sectional nature of the data restricts the possibility of drawing causality with regards to associations between SES and substance use. CONCLUSION: Targeting substance use, particularly tobacco, can especially reduce depression risk in individuals of low SES.

Ensuring mental health care during the SARS-CoV-2 epidemic in France: A narrative review.

OBJECTIVE: The lack of resources and coordination to face the coronavirus epidemic raises concerns for the health of patients with mental disorders in a country where we still have memories of the dramatic experience of famine in psychiatric hospitals during the Second World War. This article aims to propose guidance to ensure mental health care during the SARS-CoV epidemic in France. METHODS: The authors performed a narrative review identifying relevant results in the scientific and medical literature and in local initiatives in France. RESULTS: We identified four types of major vulnerabilities among patients with mental disorders during this pandemic: (1) medical comorbidities that are more frequently found among patients with mental disorders (cardiovascular and pulmonary pathologies, diabetes, obesity, etc.) which are risk factors for severe covid-19 infection; (2) age (the elderly form the population most vulnerable to the coronavirus); (3) cognitive and behavioural disorders, which can hamper compliance with confinement and hygiene measures and finally and (4) psychosocial vulnerability as a result of stigmatization and/or socio-economic difficulties. Furthermore, the mental health healthcare system is more vulnerable than other healthcare systems. Current government plans are poorly suited to psychiatric establishments in a context of major shortages of organizational, material and human resources. In addition, a certain number of structural aspects make the psychiatric institution particularly vulnerable: many beds have been closed, wards have high densities of patients, mental health community facilities are closed, and medical teams are understaffed and poorly trained to face infectious diseases. There are also major issues when referring patients with acute mental disorders to intensive care units. To maintain the continuity of psychiatric care in this pandemic situation, several directions can be considered, in particular with the creation of "COVID+ units". These units are under the dual supervision of a psychiatrist and an internist/infectious disease specialist; all new entrants are placed in quarantine for 14 days; the nursing staff receives specific training, daily medical check-ups and close psychological support. Family visits are prohibited and replaced by videoconference. At the end of hospitalization, in particular for the population of patients in compulsory ambulatory care situations, specific case-management are organized with the possibility of home visits, in order to support patients when they get back home and to help them cope with the experience of confinement, which is liable to induce recurrences of mental disorders. The total or partial closure of community mental health facilities is particularly disturbing for patients, but a regular follow-up is possible with telemedicine and should include the monitoring of suicide risk and psycho-education strategies; developing support platforms could also be very helpful in this context. Private practice psychiatrists also have a crucial role of information towards their patients on confinement and barrier measures, and also on measures to prevent the psychological risks inherent in confinement: maintenance of regular sleep r, physical exercise, social interactions, stress management and coping strategies, prevention of addictions, etc. They should also be trained to prevent, detect and treat early warning symptoms of post-traumatic stress disorder, because their prevalence was high in the regions of China most affected by the pandemic. DISCUSSION: French mental healthcare is now facing a great and urgent need for reorganization and must also prepare in the coming days and weeks to face an epidemic of emotional disorders due to the confinement of the general population.

[Ensuring mental health care during the SARS-CoV-2 epidemic in France: A narrative review]. / Assurer les soins aux patients souffrant de troubles psychiques en France pendant l'épidémie à SARS-CoV-2.

OBJECTIVE: The lack of ressources and coordination to face the epidemic of coronavirus raises concerns for the health of patients with mental disorders in a country where we keep in memory the dramatic experience of famine in psychiatric hospitals during the Second World War. This article aims at proposing guidance to ensure mental health care during the SARS-CoV epidemy in France. METHODS: Authors performed a narrative review identifying relevant results in the scientific and medical literature and local initiatives in France. RESULTS: We identified four types of major vulnerabilities in patients suffering from mental disorders during this pandemic: (1) medical comorbidities that are more frequently found in patients suffering from mental disorders (cardiovascular and pulmonary pathologies, diabetes, obesity, etc.) which represent risk factors for severe infections with Covid-19; (2) age (the elderly constituting the population most vulnerable to coronavirus); (3) cognitive and behavioral troubles which can hamper compliance with confinement and hygiene measures and finally and (4) psychosocial vulnerability due to stigmatization and/or socio-economic difficulties. Furthermore, the mental health healthcare system is more vulnerable than other healthcare systems. Current government plans are poorly adapted to psychiatric establishments in a context of major shortage of organizational, material and human resources. In addition, a certain number of structural aspects make the psychiatric institution particularly vulnerable: many beds are closed, wards have a high density of patients, mental health community facilities are closed, medical teams are understaffed and poorly trained to face infectious diseases. We could also face major issues in referring patients with acute mental disorders to intensive care units. To maintain continuity of psychiatric care in this pandemic situation, several directions can be considered, in particular with the creation of Covid+ units. These units are under the dual supervision of a psychiatrist and of an internist/infectious disease specialist; all new entrants should be placed in quarantine for 14 days; the nurse staff should benefit from specific training, from daily medical check-ups and from close psychological support. Family visits would be prohibited and replaced by videoconference. At the end of hospitalization, in particular for the population of patients in compulsory ambulatory care situations, specific case-management should be organized with the possibility of home visits, in order to support them when they get back home and to help them to cope with the experience of confinement, which is at risk to induce recurrences of mental disorders. The total or partial closure of mental health community facilities is particularly disturbing for patients but a regular follow-up is possible with telemedicine and should include the monitoring of the suicide risk and psychoeducation strategies; developing support platforms could also be very helpful in this context. Private psychiatrists have also a crucial role of information with their patients on confinement and barrier measures, but also on measures to prevent the psychological risks inherent to confinement: maintenance of sleep regularity, physical exercise, social interactions, stress management and coping strategies, prevention of addictions, etc. They should also be trained to prevent, detect and treat early warning symptoms of post-traumatic stress disorder, because their prevalence was high in the regions of China most affected by the pandemic. DISCUSSION: French mental healthcare is now in a great and urgent need for reorganization and must also prepare in the coming days and weeks to face an epidemic of emotional disorders due to the containment of the general population.

Association between depression and anemia in otherwise healthy adults.

OBJECTIVE: It remains debated whether anemia is associated with depression, independently of physical health factors. We report a large-scale cross-sectional study examining this association in adults free of chronic disease and medication from the general population. METHOD: Hemoglobin levels were measured among 44 173 healthy participants [63% men; mean [standard deviation] age = 38.4 (11.1) years] from the 'Investigations Préventives et Cliniques' (IPC) cohort study. Depression was measured with the Questionnaire of Depression 2nd version, Abridged. Logistic regression analyses were performed to examine the association between anemia and depression, while adjusting for a wide range of sociodemographic characteristics and health-related factors (i.e., sex, age, living status, education level, occupational status, alcohol intake, smoking status, physical activity, and body mass index). RESULTS: Depressed participants were significantly more likely to have anemia compared to non-depressed participants, even after adjustment for sociodemographic and health-related variables [odds ratio = 1.36; 95% confidence interval = (1.18; 1.57)]. Anemia prevalence increased with depression severity, suggesting a dose-response relationship (P for trend <0.001). CONCLUSION: In healthy adults from the general population, we found a significant and robust association between depression and anemia. Further studies are needed to assess the longitudinal relationship between both conditions and determine the mechanisms underlying this association.

Mental disorders and risk of suicide attempt: a national prospective study.

Most mental disorders, when examined independently, are associated with an elevated risk for suicide attempt. However, mental disorders often co-occur, and that co-occurrence is well explained by models where specific mental disorders are understood as manifestations of latent dimensions of psychopathology. To date, it remains unclear whether the risk of suicide attempt is due to specific mental disorders, to specific dimensions of psychopathology (that is, internalizing and externalizing dimensions), to a general psychopathology factor or to a combination of these explanations. In a large nationally representative prospective survey, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), we used structural equation modeling to examine the shared and specific effects of Axis I and Axis II disorders on the occurrence of suicide attempts in the general population and among individuals with a lifetime history of suicidal ideation. Effects of mental disorders on the risk of suicide attempt were exerted almost exclusively through a general psychopathology factor representing the shared effect across all mental disorders. Effects of remitted psychiatric disorders on the risk of suicide attempt were fully mediated by current mental disorders. Similar patterns of associations were found in individuals with suicidal ideation. These results held when using different approaches to modeling psychiatric comorbidity. Our findings underscore the importance of adopting dimensional approaches to comorbidity in the study of suicidal behavior. Because mental disorders increase the risk of suicide attempt through a general psychopathology liability, this dimension should be considered as an important therapeutic target to substantially advance suicide prevention.

[Patterns of alcohol consumption in France and their medical and social consequences as seen through the family circle and friends and general practitioners]. / L'alcool en France et ses conséquences médicales et sociales: regard de l'entourage et des médecins généralistes.

BACKGROUND: Data on the frequency of high-risk alcohol consumption and its medical and social consequences in the French general population remain fragmented. Therefore, our aim was two-fold: (i) to assess the prevalence of different patterns of alcohol consumption using the AUDIT-C scale, according to two different perspectives, i.e., that of family circle members or friends, and that of the general practitioners (GPs), and (ii) to examine the prevalence of medical and social consequences associated with alcohol consumption profiles. METHOD: Data were drawn from two national surveys conducted in 2013. Investigators were respectively GPs and family circle members or friends. These surveys were respectively representative of GPs (n=1308) and of the general adult population (n=1018). RESULTS: The 12-month prevalence rates of harmful or at risk alcohol consumption rose respectively to 11.1% in the GPs adult patients and to 11.9% in the general adult population. The majority of participants with "at risk" alcohol consumption presented with significant social and medical consequences. Thus, more than seven out of ten participants with chronic at risk consumption endorsed significant negative social event potentially associated with alcohol like withdrawal of driving licence, getting divorced or separated, and losing friends. Over 10% of these participants had liver disease and diabetes mellitus, more than 30% increased blood pressure and nearly 50% anxiety disorder or major depression. Following adjustments for sociodemographic characteristics and alcohol treatment, prevalences of numerous social and medical consequences significantly differed between alcohol-dependent participants, chronic at risk consumers and episodic at risk consumers. CONCLUSIONS: Our results suggest that more than one adult out of ten in France showed during the past year harmful or "at risk" alcohol consumption, which appears insufficiently detected and treated. In addition, the majority of at risk alcohol consumers already presents with serious medical and social consequences. Furthermore, we found that AUDIT-C scale can identify different patterns of alcohol consumption, which form a continuum in terms of medical and social consequences. Our study indicates the need for vigorous education efforts for the public, professionals and policy makers about alcohol use disorders, to encourage help-seeking among those who cannot stop drinking despite considerable harm to themselves and others, and ideally to promote early detection and treatment of individuals with at risk alcohol consumption before the development of social and medical consequences and alcohol dependence.

[Excessive alcohol consumption: what is the burden on natural caregivers?]. / La consommation excessive d'alcool: un lourd fardeau pour l'entourage.

BACKGROUND: Data on the natural caregivers burdened by the excessive consumption of alcohol by members of the family circle or friends in the general population are lacking. Therefore, our aim was twofold: (i) to assess the burden of individuals with excessive alcohol consumption on natural caregivers and (ii) to examine the factors explaining the association between alcohol consumption and the level of burden. METHOD: Data were derived from a national representative survey of the French adult population, conducted in 2013, that involved 1018 participants who had in their close environment a person consuming excessive amounts of alcohol. The level of burden was assessed using the Zarit Burden Scale (ZBI). RESULTS: The average score of the ZBI was 28.5 (SE=16.0). The average volume of alcohol consumed per day, heavy drinking days, as well as the consumers' profiles defined by the AUDIT-C were significantly associated with the level of burden. Following adjustments for the participants' characteristics and for the closeness between participants and individuals with excessive consumption, these associations remained significant. Following adjustments for these variables as well as demographic, social, behavioral and medical characteristics of individuals with excessive consumption, the associations between the level of burden and respectively consumers' profiles and heavy drinking days remained significant. At last, following adjustments for social, behavioral and medical characteristics of individuals with excessive consumption and for the closeness between them and participants, only the association between heavy drinking days and the level of burden remained significant. CONCLUSIONS: One out of five participants having in their close environment a person consuming excessive amount of alcohol reported an important burden. The association between the individuals' alcohol intake and the level of burden for natural caregivers was mainly influenced by social, behavioral and medical consequences of alcohol consumption and by the physical and affective proximity between them. Furthermore, we found that the AUDIT-C scores could define alcohol consumers' profiles which form a continuum in terms of the level of burden, even after adjustments for potentially confounding variables. At last, the high prevalence of psychological complications in participants calls for greater recognition of the natural caregivers' burden in the management of patients with alcohol dependence.

Mental health and substance use among self-employed lawyers and pharmacists.

BACKGROUND: Self-employed workers experience occupational stress and may suffer from various mental health disorders. AIMS: To assess the mental health, substance use and risk factors for psychological distress in a sample of self-employed lawyers and pharmacists. METHODS: A cross-sectional study, using self-completion postal questionnaires, of lawyers and pharmacists. The General Health Questionnaire-28 (GHQ-28) was used as a measure of current mental health, and some additional questions evaluated alcohol, tobacco and psychotropic drug use and somatic morbidity. A multiple regression model was used to analyse the respective impact of the different risk factors on psychological suffering. RESULTS: A total of 1282 lawyers and 1153 pharmacists participated representing response rates of 36 and 35%, respectively. According to the GHQ-28 score, the rate of psychological distress was high in the sample overall, especially in lawyers (52 versus 47% in pharmacists, P < 0.05). According to the mean number of drinks per day, 16% of the lawyers and 13% of the pharmacists reported alcohol misuse, and lawyers were twice as likely as pharmacists to smoke (26 versus 13%, P < 0.001). Higher GHQ-28 scores were associated in lawyers with female gender, being widowed or divorced, smoking and using anxiolytic medication and in pharmacists with being younger, smoking, alcohol abuse and anxiolytic and hypnotic use. CONCLUSIONS: In our sample of these self-employed groups, both pharmacists and lawyers reported a high rate of psychological distress.

Poor longitudinal continuity of care is associated with an increased mortality rate among patients with mental disorders: results from the French National Health Insurance Reimbursement Database.

BACKGROUND: Research on the impact of the continuity of care (COC) on health outcomes in patients with mental illness is limited. This observational study examined whether the longitudinal COC is associated with a decreased likelihood of death among patients with mental disorders in the French general population. METHOD: Data were derived from the French National Health Insurance (NHI) reimbursement database. Patients with any mental disorder who visited a psychiatrist at least twice within 6 months were included. The primary endpoint was death by all causes. We measured longitudinal COC with a psychiatrist twice a year between 2007 and 2010, using the COC index developed by Bice and Boxerman. The COC index was analysed as a time-dependent variable in a survival analysis after adjustments for age, gender and stratifying on comorbidities and social status. RESULTS: Among 14,515 patients visiting a psychiatrist at least twice in 6 months and tracked over 3 years, likelihood of death was significantly lower in patients with higher continuity of care (hazard ratio for an increase in 0.1 of continuity, adjusted for age, sex, and stratified on comorbidities and social status: 0.83 [0.83-0.83]), particularly in those with bipolar disorder, major depressive disorder and schizophrenia. CONCLUSION: Improving longitudinal continuity of care in mental health care may contribute to substantially decrease mortality.