Disentangling the Link Between Mindfulness and Dissociation in PTSD: The Mediating Role of Attention and Emotional Acceptance.

INTRODUCTION: A number of studies have investigated the relationship between mindfulness and dissociation and suggested that mindfulness-based interventions could be effective in the treatment of dissociative symptoms. A recent study in healthy volunteers found that attention and emotional acceptance mediates this relationship. However, no study has yet been performed among a clinical sample to assess this association. METHOD: We recruited 90 patients (76 women) suffering from Posttraumatic Stress Disorder (PTSD). They completed self-report questionnaires to measure PTSD, dissociation, emotion regulation difficulties, childhood trauma, mindfulness abilities and cognitive abilities. RESULTS: We found that mindfulness abilities, emotional difficulties, dissociation and attention-concentration were all related to each other. Using a step-by-step approach and bootstrapping techniques, we found a significant indirect effect of mindfulness abilities on dissociation through non-acceptance (confidence interval 95%=-.14 to -.01) and attentional difficulties (confidence interval 95%=-.23 to -.05). CONCLUSION: Patients with higher levels of dissociative symptoms have less capacity for mindfulness. Our results support Bishop et al.'s model proposing that attention and emotional acceptance are the two active components of mindfulness. To extend our findings, clinical trials are required to evaluate a causal relationship and the effectiveness of mindfulness-based interventions for patients suffering from dissociation.

Development and validation of the Symptomatic Transdiagnostic Test (S2T).

INTRODUCTION: The categorical approach in psychiatry has received many criticisms. Modern research tends to develop a transdiagnostic approach. However, transdiagnostic works lack an overall understanding and focus mainly on anxiety and depression. The aim of the present study was to develop an easy to use tool to evaluate multiple dimensions opening the way for further research in the transdiagnostic approach. This will allow researchers to quickly assess the efficacy of psychotherapeutic interventions on multiple psychopathological dimensions. METHOD: First, we identified the main symptoms of psychopathology in a sample of mental healthcare workers. Second, we developed the Symptomatic Transdiagnostic Test (S2T) to assess the main symptoms of psychopathology. Third, we evaluated its psychometric properties (exploratory and confirmatory factor analysis, internal consistency) in three non-clinical samples and one clinical sample. RESULTS: The 66-item S2T included eleven factors referring to: i) negative thoughts and mood; ii) psycho-traumatic and maladaptive symptoms; iii) addiction symptoms; iv) disturbed eating behavior; v) disturbed perception and behavior; vi) panic and agoraphobia; vii) emotional lability; viii) dejection; ix) neurodevelopmental manifestations; x) anxiety and xi) psychic hyperactivity. We found a high internal consistency for the general scale (α=0.96) and the subscales. We found a good concurrent validity. As expected, we found higher levels of symptoms within the clinical population as compared to the non-clinical samples, except for addiction symptoms and disrupted eating behavior. We found negative associations between the symptomatic dimensions and psychological skills. CONCLUSION: The S2T is a relevant tool for clinicians and researchers to assess the psychopathological profile. The main psychopathological symptoms are negatively related to the psychological skills.

Validation of the French version of the Emotion and Regulation Beliefs Scale (ERBS) and Dissociation Belief Scale (DBS).

INTRODUCTION: Dissociation is a recurrent symptom of post-traumatic stress disorder (PTSD) and is associated with emotional dysregulation. Beliefs about emotions seem to be involved in emotional dysregulation but have not been studied in relation to dissociation. Likewise, there is currently little empirical evidence of beliefs about dissociation. The aims of the study were to validate psychometric tools assessing these beliefs, to assess their role in dissociation, and to explore the mediating role of emotional dysregulation and beliefs about dissociation in the relationship between beliefs about emotion and dissociation. METHOD: We recruited a sample from the general population (n=1009) and a sample of patients with PTSD (n=90). All participants completed self-report questionnaires to evaluate symptoms of PTSD (PTSD Checklist/Impact of Event Scale, PCL-5/IES-6), dissociation (Dissociative Experiences Scale, DES), difficulties in emotion regulation (Difficulties in Emotion Regulation Scale, DERS), beliefs about dissociation (Dissociation Beliefs Scale, DBS), and beliefs about emotion (Emotion and Regulation Beliefs Scale, ERBS). RESULTS: The questionnaires used to assess the beliefs about emotion (ERBS) and dissociation (DBS) had good psychometric properties. Dissociation was positively associated with positive and negative beliefs about dissociation and with negative beliefs about emotions in both the clinical and non-clinical groups. The relationship between beliefs about emotions and dissociation was mediated by emotional dysregulation and positive beliefs about dissociation in both groups. CONCLUSION: The ERBS and DBS are effective tools to assess beliefs. Beliefs about emotion and dissociation seem to be involved in dissociative manifestations in both clinical and non-clinical individuals.

Inhibition, Attentional Control and Binding Abilities in Relation to Dissociative Symptoms Among PTSD Patients.

INTRODUCTION: The relationship between dissociation and cognitive abilities remains controversial. Empirical studies have reported positive, negative and non-existent associations between dissociation and cognition. These inconsistent results may be due to the fact that the studies focused mainly on trait dissociation, while dissociation is not stable but transient. After validating the French version of the Clinician Administered Dissociative States Scale (CADSS), the aim of the present study was to evaluate the relationship between state dissociation and cognitive abilities. METHOD: We recruited 83 patients suffering from post-traumatic stress disorder (PTSD) and assessed them twice. At T1, they performed a neutral Stroop task and a neutral binding task. At T2 (one to three weeks later), after a script-driven dissociative induction, they performed an emotional Stroop task and an emotional binding task. Between the two sessions, they completed questionnaires at home evaluating PTSD severity, trait dissociation and cognitive difficulties. State dissociation was assessed at T1 and T2 using the Clinician-Administered Dissociative States Scale (CADSS). RESULTS: We found good psychometric properties of the French version of the CADSS. After inducing dissociation, significantly lower attentional performance was found among patients with than without dissociative reactions. We found a significant positive correlation between state dissociation and increased attention and memory difficulties after induction. CONCLUSION: The French version of the CADSS is a reliable and valid tool to assess state dissociation, which is correlated with attentional difficulties. Attentional training is recommended to help patients control dissociative symptoms.

Positive and negative correlates of suicidal ideations and behaviors in the emergency department of a university hospital in Beirut: A cross-sectional comparative study.

This study aims to identify the prevalence and correlates of current suicidal ideations and past suicidal behaviors among psychiatric emergencies. A cross-sectional comparative study was conducted using the Ask Suicide Screening Questions (ASQ) as a screening tool that targeted all patients presenting for a psychiatric emergency in a university hospital in Beirut during a four-month period. One hundred and three patients of all age groups have been divided into a group of patients with a positive suicidal screening (n=67, 65%), and another one with a negative suicidal screening (n=36, 35%). Suffering from a personality disorder was found to be a positive correlate of suicide screening (OR: 21.6, 95% CI: 2.6-179.0). Female gender (OR: 4.5, 95% CI: 1.6-13.2) and an elevated number of previous hospitalizations were found to be positive correlates of past suicidal attempts. These correlates should be assessed in the emergency room department (ER) to prevent any subsequent suicidal behavior.

Interaction of mediation and moderation effects of positivity, cognitive fusion, brooding and mindfulness.

INTRODUCTION: Currently, cognitive behavior therapy (CBT) targets multiple cognitive processes. However, only a few studies have focused on the interaction among these processes. Preliminary studies have identified a moderation effect of rumination on the link between thought content and emotional difficulties, and a mediation effect of ruminations on the link between mindfulness and emotional difficulties. METHOD: We recruited 236 participants (185 women) who consented online to participate by choosing to either continue with the study or decline to proceed. They completed a battery of questionnaires online, namely Positivity scale, General Health Questionnaire, Rumination Response Scale, Five Facet Mindfulness Questionnaire and Cognitive Fusion Questionnaire. RESULTS: All cognitive processes were significantly correlated with emotional distress. Step-by-step linear regression analysis revealed that positivity, cognitive fusion and brooding were significant independent predictors of emotional difficulties. Bootstrapping analysis confirmed that cognitive fusion and brooding mediate the link between mindfulness and depression and anxiety-insomnia. They also demonstrated that cognitive fusion moderates the link between positivity and depression but not anxiety-insomnia. CONCLUSION: Cognitive processes interact with each other. Taken together, these results suggest that combining cognitive interventions is not useful and that different cognitive interventions may be selected depending on the patient's profile.

Psychological consequences of the COVID-19 pandemic: A qualitative study.

Multiple psychological health problems related to the COVID-19 pandemic among both the general public and health-care workers have been identified in the scientific literature. However, most studies used quantitative methods with scales selected on the basis of the researchers' pre-established knowledge derived from the experience of other situations and which can therefore induce biases. The dual aim of the present study was to explore qualitatively the perceived psychological consequences of lockdown on members of the general public and the perceived psychological consequences of COVID-19 on health-care workers. We recruited 241 participants from the general public and 120 health-care workers. They consented online to participate and completed open-ended questions evaluating the consequence of the health crisis on their life as a couple, on their friendships, family life, work, studies, psychological health, stress, and vision of the future. Finally, participants were asked to add any further consequences that had not been mentioned. We used double coding to process the data. We identified five main themes among the participants from the general public: improved and maintained social relationships, deterioration of health, improved health, personal growth, and lack of direct social contact. We also identified five main issues among the health-care workers: psychological and emotional impact, adjusting, negative impact on work, worries, and uncertainty about the future. The results confirmed the existence of psychological health problems related to the COVID-19 pandemic. They also highlighted positive consequences. Health-care workers tended to perceive more negative consequences than the participants from the general public.

Social representations of intellectual disability; a comparison between cultures.

OBJECTIVES: People with Intellectual disability consistently appear to be one of the most looked-down upon and repressed subgroups of society in many cultures. The main aim of this study was to compare social representations of intellectual disability in its various aspects between different cultures. MATERIALS AND METHODS: The study was conducted in four different sites: Beirut-Lebanon, Algiers-Algeria, Tours-France and Namur-Belgium. Participants were asked to complete a questionnaire evaluating social representations of intellectual disability. RESULTS: A total of 755 participants consented to take part in the study. Gender only affected social representations in the Lebanese population. Overall, Algerians appeared to have the least positive social representations and Lebanon to have more positive attitudes, while France and Belgium tended to have the most favourable representations. DISCUSSION AND CONCLUSIONS: Findings highlight the imbalance between a European and a non-European country showing the importance of developing tailored interventions to improve general attitudes towards intellectual disability.

Childhood trauma increases vulnerability to attempt suicide in adulthood through avoidant attachment.

BACKGROUND: Childhood trauma and affective disorders are known risk factors for adult suicidal behavior. Studies have shown a mediating effect of insecure attachment on the effect of childhood trauma and suicidal behavior but so far it is not clear whether this effect is related to an attachment dimension (anxiety, avoidance). AIM: The present study sought to examine the mediating effect of attachment anxiety and avoidance on suicidal behavior. METHODS: We analyzed data on childhood trauma, attachment style, depression severity, presence of prior suicide attempts and current suicide ideation from 96 patients diagnosed with an affective disorder. Two mediation analyses were conducted to assess the effect of childhood trauma on 1) prior suicide attempts and 2) current suicidal ideation through its effect on attachment. RESULTS: We found that childhood trauma had a complete mediated effect on the presence of prior suicide attempts through its effect on avoidant attachment (a1b1 = 0.0120, 95%-CI [0.0031, 0.0276]). However, only emotional abuse had a direct influence on suicidal ideation (c' = 0.0273, p < 0.01) without any indirect effect of anxious or avoidant attachment. LIMITATIONS: Variables were not assessed in a prospective way and sample size was small. CONCLUSIONS: Our findings suggest that individuals with avoidant attachment and childhood trauma are likely to present a high suicide risk. Since avoidant attachment is associated with altered perceptions and eventual rejection of social support, we recommend to screen for attachment early and to engage patients in therapeutical approaches focusing on the client-therapist alliance.

Validation of the French ADNM-20 in the assessment of emotional difficulties resulting from COVID-19 quarantine and outbreak.

BACKGROUND: Multiple psychological consequences of the COVID-19 outbreak and quarantine have been described. However, there is a lack of global conceptualization. We argue that the stressful aspects of the situation, the multiple environmental consequences of the outbreak, and the diversity of symptoms observed in such a situation, suggest that Adjustment disorder (AD) is a promising way to conceptualize the psychological consequences of the outbreak and quarantine. The first aim of the study was to validate the French version of the ADNM. The second aim was to set out adjustment difficulties resulting from COVID-19 outbreak and quarantine. METHOD: We recruited 1010 (840 women, 170 men) who consented online to participate. They filled out the French ADNM, visual analogic scales, HADS, IES, and the COPE, to evaluate coping strategies. RESULTS: We confirmed the factor structure of the ADNM and we found good psychometric properties. We found that 61.3% of participants presented an adjustment disorder related to COVID-19 outbreak. We found multiple risk factors and protective factors to AD due to quarantine and outbreak. We also identified the coping strategies negatively and positively associated with AD. CONCLUSION: Adjustment disorder is a relevant concept to understand psychological manifestations caused by quarantine and outbreak. The French ANDM has good psychometric properties to evaluate such manifestations. The association between coping strategies and AD symptoms suggest that CBT may be the best intervention to help people suffering from AD.

[Interictal psychosis of epilepsy]. / Les psychoses épileptiques interictales.

Interictal psychosis (IIP) refers to psychosis that occurs in clear consciousness in persons with epilepsy (PWE) with temporal onset not during or immediately following a seizure. The pooled prevalence estimate of psychosis in PWE is 5.6%. PWE and schizophrenia have very high mortality, and more than one in four persons with both disorders die between the age of 25 and 50years. IIP can manifest in brief or chronic forms. The chronic forms of IIP may closely resemble schizophrenia. However, some authors have described the typical presence of persecutory and religious delusions, sudden mood swings and the preservation of affect, as well as rarity of negative symptoms and catatonic states, but these differences remain controversial. Typically, IIP starts after many years of active temporal lobe epilepsy. Several epilepsy-related variables are considered pathogenically relevant in IIP including epilepsy type and seizure characteristics. Risk factors for developing IIP are family history of psychosis, learning disability, early age of onset of epilepsy, unilateral or bilateral hippocampal sclerosis, history of status epilepticus, history of febrile seizures, and poorly controlled temporal lobe epilepsy. In patients with epilepsy and psychosis, structural imaging studies have shown several relevant changes leading to conflicting findings. Altered neuronal plasticity and excitability have been described in epilepsy and psychotic disorders. Neuropathological data suggest that IIP are not the result of classic epileptic pathology of the temporal lobe. Forced normalization (FN) and alternating psychosis refer to patients with poorly controlled epilepsy (focal or generalized) who have had psychotic episodes associated with remission of their seizures and disappearance of epileptiform activity on their EEGs. FN mainly occurs in temporal lobe epilepsy when patients have frequent seizures that are abruptly terminated triggered by an antiepileptic drug, vagus nerve stimulation or epilepsy surgery. Treatment is based on withdrawal of the responsible drug, and by transient use of antipsychotics for acute symptomatic control on a case-by-case basis. FN is an entity whose pathophysiology remains uncertain. Antiepileptic drugs (AEDs) may sometimes induce psychotic symptoms and psychosis could be a direct effect of the AEDs. IIP has been reported more frequently following the initiation of zonisamide, topiramate, and levetiracetam when compared with other antiepileptic drugs. However, AEDs do not appear to be the only determinant of IIP. The management of IIP requires a multidisciplinary approach with early involvement of a liaison psychiatrist associated with a neurologist. IIP are underdiagnosed and mistreated. Existing recommendations are extrapolated from those established for the treatment of schizophrenia with some additional guidance from expert opinions. A two-step procedure, not necessarily consecutive, is suggested. The first step requires reevaluation of the antiepileptic treatment. The second step requires initiation of atypical neuroleptics. Antipsychotic drugs should be selected with consideration of the balance between pharmacological profiles, efficacy, and adverse effects. Regarding pharmacokinetic interactions, AEDs with inducing properties reduce the blood levels of all antipsychotics. It is important to consider implications of combining neuroleptics and AEDs with a similar spectrum of side effects. Regarding the duration of treatment, IIP episodes are more likely to be recurrent than in primary schizophrenia. In practice, atypical neuroleptics with few motor side effects such as risperidone can be used as first choice, given the low propensity for drug-drug interactions and the low seizure risk, with the added suggestion to start low and go slow. Clozapine could be prescribed in selected cases.

[Health professionals facing the coronavirus disease 2019 (COVID-19) pandemic: What are the mental health risks?] / Les professionnels de santé face à la pandémie de la maladie à coronavirus (COVID-19) : quels risques pour leur santé mentale ?

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has caused major sanitary crisis worldwide. Half of the world has been placed in quarantine. In France, this large-scale health crisis urgently triggered the restructuring and reorganization of health service delivery to support emergency services, medical intensive care units and continuing care units. Health professionals mobilized all their resources to provide emergency aid in a general climate of uncertainty. Concerns about the mental health, psychological adjustment, and recovery of health care workers treating and caring for patients with COVID-19 are now arising. The goal of the present article is to provide up-to-date information on potential mental health risks associated with exposure of health professionals to the COVID-19 pandemic. METHODS: Authors performed a narrative review identifying relevant results in the scientific and medical literature considering previous epidemics of 2003 (SARS-CoV-1) and 2009 (H1N1) with the more recent data about the COVID-19 pandemic. We highlighted most relevant data concerning the disease characteristics, the organizational factors and personal factors that may contribute to developing psychological distress and other mental health symptoms. RESULTS: The disease characteristics of the current COVID-19 pandemic provoked a generalized climate of wariness and uncertainty, particularly among health professionals, due to a range of causes such as the rapid spread of COVID-19, the severity of symptoms it can cause in a segment of infected individuals, the lack of knowledge of the disease, and deaths among health professionals. Stress may also be caused by organizational factors, such as depletion of personal protection equipment, concerns about not being able to provide competent care if deployed to new area, concerns about rapidly changing information, lack of access to up-to-date information and communication, lack of specific drugs, the shortage of ventilators and intensive care unit beds necessary to care for the surge of critically ill patients, and significant change in their daily social and family life. Further risk factors have been identified, including feelings of being inadequately supported, concerns about health of self, fear of taking home infection to family members or others, and not having rapid access to testing through occupational health if needed, being isolated, feelings of uncertainty and social stigmatization, overwhelming workload, or insecure attachment. Additionally, we discussed positive social and organizational factors that contribute to enhance resilience in the face of the pandemic. There is a consensus in all the relevant literature that health care professionals are at an increased risk of high levels of stress, anxiety, depression, burnout, addiction and post-traumatic stress disorder, which could have long-term psychological implications. CONCLUSIONS: In the long run, this tragic health crisis should significantly enhance our understanding of the mental health risk factors among the health care professionals facing the COVID-19 pandemic. Reporting information such as this is essential to plan future prevention strategies. Protecting health care professionals is indeed an important component of public health measures to address large-scale health crisis. Thus, interventions to promote mental well-being in health care professionals exposed to COVID-19 need to be immediately implemented, and to strengthen prevention and response strategies by training health care professionals on mental help and crisis management.

[Representation of Female speakers at French psychiatry conferences]. / Sous-représentation des femmes intervenant dans les congrès de psychiatrie en France.

OBJECTIVES: First, the main objective was to describe the evolution of the representation of women at the two main conferences of psychiatry in France-Encephale and French Congress of Psychiatry-from 2009 to 2018, and to compare it to the evolution of the representation of women among French psychiatrists. Second, we aimed to describe this evolution within the themes of general psychiatry, child psychiatry and addictology and compare it to the evolution of the number of adult psychiatrists, child psychiatrists and addictologists in France, and likewise to describe this evolution within the organizing and scientific committees, chairpersons and symposia of pharmaceutical companies at these conferences. We hypothesized that women are underrepresented at French speaking psychiatry conferences and sought to quantify this. METHODS: Programs from the 2009-2018 meetings of the Encephale and the French Congress of Psychiatry were included in analysis. We collected for each intervention information about the sex of the participant, the type of the intervention (i.e., speaker, moderator, chairperson) and its main theme (i.e., general psychiatry, child psychiatry, addictology, pharmaceutical company symposium). We also collected from the National Council of the French Medical Association the number of male and female psychiatrists active in France from 2009 to 2018, and the number of male and female psychiatrists who have validated a specific competence in child psychiatry and addictology. The average proportion of women at the two conferences per year was obtained by weighting the average by the different numbers of speakers at the two conferences. À Chi-squared test was used to compare the evolution of the proportion gap over time. RESULTS: The proportion of women speaking at these conferences ranged from 25 % in 2009 to 32 % in 2018. Among French psychiatrists, the proportion of female psychiatrists increased from 46 % to 51 %, with a higher proportion of women since 2016. In that ten year span, the difference between the proportion of females amongst the French psychiatrists and the speakers at these French conferences varied between 21 % in 2009 and 17 % in 2016, with a higher proportion of female psychiatrists registered at the National Council of the French Medical Association than female speakers at these conferences. The proportion of female speakers at these conferences tends to increase more quickly than the proportion of active female psychiatrists. The proportion of women speaking on child psychiatry topics (41-59 %) is much higher for each year than those of women speaking on general psychiatry topics (24-33 %) or on addictology topics (10-39 %). Also, the proportion of women speaking on child psychiatry and addictology topics tends to increase more quickly than the proportion of active female child psychiatrists and addictologists in France, while the proportion of women speaking on general psychiatry topics tends to increase more slowly than the proportion of active female psychiatrists for adults in France. The proportion of female speakers is very low in symposia of pharmaceutical companies (7-24 %), members of organizing and scientific committees (13-33 %) and chairpersons (19-28 %), although it increases sfrom 2009 to 2018. PERSPECTIVES: This observation of the underrepresentation of women at French psychiatry conferences could make it possible to achieve greater equity. This count could be continued in the next few years and could raise the question of the inclusion of parity in the policy of psychiatric conferences, both among the speakers and among the scientific and organizational committees. Higher exposure of women to conferences would reduce the Matilda effect, defined by minimizing women's contribution to research.

Adherence to treatment guidelines in clinical practice for using electroconvulsive therapy in major depressive episode.

BACKGROUND: ECT is the most effective treatment of major depressive episode (MDE) but remains a neglected treatment. The French Society for Biological Psychiatry and Neuropsychopharmacology aimed to determine whether prescribing practice of ECT followed guidelines recommendations. METHODS: This multicenter, retrospective study included adult patients with major depressive disorder (MDD) or bipolar disorder (BD), who have been treated with ECT for MDE. Duration of MDE and number of lines of treatment received before ECT were collected. The reasons for using ECT, specifically first-line indications (suicidality, urgency, presence of catatonic and psychotic features, previous ECT response, patient preference) were recorded. Statistical comparisons between groups used standard statistical tests. RESULTS: Seven hundred and forty-five individuals were included. The mean duration of MDE before ECT was 10.1 months and the mean number of lines of treatment before ECT was 3.4. It was significantly longer for MDD single episode than recurrent MDD and BD. The presence of first-line indications for using ECT was significantly associated to shorter duration of MDE (9.1 vs 13.1 months, p<0.001) and lower number of lines of treatment before ECT (3.3 vs 4.1, p<0.001). LIMITATIONS: This is a retrospective study and not all facilities practicing ECT participated that could limit the extrapolation of the results. CONCLUSION: Compared to guidelines, ECT was not used as first-line strategy in clinical practice. The presence of first-line indications seemed to reduce the delay before ECT initiation. The improvements of knowledge and access of ECT are needed to decrease the gap between guidelines and clinical practice.

[GABAergic approach of postpartum depression: A translational review of literature]. / Approche GABAergique de la dépression du post-partum : une revue critique translationnelle.

INTRODUCTION: Prevalence of postpartum depression (PPD) ranges from 10 to 15 % of parturients. The impact of the PPD is major on the maternal bond and the health of both mother and child. Its physiopathological mechanisms appear to differ from other types of depression. Today, pharmacotherapy is based on nonspecific treatment, and recent therapeutic advances in this field require a comprehensive approach of the implication of the GABAergic system in the development of PPD. Neurosteroid levels during pregnancy and after parturition and the GABA-A-r modulation are thought to be involved in PPD. OBJECTIVE: To evaluate if the GABAergic approach is relevant in postpartum depression management. METHODS: We conducted a systematic review of literature based on the MEDLINE database with the following Medical Subject Headings (MeSH): "postpartum depression", "GABA", "ganaxolone", "brexanolone", "allopregnanolone", prior to September 2019. We selected articles in English: preclinical and clinical studies, literature review, observational and therapeutic studies. RESULTS: Preclinical models (mouse and rat) show changes in GABAergic inhibition in the peripartum period and correlation between allopregnanolone and GABA-A-r plasticity. This plasticity in the peripartum period maintains levels of inhibition adapted despite increased neurosteroid levels. KO models for the GABA-A-r δ subunit develop depression and anxiety symptoms in the postpartum period, and a change in the expression of the gene coding for the GABA-R alpha-4 subunit was found. Artificial inhibition of progesterone metabolism during post-partum increased depression symptoms. GABAergic fluctuation seems to be interrelated with other systems such as those of oxytocins. A synthetic neurosteroid (SGE-516) was tested on mouse models of PPD, KO for δ-GABA-A-r or KCC2, and showed decreased depressive symptoms and better mothering. Clinical studies confirm neurosteroid fluctuation and changes in the GABAergic system during the peripartum period. Allopregnanolone is the neurosteroid the most studied in PPD, and it is elevated in the brain during the pregnancy. Studies disagree on the presence of significant differences in allopregnanolone plasma levels during pregnancy or postpartum between women with PPD or not. Women with a history of PPD have greater susceptibility to neurosteroid withdrawal. Imagery and genetical data also show a link between allopregnanolone and PPD. The GABA-A-r may not recover in time following a reduced number during pregnancy, and this mismatch between neurosteroid levels and their receptor may trigger PPD. Several randomized controlled trials investigated brexanolone administrated IV, a synthetic formulation of allopregnanolone, and demonstrated a rapid and well tolerated reduction in depressive symptoms. In March 2019 brexanolone obtained FDA approval in PPD indication under the name Zulresso. However, there are differences in the time of beginning of PPD, which could constitute different subgroups of this disease, and which physiopathology could respond to different mechanisms. Prenatal depression does not respond to a GABAergic approach, but women without any risk factor or previous mood disorder developing PPD in the weeks following childbirth could be particularly responsive to this kind of treatment. CONCLUSION: Disability to modulate GABA-A-r expression during pregnancy and restore its previous state after parturition appears to trigger PPD. The GABAergic system is a promising pharmacotherapy target. From preclinical to clinical studies for about twenty years the GABAergic system has been incriminated and targeted in this challenging mental disease.

Clinical guidelines for the management of treatment-resistant depression: French recommendations from experts, the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental.

BACKGROUND: Clear guidance for successive antidepressant pharmacological treatments for non-responders in major depression is not well established. METHOD: Based on the RAND/UCLA Appropriateness Method, the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental developed expert consensus guidelines for the management of treatment-resistant depression. The expert guidelines combine scientific evidence and expert clinicians' opinions to produce recommendations for treatment-resistant depression. A written survey comprising 118 questions related to highly-detailed clinical presentations was completed on a risk-benefit scale ranging from 0 to 9 by 36 psychiatrist experts in the field of major depression and its treatments. Key-recommendations are provided by the scientific committee after data analysis and interpretation of the results of the survey. RESULTS: The scope of these guidelines encompasses the assessment of pharmacological resistance and situations at risk of resistance, as well as the pharmacological and psychological strategies in major depression. CONCLUSION: The expert consensus guidelines will contribute to facilitate treatment decisions for clinicians involved in the daily assessment and management of treatment-resistant depression across a number of common and complex clinical situations.

Clinical guidelines for the management of depression with specific comorbid psychiatric conditions French recommendations from experts (the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental).

BACKGROUND: Recommendations for pharmacological treatments of major depression with specific comorbid psychiatric conditions are lacking. METHOD: The French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental developed expert consensus guidelines for the management of depression based on the RAND/UCLA Appropriatneness Method. Recommendations for lines of treatment are provided by the scientific committee after data analysis and interpretation of the results of a survey of 36 psychiatrist experts in the field of major depression and its treatments. RESULTS: The expert guidelines combine scientific evidence and expert clinician's opinion to produce recommendations for major depression with comorbid anxiety disorders, personality disorders or substance use disorders and in geriatric depression. CONCLUSION: These guidelines provide direction addressing common clinical dilemmas that arise in the pharmacologic treatment of major depression with comorbid psychiatric conditions.

[Klinefelter'syndrome: A predisposition to sexual crime?] / Le syndrome de Klinefelter : une prédisposition au crime sexuel ?

BACKGROUND: Several studies have reported over-representation of psychiatric disorders among patients with Klinefelter' Syndrome (KS), with forensic complications. OBJECTIVE: Consider determinants of sexual assault in patient with KS. REVIEW: In this work, we present the case of Jules, 23 years old, with KS, benefiting from steroid replacement therapy, convicted of rape of a minor and evaluated in this context. We question here the role of his genetic pathology and of his hormonal treatment in this sexual assault. FINDINGS: According to evidence from the literature, it is not possible to determine with certainty the fair value of each factor and their impact on the occurrence of the sexual criminal act. Indeed, although the crime rate among KS subjects is higher than in the general population, the majority of them have never been in trouble with the law; moreover, these subjects were no more likely to commit violent sexual acts than were criminals without KS. As for hormonal treatment, it seems that testosterone is better viewed as a facilitator of initiating an aggressive response than as a primary inductor. CONCLUSION: In conclusion, the onset of sexual violence that accompanied the introduction of hormonal treatment into a patient with KS suggests an effective involvement of steroid replacement therapy, even small, in the criminal act. This must incite clinicians to extreme prudence and to take account of multidisciplinary expertise (psychiatrist, endocrinologist) in order to reconsider the continuation of the treatment in this particular forensic context. Finally, we discuss other factors that can precipitate such a violent act.

Validation of the Arabic version of the MADRS scale among Lebanese patients with depression.

AIM: To use the Arabic version of the MADRS in Lebanese depressed patients, check its validity and reproducibility compared to other versions of the questionnaire and assess risk factors affecting the total MADRS score. METHODS: This case-control study, performed between September 2016 and January 2017, included 200 patients (100 patients, 100 controls). The questionnaire included two parts, the first one concerning the socio-demographic characteristics another one that included the Montgomery-Asberg Depression Rating Scale (MADRS) questions, which was translated from English to Arabic through an initial translation and back translation process. RESULTS: The MADRS scale items converged over a solution of one factor that had an Eigenvalue over 1, explaining a total of 83.90% of the variance. A Kaiser-Meyer-Olkin measure of sampling adequacy of 0.953 was found, with a significant Bartlett's test of sphericity (P<0.001). A stepwise linear regression, using the total MADRS score as continuous variable, showed that a university level of education would significantly decrease the total MADRS score by 20 points (beta=-20.02, CI: from -26.337 to -13.709, P<0.001). Unemployment was significantly more associated with an increase in the total MADRS score level by 10.23 points (beta=10.23, CI: 3.944-16.526, P=0.002). CONCLUSION: This study shows that the Arabic version of the MADRS has promising psychometric properties, and thus it is a good tool to use for the diagnosis of patients with depression. Based on this study, health care professionals and researchers can readily use the MADRS questionnaire to estimate the overall severity of depression among psychiatric patients in Lebanon.