Optimizing co-prescription of clozapine and antiseizure medications: a systematic review and expert recommendations for clinical practice.

INTRODUCTION: Antiseizure medication (ASM) add-on to clozapine may be efficient to target clozapine-resistant mood or psychotic symptoms or clozapine-related adverse drug reactions (ADR) such as seizures. We aimed to synthesize the information relevant for clinical practice on the risks and benefits of clozapine-ASM co-prescription. AREAS COVERED: Articles were identified with MEDLINE, Web of Sciences and PsycINFO search from inception through October 2023. The review was restricted to ASM with mood-stabilizing properties or with potential efficacy for resistant psychotic symptoms (valproate (VPA), lamotrigine, topiramate, carbamazepine, oxcarbazepine). EXPERT OPINION: VPA add-on to clozapine is associated with a high risk of serious ADR (myocarditis, neutropenia, pneumonia) mostly explained by complex time-dependent drug-drug interactions. The initial inhibitory effects on clozapine metabolism require slow titration to avoid immuno-allergic reactions. After the titration period, VPA has mainly inductive effects on clozapine metabolism that are more marked in smokers requiring therapeutic drug monitoring. Lamotrigine and topiramate add-on may be recommended as the first-line treatment for clozapine-related seizures, but there is limited evidence regarding the efficacy of this strategy for clozapine-resistant psychotic symptoms. Carbamazepine should not be co-prescribed with clozapine because of its potential for agranulocytosis and for inducing clozapine metabolism.

[Pathophysiological hypothesis and diagnosis of insomnia disorder]. / Hypothèses physiopathologiques et diagnostic du trouble insomnie.

PATHOPHYSIOLOGICAL HYPOTHESES AND DIAGNOSIS OF INSOMNIA DISORDER. All pathophysiological models place hyperarousal as a central process in the mechanisms of insomnia. These models differ, however, in terms of the importance and role of the variables explaining this hyperarousal. Behavioral and cognitive models describe self-maintenance behaviors and dysfunctional thoughts, such as worries and concerns about sleep and the consequences of insomnia. Alterations in cognitive functions related to hyperarousal in perceptual and memory processes can explain these behaviors and thoughts. Neurobiological models show instability in the sleepwake balance, with orexin possibly involved, but this remains to be confirmed. The diagnosis of insomnia must consider the semiology related to the mechanisms of insomnia, as well as co-morbidities.

HYPOTHÈSES PHYSIOPATHOLOGIQUES ET DIAGNOSTIC DU TROUBLE INSOMNIE. L'ensemble des modèles physiopathologiques place l'hyperéveil comme processus central dans les mécanismes de l'insomnie. Les modèles se différencient cependant au regard de l'importance et du rôle des variables expliquant cet hyperéveil. Les modèles comportementaux et cognitifs décrivent les comportements d'autoentretien et les pensées dysfonctionnelles, de types soucis et inquiétudes concernant le sommeil et les conséquences de l'insomnie. Des altérations des processus cognitifs en lien avec l'hyperéveil dans les domaines perceptuels et mnésiques peuvent expliquer ces comportements et pensées. Les modèles neurobiologiques retrouvent une instabilité de la balance éveil/sommeil avec une possible implication de l'orexine, qui reste à confirmer. Le diagnostic de l'insomnie doit tenir compte de la sémiologie en lien avec ses mécanismes, tout en tenant compte des comorbidités.

Stigmatization towards electro convulsive therapy: Impact of practical teaching on medical and nursing students.

BACKGROUND: This study explored the impact of theoretical and practical teaching on electro convulsive therapy (ECT) on medical and nursing students' stigmatizing attitudes towards ECT and representations of it. METHOD: Fourth-year medical students and nursing students answered questions from the Questionnaire on Attitudes and Knowledge of ECT (QuAKE) and from the Mental Illness: Clinicians' Attitudes version 2 (MICA v2) scale. The questionnaires were completed before and after observing a 3-hour practical training session in the ECT unit. The endpoint was the impact of practical training as assessed by MICA and QuAKE scores. Multivariate analyses were used to explore the impact of practical training on MICA and QuAKE total scores. RESULTS: Stigmatizing attitudes and representations of both medical and nursing students towards ECT were reduced after practical training (ß=-4.43 [95% CI -6.15; -2.70] p=0.0001). The impact was greater in medical students (ß=-8.03; 95% CI [-10.71; -5.43], P=0.0001) than in nursing students (ß=-2.77; 95% CI [-4.98; to 0.44], P=0.02). Gender, psychiatric history in close persons, and having already followed a psychiatric/ECT course had no independent impact on stigmatizing attitudes towards ECT and representations of it. CONCLUSION: Practical training in ECT should be given to all health professionals to improve access to it.

Optimizing antidepressant and clozapine co-prescription in clinical practice: A systematic review and expert recommendations.

OBJECTIVES: To synthesize the information relevant for clinical practice on clozapine-antidepressant co-prescription concerning pharmacokinetic drug-drug interactions (DDI), adverse drug reactions (ADRs) associated with the co-prescription, antidepressant add-on for clozapine-resistant symptoms and antidepressant add-on for clozapine-induced ADRs. METHODS: Articles were identified with MEDLINE, Web of Sciences and PsycINFO search from inception through April 2023. Data were synthesized narratively. RESULTS: ADRs are most often induced by the co-prescription of antidepressants that inhibit CYP enzymes (fluvoxamine, fluoxetine, paroxetine). Fluvoxamine add-on is hazardous because of its potent inhibition of clozapine metabolism and has few indications (lowering daily number of clozapine tablets, reducing norclozapine-induced metabolic disturbances and other dose-dependent clozapine-induced ADRs). ADR frequency may be reduced by therapeutic drug monitoring and knowledge of other factors impacting clozapine metabolism (pneumonia, inflammation, smoking, etc.). Improvement of negative symptoms is the most documented beneficial effect of antidepressant add-on for clozapine-resistant psychotic symptoms. The add-on antidepressant should be chosen according to its safety profile regarding DDI with clozapine: antidepressants inhibiting clozapine metabolism or increasing the anticholinergic load should be avoided. Other indications of antidepressant add-on (affective or obsessive compulsive symptoms, sialorrhea, and enuresis) are poorly documented. CONCLUSION: Antidepressant add-on to clozapine is associated with potential benefits in clozapine users as this strategy may contribute to reduce the burden of clozapine-resistant symptoms or of clozapine-induced ADRs. Further studies are needed to determine whether antidepressant add-on can reduce the risk of clozapine discontinuation.

Risks and benefits of clozapine and lithium co-prescribing: A systematic review and expert recommendations.

OBJECTIVES: To identify the risks and benefits of clozapine­lithium co-prescription. METHODS: Articles published in English or French were identified with a MEDLINE, Web of Sciences and PsycINFO search, from inception through January 2023, using the term 'clozapine' in combination with 'lithium'. Data were synthesized narratively. RESULTS: Of the 67 articles included in the review, more than half (n = 38, 56.7 %) were focused on clozapine-related blood dyscrasia. A body of evidence drawn from case reports and retrospective chart studies highlights the potential benefits of lithium prescription for clozapine-related neutropenia, since this strategy may avoid clozapine discontinuation or allow its rechallenge. The most documented adverse drug reactions (ADRs) associated with clozapine­lithium co-prescription are neurotoxic events, which may be prevented or detected early by clinical, electroencephalographic and therapeutic drug monitoring. Causality assessment cannot be established for other reported ADRs occurring during clozapine­lithium co-prescription. The benefits of the combined prescription on psychotic and/or mood symptoms are poorly documented. CONCLUSION: The risks and benefits of clozapine­lithium co-prescription require further exploration as the combination might significantly contribute to reducing underprescription or premature discontinuation of clozapine.

Benefits of video games for people with schizophrenia: a literature review.

PURPOSE OF REVIEW: In spite of the overwhelming concerns about the deleterious impact of exposure to video games, a growing body of evidence suggests that it may be of potential interest for therapeutic purposes, particularly in schizophrenia. As literature is rapidly evolving, we carried out a systematic review of recent articles on this issue. RECENT FINDINGS: We identified seven studies published from 2017 to 2022 exploring the benefits of commercial video games in people with schizophrenia and related disorders regarding symptoms, cognition and functional outcome. Six studies used an RCT design. Associations between gaming and better outcomes were found in three main areas: physical condition (walking speed, aerobic fitness), neurocognition (processing speed, memory and executive functions), and social functioning, self-efficacy in daily life activities and quality of life. SUMMARY: Active use of video games is associated with better aerobic fitness and cognitive performances. Video gaming may contribute to better functional outcome and quality of life in patients suffering from cognitive impairments and difficulties in social functioning. Persons with schizophrenia may benefit from using commercial video games because of their potential therapeutic impact on functioning and cognition.

Actionable Predictive Factors of Homelessness in a Psychiatric Population: Results from the REHABase Cohort Using a Machine Learning Approach.

BACKGROUND: There is a lack of knowledge regarding the actionable key predictive factors of homelessness in psychiatric populations. Therefore, we used a machine learning model to explore the REHABase database (for rehabilitation database-n = 3416), which is a cohort of users referred to French psychosocial rehabilitation centers in France. METHODS: First, we analyzed whether the different risk factors previously associated with homelessness in mental health were also significant risk factors in the REHABase. In the second step, we used unbiased classification and regression trees to determine the key predictors of homelessness. Post hoc analyses were performed to examine the importance of the predictors and to explore the impact of cognitive factors among the participants. RESULTS:  First, risk factors that were previously found to be associated with homelessness were also significant risk factors in the REHABase. Among all the variables studied with a machine learning approach, the most robust variable in terms of predictive value was the nature of the psychotropic medication (sex/sex relative mean predictor importance: 22.8, σ = 3.4). Post hoc analyses revealed that first-generation antipsychotics (15.61%; p < 0.05 FDR corrected), loxapine (16.57%; p < 0.05 FWER corrected) and hypnotics (17.56%; p < 0.05 FWER corrected) were significantly associated with homelessness. Antidepressant medication was associated with a protective effect against housing deprivation (9.21%; p < 0.05 FWER corrected). CONCLUSIONS: Psychotropic medication was found to be an important predictor of homelessness in our REHABase cohort, particularly loxapine and hypnotics. On the other hand, the putative protective effect of antidepressants confirms the need for systematic screening of depression and anxiety in the homeless population.

Contrasting the Social Cognitive and Metacognitive Capacities Among Patients With Schizophrenia and Autism Spectrum Disorders Enrolled in Psychiatric Rehabilitation.

ABSTRACT: Unique deficits in synthetic metacognition have been found in schizophrenia when compared with other psychiatric conditions and community controls. Although persons with autism spectrum disorders (ASD) display similar deficits in social cognition relative to those with schizophrenia, to date no study has compared metacognitive function between these groups. We aimed to compare the metacognitive capacities of persons with schizophrenia and ASD and their associations with other outcomes (neurocognition, social cognition, depression, and quality of life). Fifty-six outpatients with schizophrenia or ASD (mean age, 32.50 [9.05]; 67.9% male) were recruited from two French Centers of Reference for Psychiatric Rehabilitation of the REHABase cohort. Evaluation included the Indiana Psychiatric Illness Interview, Metacognition Assessment Scale-Abbreviated, Movie for the Assessment of Social Cognition, and a large cognitive battery. Compared with those with schizophrenia, participants with ASD had higher self-reflectivity ( p = 0.025; odds ratio, 1.38 [1.05-1.86]) in univariable analyses. Metacognitive deficits may be found in ASD with a profile that varies from what is found in schizophrenia. It is possible that methods for enhancing metacognitive abilities during psychiatric rehabilitation may be refined to assist adults with ASD to better manage their own recovery.

The central role of self-esteem in the quality of life of patients with mental disorders.

In psychiatry, recent years have seen a change of focus from a clinician- to a patient-centered perspective that emphasizes quality of life as a treatment target. As a complex construct, quality of life is composed of multiple dimensions that interact with one-another (e.g. physical and psychological well-being, relationships, autonomy, self-esteem). Here, we used data from the REHABase cohort, which includes N = 2180 patients from 15 psychosocial rehabilitation centers in France, to explore networks of quality-of-life dimensions among six psychiatric disorders: schizophrenia, neurodevelopmental, bipolar, depressive, anxiety, and personality disorders. Stronger connections (edges) involved the Self-Esteem dimension, such as Self-Esteem-Physical Well-Being, Self-Esteem-Autonomy, Self-Esteem-Psychological Well-Being, and Self-Esteem-Resilience. Self-esteem was also consistently retrieved as the most central node (the dimension with the most connections within each network). Between-group tests did not reveal any differences regarding network structure, overall connectivity, edge-weights, and nodes' centrality. Despite presenting with different symptom profiles, various psychiatric disorders may demonstrate similar inter-relationships among quality-of-life dimensions. In particular, self-esteem may have a crucial inter-connecting role in patients' quality of life. Our findings could support treatment programmes that specifically target self-esteem to improve patients' quality of life in a cost-effective way.

Trauma and resistance to antipsychotic treatment in schizophrenia: A narrative review.

This review explored whether trauma exposure is associated with poorer response to antipsychotic treatment in schizophrenia patients. A systematic search identified eight studies, of which five reported an association between trauma and non-remission of psychotic symptoms (n = 4) or treatment-resistant schizophrenia (TRS, n = 1). Although evidence supporting the link between trauma and resistance to antipsychotic treatment is scarce, trauma history should be systematically investigated in all persons with TRS, as there is a growing body of evidence showing that schizophrenia patients benefit from therapies for post-traumatic symptoms.

An International Adult Guideline for Making Clozapine Titration Safer by Using Six Ancestry-Based Personalized Dosing Titrations, CRP, and Clozapine Levels.

This international guideline proposes improving clozapine package inserts worldwide by using ancestry-based dosing and titration. Adverse drug reaction (ADR) databases suggest that clozapine is the third most toxic drug in the United States (US), and it produces four times higher worldwide pneumonia mortality than that by agranulocytosis or myocarditis. For trough steady-state clozapine serum concentrations, the therapeutic reference range is narrow, from 350 to 600 ng/mL with the potential for toxicity and ADRs as concentrations increase. Clozapine is mainly metabolized by CYP1A2 (female non-smokers, the lowest dose; male smokers, the highest dose). Poor metabolizer status through phenotypic conversion is associated with co-prescription of inhibitors (including oral contraceptives and valproate), obesity, or inflammation with C-reactive protein (CRP) elevations. The Asian population (Pakistan to Japan) or the Americas' original inhabitants have lower CYP1A2 activity and require lower clozapine doses to reach concentrations of 350 ng/mL. In the US, daily doses of 300-600 mg/day are recommended. Slow personalized titration may prevent early ADRs (including syncope, myocarditis, and pneumonia). This guideline defines six personalized titration schedules for inpatients: 1) ancestry from Asia or the original people from the Americas with lower metabolism (obesity or valproate) needing minimum therapeutic dosages of 75-150 mg/day, 2) ancestry from Asia or the original people from the Americas with average metabolism needing 175-300 mg/day, 3) European/Western Asian ancestry with lower metabolism (obesity or valproate) needing 100-200 mg/day, 4) European/Western Asian ancestry with average metabolism needing 250-400 mg/day, 5) in the US with ancestries other than from Asia or the original people from the Americas with lower clozapine metabolism (obesity or valproate) needing 150-300 mg/day, and 6) in the US with ancestries other than from Asia or the original people from the Americas with average clozapine metabolism needing 300-600 mg/day. Baseline and weekly CRP monitoring for at least four weeks is required to identify any inflammation, including inflammation secondary to clozapine rapid titration.

Sex Differences in Recovery-Related Outcomes and Needs for Psychiatric Rehabilitation in People With Schizophrenia Spectrum Disorder.

BACKGROUND: Female sex/gender has been associated with better longitudinal outcomes in schizophrenia spectrum disorders (SSDs). Few studies have investigated the relationships between female gender and recovery-related outcomes. Women's specific psychiatric rehabilitation needs remain largely unknown. OBJECTIVE: The objectives of the present study are to investigate sex differences in (1) objective and subjective aspects of recovery and (2) psychiatric rehabilitation needs in a multicenter non-selected psychiatric rehabilitation SSD sample. METHODS: 1,055 outpatients with SSD (DSM-5) were recruited from the French National Centers of Reference for Psychiatric Rehabilitation (REHABase) cohort between January 2016 and November 2019. Evaluation included standardized scales for quality of life, satisfaction with life, and well-being and a broad cognitive battery. Socially valued roles at enrollment were recorded. Functional recovery was measured using the Global Assessment of Functioning scale (GAF) and personal recovery with the Stages of Recovery Instrument (STORI). RESULTS: Female sex was the best predictor of having more than 2 socially valued roles in the multivariate analysis (P < .001; OR [95% CI] = 5.42 [2.34-13.06]). No sex differences were found for functional recovery or personal recovery. Female gender was positively associated with self-stigma (P = .036) and suicidal history (P < .001) and negatively correlated with quality of life (P = .004) and satisfaction with interpersonal relationships (P = .029), an area in which women reported more unmet needs (P = .004). CONCLUSIONS: The present study found that women had poorer subjective recovery-related outcomes and more unmet needs than men. It would therefore be beneficial to develop recovery-oriented interventions addressing women's specific needs and implement these in psychiatric rehabilitation services.

Impact of anticholinergic load on functioning and cognitive performances of persons with psychosis referred to psychosocial rehabilitation centers.

BACKGROUND: Few studies have explored whether high-anticholinergic load may hamper rehabilitation in persons with schizophrenia. We aim to explore the associations between anticholinergic load of psychotropic treatment and functioning or cognitive performances of persons with psychosis engaged in psychosocial rehabilitation. METHODS: The study was performed using data collected at baseline assessment in the REHABase cohort including persons referred to a French network of psychosocial rehabilitation centers. The composite-rating scale developed by Salahudeen et al. was used to rate the anticholinergic load of psychotropic drugs prescribed at baseline assessment. The associations between total anticholinergic load score (categorized as 'low' <3 v. 'high' ⩾3) and functioning or cognitive characteristics were explored using multivariate analyses. RESULTS: Of the 1012 participants with schizophrenia spectrum disorders identified in the REHABase, half used at least two psychotropic drugs with anticholinergic activity and one out of three was prescribed at least one psychotropic drug with high-anticholinergic activity. High-anticholinergic load was significantly associated with lower stage of recovery [odds ratio (OR) = 1.70, 95% confidence interval (CI) 1.05-2.76, p = 0.03], poor mental well-being (OR = 1.55, 95% CI 1.02-2.33, p = 0.04) and poor self-rated medication adherence (OR = 2.14, 95% CI 1.29-3.53, p = 0.003). Regarding cognition, a high-anticholinergic score was associated with poorer delayed-episodic memory (OR = 1.69, 95% CI 1.01-2.85, p = 0.05) and at the trend level with faster completion time on the test exploring executive performance (OR = 0.67, 95% CI 0.43-1.04, p = 0.07). CONCLUSIONS: The psychosocial rehabilitation plan of persons with psychosis should integrate optimization of psychotropic treatment in order to lessen the functional and cognitive impact of high-anticholinergic load.

Characteristics associated with self-reported medication adherence in persons with psychosis referred to psychosocial rehabilitation centers.

The aim of the present study was to explore the characteristics of psychotropic treatment and of psychosocial functioning associated with self-reported medication adherence in persons with psychosis engaged in rehabilitation. The study was performed in the REHABase cohort including persons referred to a French network of psychosocial rehabilitation centers. Treatment adherence was assessed using the Medication Adherence Rating Scale (MARS). The associations between MARS score (categorized as "low" < 7 vs. "high" ≥ 7) and functioning or psychotropic treatment characteristics were explored using multivariate analyses in 326 participants with schizophrenia spectrum disorders. Regarding psychotropic treatment, high anticholinergic load was the only characteristic associated with poor medication adherence (adjusted OR, aOR 1.98, 95% CI 1.07-3.66). Regarding functioning measures, participants with poor medication adherence were more likely to present with lower stage of recovery (aOR 2.38, 95% CI 1.31-4.32), poor quality of life (aOR 2.17, 95% CI 1.27-3.71), mental well-being (aOR 1.68, 95% CI 1.03-2.72) and self-esteem (aOR 1.74, 95% CI 1.05-2.87), and higher internalized stigma (aOR 1.88, 95% CI 1.09-3.23). Self-reported poor medication adherence is a marker of poor functioning in persons with psychosis. The MARS is a quick and simple measure of adherence that may be helpful in clinical and rehabilitation settings to identify persons with specific rehabilitation needs.

Functioning and cognitive characteristics of clozapine users referred to psychosocial rehabilitation centers: A REHABase cohort study.

OBJECTIVES: To explore whether clozapine users have specific rehabilitation needs compared to users of other antipsychotics. METHODS: The study was performed using the REHABase collecting data on persons referred to a French network of psychosocial rehabilitation centers. It was restricted to persons with schizophrenia spectrum disorder using antipsychotics. Multivariate analyses were used to compare baseline functioning and cognitive characteristics in clozapine users vs. users of other antipsychotics. RESULTS: Of the 675 patients identified in the REHABase, one out of ten (n = 70) used clozapine. Compared to users of other antipsychotics, clozapine users had been more frequently hospitalized in psychiatry and presented less frequently with psychoactive substance use. Functional measures did not significantly differ between the two groups. Clozapine users had poorer short-term verbal memory performance than users of other antipsychotics and did not differ on executive performance. CONCLUSION: Clozapine users may reach a recovery level comparable to that obtained in persons without treatment-resistant schizophrenia. In order to reduce the negative impact of memory deficits on the recovery process of clozapine users, it is necessary to optimize their psychotropic treatment and to promote their access to cognitive remediation programs addressing their specific needs.

Clinical determinants of fever in clozapine users and implications for treatment management: A narrative review.

OBJECTIVES: To identify the clinical determinants of fever in clozapine users and their impact on management of clozapine treatment. METHODS: Articles published in English or French identified with a MEDLINE, Web of Sciences, Cochrane Library and PsycINFO search, from inception through February 2019, using the term "clozapine" in combination with "fever" OR "hyperthermia" OR "body temperature" OR "pyrexia" OR "febrile" OR "heat" OR "thermoregulation". Information extracted for each medical condition were frequency, time to onset after initiation of clozapine treatment, characteristics of fever, associated symptoms, laboratory tests used for diagnosis, course, lethality, discontinuation of clozapine. Data were synthesized narratively. RESULTS: Our search yielded 394 unique hits published from 1993 to 2018. We included 73 articles in the review: two meta-analyses, 14 reviews, six epidemiological studies, 11 clinical studies and 40 case reports. During clozapine initiation, fever is most frequently benign and transient but should be closely monitored as it may be the first stage of potentially life-threatening adverse drug reactions (ADR) (agranulocytosis, neuroleptic malignant syndrome myocarditis, hepatitis, pancreatitis, nephritis, colitis, etc.). Other ADR associated with fever are independent of duration of exposure to clozapine (heat stroke, pneumonia, pulmonary embolism, necrotizing colitis). If fever is due to intercurrent infection, therapeutic drug monitoring is recommended to adjust clozapine daily dosage. CONCLUSION: Benign causes of fever are much more frequent than life-threatening ADR during clozapine treatment. Discontinuation should not be considered as automatic in the event of fever, especially during the early phase of clozapine initiation.

[Definition of somatoform disorders: somatic symptoms or mental symptoms?] / Définition des troubles somatoformes : entre symptômes physiques et symptômes mentaux.

Definition of somatoform disorders: somatic symptoms or mental symptoms? Somatoform disorders, which used to be considered as mental disorders, are frequent, especially in the context of non-psychiatric medical consultations. The absence of an identifiable organic cause for these disorders often leads clinicians to underestimates their harmful consequences or even challenge their validity as disease. However, they are real disorders that may have a major impact on the quality of life and functional outcomes of the subject and whose mechanisms can be targeted by therapeutic interventions. Although psychiatric classifications support a unitary approach (i.e. the "somatic symptom disorder and related disorders" of the American Psychiatric Association's DSM - Diagnostic and Statistical Manual of Mental Disorders - or the "bodily distress disorder" of the World Health Organization), each non-psychiatric specialty has described some "functional somatic syndromes", which are deemed more specific and less severe regarding psychiatric severity, and thus more often remain in the field of non-psychiatric specialties. In this article, we have presented the initial stage of any medical approach of suffering: a clarification of the issues involved in the delimitation of the normal and the pathological, and the organization of the different categories between them. These nosographic aspects are the condition of a rigorous approach in medicine, and of a relationship with the patient that is useful to understand and relieve his or her genuine suffering.

Définition des troubles somatoformes : entre symptômes physiques et symptômes mentaux. Les troubles somatoformes, considérés comme des troubles mentaux par la nosographie psychiatrique, sont particulièrement fréquents, mais surtout rencontrés dans le contexte des consultations médicales non psychiatriques. L'absence de cause organique identifiable pour ces maladies fait souvent sous-estimer leur retentissement, voire douter de leur existence. Il s'agit pourtant de troubles à part entière, avec un impact majeur sur la qualité de vie et les activités des sujets en souffrant et avec des mécanismes accessibles à la thérapeutique. Si la nosographie psychiatrique contemporaine privilégie une approche unitaire (« troubles à symptomatologie somatique et apparentés ¼ du Manuel diagnostique et statistique des troubles mentaux, « bodily distress disorder ¼ de l'Organisation mondiale de la santé), chaque spécialité a décrit un ou plusieurs « syndromes somatiques fonctionnels ¼ qui, du fait de leur spécificité présumée et de leur sévérité psychiatrique moins grande, restent le plus souvent du domaine des spécialités non psychiatriques. Dans cet article est présentée l'étape initiale à toute approche médicale de la souffrance : une clarification des enjeux de la définition du normal et du pathologique et de l'organisation des différentes catégories nosographiques entre elles. Ces aspects nosographiques sont la condition d'une approche rigoureuse en médecine et d'une relation avec le patient qui soit utile à la compréhension et au soulagement de sa souffrance.

Satisfaction and Needs in Serious Mental Illness and Autism Spectrum Disorder: The REHABase Psychosocial Rehabilitation Project.

OBJECTIVE: The REHABase project is a French observational, prospective, and multicenter cohort study of serious mental illness and autism spectrum disorder (ASD), launched in 2016 for a planned minimum duration of 15 years. The aim is to characterize the care and quality-of-life needs of participants. This article presents initial results from data collection. METHODS: Psychosocial, cognitive, and functional data were collected at baseline, annually, and after rehabilitation care. Data from the baseline evaluation on diagnoses, medications, well-being, insight, life satisfaction, and care needs are presented. The clinical profiles of REHABase participants with serious mental illness or ASD were assessed in relation to their level of satisfaction with life and well-being in nine life dimensions and their needs, according to their stage of recovery in a five-stage model. RESULTS: Baseline data were collected for 1,397 participants between January 2016 and August 2018. Main diagnoses were schizophrenia spectrum disorder (49%); ASD (13%); and personality (12%), bipolar (9%), and major depressive (6%) disorders. More than 50% of participants reported needs for care or interventions in four of nine dimensions: employment, cognitive functioning, symptom management, and interpersonal relationships. Nearly half of participants were not in the active stages of recovery (stages 4 and 5), and even those considered to have reached the final stage continued to require help in several areas. CONCLUSIONS: Most participants had already received psychiatric care for several years, and most remained dissatisfied with their social and emotional life and their psychological well-being.