[PLAID-Care: Research into the reduced use of coercion in France]. / PLAID-Care : une recherche sur le moindre recours à la coercition en France.

The use of coercion is a common practice in psychiatry despite its deleterious effects and insufficient evidence of benefits. It is so deeply rooted that the mention of establishments that make little use of it arouses a form of incredulity. However, the history of psychiatry and the international literature provide numerous examples of a psychiatry that is hardly coercive and numerous experiences of a reduction in the use of seclusion and/or restraint in psychiatric facilities. Today, in France, there are also less coercive establishments, which, for example, do not use mechanical restraint, have all their units open, or have reduced their use of seclusion and restraint. With regard to the stated policy objectives of reducing the use of coercion, it is surprising that most of these facilities receive little attention. PLAID-Care research aims to contribute to the visibility and analysis of these institutions and the factors involved in the reduced use of coercion. While these factors have already been identified in the international literature, the research is based on the multiplication of disciplinary perspectives (nursing, sociology, anthropology, geography) and the mobilization of a multi-level analytical framework that allows us to embrace their multiplicity and better understand their articulation. The originality of the research also lies in its historical dimension, which allows us to understand, on the scale of an institution, how a policy and practices aiming at the least recourse emerge and are consolidated. The project timeline is divided in three tasks: firstly, an inventory of "low-coercion" facilities in France; secondly, we will select and research four traditionally "low-coercion" facilities in France; thirdly we will focus on recently emerged "low-coercion" practices. PLAID-Care aims to revitalize French research on this theme which to date has been relatively lagging behind the numerous international studies. It will bring together and articulate the knowledge, tools and forms of organization and collaboration that contribute to making a policy of lesser use of coercion operational.

[When ideals put on the pressure]. / Quand les idéaux mettent la pression.

In a society where positive parenting is becoming more and more important, both external and internal pressures on parents are not to be taken lightly. Educational ideals influence the way in which each of us will exercise our parenthood and can lead to risk factors for parental burn-out. Whether in a process of prevention or therapeutic intervention, avenues are envisaged to help parents cope.

[Is involuntary commitment to treatment applicable in case of an addictive disorder in the French context? A critical review of available evidence]. / Les soins sans consentements peuvent-ils s'appliquer en cas d'addiction dans le contexte français ? Une analyse critique des données.

OBJECTIVE: The objective of this work was to determine whether compulsory psychiatric treatment is applicable in France to patients with an addiction. To this end, several questions were formulated, at the legislative level and in terms of professional recommendations. Our secondary objective was to analyse those practices epidemiologically and in terms of evaluating their impact. METHODS: Using the PRISMA method for systematic research, documents were selected from the following databases: regulatory (Legifrance), scientific societies [High Authority for Health (HAS), French Society of Emergency Medicine (SFMU), French Society of Alcohology (SFA)]; concerning our secondary objective (epidemiological and evaluative) documents from several data bases [Public Health Database (BDSP), Psy Health Foundation, EM-Premium, Pubmed] were reviewed. RESULTS: The search retrieved 163 documents, of which 13 were included based on examination. Legislative texts and professional recommendations do not exclude involuntary commitment to treatment in case of an addictive disorder. Epidemiological data describe use disorder as one of the most mentioned disorders in cases of involuntary commitment to treatment, with clinical improvement as long as treatment lasts. CONCLUSION: French law does not prohibit compulsory addiction treatment in psychiatry. Compulsory addiction treatment could be an access to health care for some patients and an emergency measure to limit at one point the accumulation of damage or in view of a life-threatening situation.

[Care programmes, to respond to the breakdown of care and lack of consent in psychiatry]. / Programmes de soins, pour répondre à la rupture de soins et au défaut de consentement en psychiatrie.

We need to go back to the time of alienist doctors to understand the interest of the care programme established in 2011. In fact, the psychiatric clinic requires professionals to accompany the patient over time, while accepting the variability of suffering. In this context, this system proposes an alternative to full in-patient care while preserving the aspect of compulsory treatments. Caring for the patient, acquiring their consent while preserving their rights is a real challenge for the psychiatrist and their team.

[Care programmes: the ambiguity of normality, exception and forms of control]. / Programmes de soins : ambiguïté de la normalité, exception et formes de contrôle.

The care programmes are medical-legal and therapeutic systems that showcase different spaces, the law, the patient's clinic, their freedom and their rights. In this context, the patient preserves their freedom to come and go. In applying the care programme, the doctor must acquire their approval, not to say consent. Outside hospitalisation, the care programmes bring patients and teams together within the city. The matter of social and community psychiatry, a vector of catchment-area psychiatry, then makes full sense.

[Isolation and protection, a contradiction and a necessity]. / Isolement et protection, une contradiction et une nécessité.

The association of the two terms 'isolating' and 'protecting', seems counterintuitive. The practice of isolation conjures up images of an asylum or even prison, rather than a notion of safeguarding. Isolation is defined within caregiving institutions by a vast range of practices, neither rare nor recent. It is used in a variety of departments, from psychiatric isolation to septic isolation or a form of isolation common to both: social isolation resulting from institutionalisation.

[From impasse to alliance, a singular encounter]. / De l'impasse à l'alliance, une rencontre singulière.

The story of Amina, hospitalised at the Oasis at the Ain psychotherapy centre (CPA), illustrates how a nursing team can be mobilised to avoid the use of seclusion. Time, creativity and respect for the patient are key to the success of the care approach.

[Care and restraint, when the law questions nursing practice]. / Soins sous contrainte, quand le droit interroge la pratique.

With the reforms of 2011 and 2013 relating to psychiatric hospitalisation, raises the question of the suitability of modern psychiatric practice with regard to a person's recognised principles and basic rights. Achieving a balance is difficult and the Constitutional Council has joined the debate, bringing to an end any idea of compromise between safety and freedom. A decision which was made as a result of a clarification of certain regulations which have proved controversial from the point of view of individual liberties.

[Freedom of movement: a basic right, a regulated restriction]. / Liberté d'aller et venir : un droit fondamental, une restriction encadrée.

Freedom of movement is recognised by national and supranational law. It falls within the scope of the definition of freedom set out in the Declaration of the Rights of Man and of the Citizen, in 1789. It is also legally formulated and recognised as a basic right in two European texts: the Universal Declaration of Human Rights of 10th December 1948 and the European Convention for the Protection of Human Rights and Fundamental Freedoms of 4th November 1950. How can it be respected in psychiatry, in view of the obligation to provide care and safety?

["For us, as 'patients/users', the essential point remains the respect of the person"]. / « Pour nous "usagers patients", le point essentiel reste le respect de la personne ¼.

The first organisation to bring together the users of care in the history of the speciality, the French National Federation of Patient Associations in Psychiatry has always campaigned for the respect of users' freedom of movement. Despite the progress made in terms of legislation, the federation presents a mixed picture. For Claude Filkenstein, its president, there remains a long way to go, notably in the field of the culture of psychiatric care. In her opinion, training should be a major advantage.

[From constraint to containment through the nursing link]. / De la contention à la contenance par le lien soignant.

The implementation of a sufficiently strict, adapted care setting provides constructive support for a move away from isolation and restraint towards new spaces of freedom. The account of the evolutive management of a patient by a nursing team in Bourg-en-Bresse, presents possible therapeutic strategies.

[Towards recovery, from constraints to the sharing of experience]. / Vers le rétablissement, de la contrainte au partage d'expérience.

The pathway towards recovery is littered with constraints and stages in an environment which has to be reinvented. While the constraints are related to legislation, the condition, or stigmatisation, the stages are based on hope, self-determination and on the patient's capacity to exist as a subject. A partnership between caregivers, patients and families is necessary to construct a positive care pathway towards recovery.

[Therapeutic restraint and freedom of movement, changing practices]. / Contrainte thérapeutique et liberté d'aller et venir, changer les pratiques.

From confinement to the philosophy of care in the community, the history of psychiatry testifies to the evolution of practices in the matter of the restriction of freedom. The French National Health Authority still too often recommends practices based on restraint. Caregivers, in relation to the clinical aspect of the patients, need clearly identified therapeutic projects. While training can be vital for them, risk management policies can prove to be a hindrance to patients' freedom.

[The imminent peril in the law of July the fifth 2011, two years later: the impact on health?]. / Le péril imminent dans la loi du 5 juillet 2011: quelles implications sur les soins?

In 1938, the French government decided to enact a first legislation to enforce admission of the mentally ill to hospitals. Later in 1990, the law took into consideration the evolution of practices with an increase of free admissions and the right to maintain the mentally ill in cities. Three types of psychiatric hospitalization were defined: free, on third party request and for involuntary confinement. A review had theoretically to be conducted every 5 years. In practice this was not the case, probably due to the balance between individual freedom, patient care and public safety always hard to find. However, considering the imperative European harmonization and the fact the Constitutional Council declared a double unconstitutionality of the law, the Act of July 5th was enacted in a hurry during the summer 2011. The Act defines the "rights and the protection of people subject to psychiatric care and methods of coverage". In this document, we will briefly review the context of this law. We will also explore the clinical implications of the very innovative measure: the "péril imminent". We will use the admissions at the Sainte-Anne hospital in Paris in 2010 to 2012. Three major key points were introduced in the law: a judge controls an agreeable release after 15 days and 6 months of continuous hospitalization. The law let the new possibility to provide ambulatory cares under constraints, and these to make an involuntary confinement without a third party request, using the "imminent peril". This law implies the involvement of the judge and the lawyer. This one has to defend a client who needs care, he controls the formal validity of decisions concerning the patient. To provide treatment without consent in "imminent peril" to someone, conditions are requested: these mental disorders make his consent impossible and his mental state requires immediate care with immediate care of constant medical monitoring justifying a full hospitalization or regular medical monitoring for support under another form of full hospitalization (Article L.3212. 1 of the Code of Public Health). Moreover, a demand for care by a third party has also to be impossible to obtain and an imminent peril to the person's health has to exist, supported by a medical certificate from a doctor who does not belong to the patient's psychiatric hospital. The imminent peril would be an immediate danger to the health or life of the patient. What has been the impact of this law adopted in emergency at Sainte-Anne hospital? This psychiatric hospital is in charge of the population in southern Paris, where reside about 655,000 people. This work observes the evolution of the type of hospitalization and care before and after the adoption of the law. We can observe an overall increase in entries under constraints. There is a decrease in admissions for involuntary confinement for the benefit of imminent peril. This imminent peril corresponds to only a small proportion of hospitalizations without consent but are rising between 2011 and 2012, perhaps in part due to a better understanding of the law. But this progression is to monitor to ensure compliance with the restrictive conditions laid down by this law. Also note that the imminent peril may be used at the refusal of the family or entourage to make the demand for care. The number of hospitalizations at the request of a third party with two certificates is down, which is probably due to a change in status of the CPOA, emergency structure within Sainte-Anne, which is no longer seen as extraterritorial. The imminent peril has advantages: it allows access to the care of people isolated and desocialized, of people whose identity is unknown, of pathological travellers. It avoids hospitalization at the request of the representative of the State for social reasons and not for risks to the safety of persons, even when this type of hospitalization is more stigmatizing and often more difficult to remove. It protects the entourage sometimes, when the family is ambivalent or hostile to care, or has been designated as a persecutor. The imminent peril also has disadvantages. One of them is the risk of its misuse to allow rapid hospitalization without taking the time to seek a third party. The imminent danger made when there is an entourage but which refuses to request care can undermine the development work on information about the disease, the need for care and treatment and the importance of the involvement of the entourage in the care plan. The alliance with the patient may be compromised. In some cases, a decision of care by the request of the representative of the State is more appropriate than the "imminent peril". The "imminent peril" may be preferred because of the administrative burden of prefectural measures when patient presents clinical improvement and we would go up to the ambulatory care in a care program. Yet, the use of a symbolic third, carrying authority, can avoid the too direct confrontation with the patient. Do not use it can complicate the management of the patient. Finally, with desocialized patients, imminent peril can facilitate access to care, but not continuity of care. Indeed, for the care program it is necessary to have an address for the patient. Once the crisis is not to develop a plan of care. Finally in some situations of desocialized patients, the imminent peril can promote access to care but not the continuity of care as to the care program it is necessary to have an address for the patient. Once the crisis is past, it is impossible to implement a program of care. The Law of 5 July 2011 marks a change in the practice of psychiatrists. Take into account the fundamental rights of the patient and to harmonize legislation at EU level was necessary. Some measures are designed to promote access to care as the "imminent peril", we now need to be vigilant to ensure that it is not diverted to promote an increase in care under constraints and that psychiatrists remain in an obligation of means and not of result.

[Restraint during care: The legal aspects]. / La contention lors des soins : les aspects juridiques.

Restraint in care must be a practice of last resort. To date, it is only regulated in the texts for psychiatric care without consent and only in full hospitalization. Healthcare teams can only use it with great caution, in a manner strictly proportionate to the situation and, if they act outside the legal framework, by taking good professional practices as a reference.

[Constraint during care in elderly people with cognitive disorders]. / La contrainte lors des soins chez le sujet âgé atteint de troubles cognitifs.

Constraints in the care of vulnerable elderly people are part of the daily life of services. This practice must not avoid multidisciplinary reflection by preserving the autonomy of patients' decisions despite cognitive disorders. The search for consent and reasons for refusing care must be the leitmotif and coercion the exception and must be supported.

[Advanced directives in psychiatry: A review of the qualitative literature, a state-of-the-art and viewpoints]. / Les directives anticipées en psychiatrie : revue de la littérature qualitative, état des lieux et perspectives.

BACKGROUND: Advance Directives are written documents, which are used for people to notify their preference for a future situation when they are unable to give their consent. In psychiatry, psychiatric advance directives (PADs) can be used for patients with chronic psychotic disorders such as schizophrenia, or a bipolar disorder. PADs give the patient an opportunity to state wishes in advance about his/her treatment when he/she is in an acute state of illness. PADs were initially developed as a way for patients to defend themselves against the power of the psychiatrists, but are likely to become a useful tool in psychiatric care. PADs may contain information about medication, non pharmaceutical devices, and the name of a proxy decision maker. The main objective is to reduce the number of compulsory hospitalisations. OBJECTIVE: This article is a qualitative review which carries out a state-of-the-art on the use of PADs for people with chronic psychotic disorders and defines suggestions to include this intervention in the French psychiatric context. METHOD: We used the keywords psychiatric advance directives, crisis card, Ulysse directives, joint crisis plan (JCP) in the MEDLINE database to propose a qualitative review. We selected original clinical studies about the use of PADs for people with psychotic disorders. RESULTS: We included 36 articles. The qualitative analysis identified seven main themes: different types of PADs, effectiveness of PADs, practical use of PADs, patient's views, clinician's views, economical aspects, and legal aspects. The content of the PADs is consistent with psychiatric standard care in nearly all cases, regarding medical instructions, pre-emergency interventions, non-hospital alternatives and non-medical personal care. Patients use their PADs to describe prodromal symptoms of relapse and to suggest a treatment and a hospitalisation in advance. PADs are not used to refuse all treatments. Patients show a strong interest in creating a directive and a high level of satisfaction when using it. They feel they have more control over their mental health problem and are more respected and valued as a person. Thirty-six to fifty-three percent of clinicians had positive opinions regarding PADs. They valued the increase of the patient's autonomy and the prevention of relapse, but were concerned about difficulties for accessing the documents, and about the lack of training of the medical teams. Clinicians also feared the pressure of relatives or partners on treatment decisions. The qualitative analysis revealed the specific benefit of the JCP, a particular type of PADs negotiated with the medical team, on the reduction of the general number of admissions. We can identify practical problems such as the lack of accessibility to PADs in emergency situations, and the clinician's reluctance to use PADs. The only economical evaluation showed a non-significant decrease in total costs. DISCUSSION: PADs are used in a few countries, although their benefits in terms of patient's perceptions and compulsory admissions are promising. The JCP proposes a specific clinical approach based on therapeutic alliance. Its creation also involves the clinician, family members and a neutral mediator in a negotiated process. The JCP is likely to be the most efficient PAD model in reducing compulsory admissions. The use of the JCP appears to be relevant in the context of the new French legislation, establishing outpatient commitment orders and could be an effective way to improve the relationships with patients.

[The care partnership pact in adult psychiatry]. / Le pacte du partenariat de soins en psychiatrie adulte.

Programs to reduce the use of coercive measures emphasize the importance of patient involvement in their care and the use of formalized tools. An adult psychiatric care admission unit offers a specific tool to the hospitalized patient: the "Preventive Emotion Management Questionnaire", as soon as the patient is admitted to the unit. Thus, in case of a crisis period, caregivers will know what the patient's wishes are, which will facilitate the implementation of a care partnership, guided by two nursing theories.

Heat tolerance and the validity of occupational heat exposure limits in women during moderate-intensity work.

To mitigate excessive rises in core temperature (>1 °C) in non-heat acclimatized workers, the American Conference of Governmental Industrial Hygienists (ACGIH) provides heat stress limits (Action Limit Values; ALV), defined by the wet-bulb globe temperature (WBGT) and a worker's metabolic rate. However, since these limits are based on data from men, their suitability for women remains unclear. We therefore assessed core temperature and heart rate in men (n = 19; body surface area-to-mass ratio: 250 (SD 17) cm2/kg) and women (n = 15; body surface area-to-mass ratio: 268 (SD 24) cm2/kg) aged 18-45 years during 180 min of walking at a moderate metabolic rate (200 W/m2) in WBGTs below (16 and 24 °C) and above (28 and 32 °C) ACGIH ALV. Sex did not significantly influence (i) rises in core temperature, irrespective of WBGT, (ii) the proportion of participants with rises in core temperature >1 °C in environments below ACGIH limits, and (iii) work duration before rises in core temperature exceeded 1 °C or volitional termination in environments above ACGIH limits. Although further studies are needed, these findings indicate that for the purpose of mitigating rises in core temperature exceeding recommended limits (>1 °C), ACGIH guidelines have comparable effectiveness in non-heat acclimatized men and women during moderate-intensity work. Novelty: Sex did not appreciably influence thermal strain nor the proportion of participants with core temperatures exceeding recommended limits. Sex did not significantly influence tolerance to uncompensable heat stress. Despite originating from data obtained in only men, current occupational heat stress guidance offered comparable effectiveness in men and women.

GPR-68 in human lacrimal gland. Detection and possible role in the pathogenesis of dry eye disease.

INTRODUCTION: In parallel to ocular surface disease in dry eye there is often a dysfunctionality of the lacrimal gland apparatus. The functionality of the lacrimal gland is of major importance for maintenance of ocular surface integrity and health, even in conditions of enhanced stimulation and secretion requirements. Such enhanced secretion demands can push the lacrimal gland to its limits, with maximized tear fluid secretion and increased flow through the lacrimal ducts. The goal of this study was to investigate whether G protein-coupled receptor GPR-68 is present in the lacrimal gland, as this protein has recently been shown to be sensitive to flow rate and osmolarity. METHODS: For this purpose, de-identified sections of human lacrimal gland tissue were stained for the presence of G protein-coupled receptor 68 with specific antibodies using immunohistochemistry. RESULTS: Specific staining was detected in the acini and ducts of human lacrimal gland. In the ducts, the specific staining was found around the lumen of the ducts. In the acini, the specific staining was observed more towards the lumen but also intercellularly between the acinar cells. DISCUSSION: The detection of G protein-coupled receptor GPR-68 in the lacrimal gland, especially around the lumen of the ducts, raises the question about its function and purpose. Activation of GPR68 leads to modification of various cell functions and is associated with regulation of inflammation. Accordingly, enhanced, secretion-induced, augmentation of flow might exert fluid flow stress on the ducts and acini. This might lead to transient, localized activation of GPR-68 and secondary inflammation within the gland. Depending on the intensity, continuity or repetitive nature of the stimuli, exhaustion of the lacrimal gland secretion capacity might follow, and chronicity of the inflammation in the parenchyma as well as around the ducts might be a consequence. CONCLUSION: G protein-coupled receptor GPR-68, sensitive to flow, is present in the human lacrimal gland. Increased flow, triggered by sensations such as are typical for dry eye, might lead to local inflammation. It is possible that these sensations might serve as a better indicator for the need and success of therapy than the clinical signs of dry eye disease, at least in the early stages of the disease.