[Metabolic side effects of risperidone in early onset schizophrenia]. / Effets secondaires métaboliques de la rispéridone dans les schizophrénies à début précoce.

BACKGROUND: Atypical antipsychotics have a favourable risk/benefit profile in early onset schizophrenia (EOS). However, despite increasing use of psychotropic medication in children and adolescents, their endocrine and metabolic side-effects (weight gain, obesity, and related metabolic abnormalities such as hyperglycaemia and dyslipidemia) are of particular concern, especially within this paediatric population that appears to be at greater risk as compared with adults for antipsychotic-induced metabolic adverse effects. In addition to medication, many factors contribute to weigh gain in psychiatric patients, including sedentary lifestyle and poor diet. Excessive weigh gain has several deleterious effects in psychiatric patients, including stigmatization and further social withdrawal, and non compliance with medication. Furthermore, excessive corpulence may evolve to a metabolic syndrome with a high-risk state for future cardiovascular morbidity and mortality in adult age. Because youths are still developing at the time of psychotropic drug exposure, in a context of physiological changes in hormonal and endocrines levels and body composition, most reference values need to be adjusted for gender, age and growth charts. Hence, sex- and age-adjusted BMI percentiles and BMI Z scores are crucial to assess weight gain in children and adolescents. LITERATURE FINDINGS: Obesity thresholds have been proposed to define "at risk" categories of patients. In recently issued guidelines, thresholds for antipsychotic-induced weight gain in adults have been set at a 5% increase or one point increase in BMI unit. To date, no definition has reached a consensus in childhood and adolescence. However, some at risk states requiring action are proposed in literature: more than 5% increase in weight within a three-month period; more than half a point increase in BMI Z score; between 85th and 95th BMI percentile plus one adverse health consequence (i.e. hyperglycaemia, dyslipidemia, hyperinsulinemia, hypertension, or orthopaedic, gallbladder, or sleep disorder); or more than 95th BMI percentile or abdominal obesity (i.e. abdominal circumference above 90th percentile). As a matter of fact, numerous studies that have assessed weight gain during antipsychotic treatment are clearly limited, either because of their short duration (a few weeks), or because of their methodology: indeed, only weight gain is generally reported as an assessment tool. Merely noting an increase in body weight over time does not in itself signify a problem, and may underscore the importance of excessive corpulence growth as compared with controls. Adjusted BMI percentiles and BMI Z scores were calculated in only a few studies. AIM OF THE STUDY: This pilot study focuses on the metabolic effects of risperidone in children and adolescents up to 16 years of age. This study is part of a larger, regional study on metabolic side effects of antipsychotic medication in adults, promoted by the university hospital centre in Lille, France. DESIGN OF THE STUDY: Patients included in the study were referred to our department of child and adolescent psychiatry for EOS (K-SADS). They had received no antipsychotic treatment prior to their inclusion. Weight, height, sex- and age-related BMI percentiles and BMI Z scores, waist circumference, blood pressure, fasting triglyceride levels, fasting total and high-density lipoprotein cholesterol levels, and fasting glucose level were measured at M0, M3, and M6. BMI, sex- and age-related BMI percentiles and adjusted BMI Z scores were obtained from tables and calculator (www.kidsnutrition.org). RESULTS: Twenty-six children and adolescents (21 males, five females) aged 7 to 15.5 years (mean=12.9 years, sd=2.3) were included. They all received a diagnosis of schizophrenia according to the schedule for affective disorders and schizophrenia for school-aged children (K-SADS). They all received risperidone from 1mg/day to a maximum of 6 mg/day. Statistical analysis principally shows a significant link between prescription of risperidone in EOS and six-months increases of BMI (increase of 4.7 kg/m(2), p<0.0001), sex- and age-adjusted BMI percentile (increase of 29.3 points, p<0.0025), and BMI Z scores (increase of 1.1 point, p<0.0001). No patient showed metabolic syndrome, but one girl presented with a 1g/l increase of fasting total cholesterol at two-months. DISCUSSION: Despite the limited number of children included, our results confirm a strong link between prescription of risperidone in EOS and risk of obesity. Clinicians and caregivers need to be aware of the potential endocrine and metabolic adverse effects of atypical antipsychotics, and systematically ask for family history of metabolic disorder, life style, diet and habits. With adolescents, the sole monitoring of weight gain, and even of BMI, underestimates the gain of corpulence. One methodological implication of our study is that adjusted BMI Z scores are the best-suited measure to assess long-term drug-induced weight gain in comparison to developmental changes. CONCLUSION: Alternative treatment should be considered in some cases. Other antipsychotics, like aripiprazole, may have a better benefit/risk ratio and then may be prescribed as a first prescription or as a switch. Associations of antipsychotics may also be of interest but we lack controlled studies in children and adolescents. In some cases, alternative treatments like repetitive trans-cranial magnetic stimulations (rTMS) may be required. Their efficacy and their place in the therapeutic strategy of pharmacoresistant schizophrenia in children and adolescents have to be assessed in regard to metabolic and blood side effects of clozapine.

Psychiatric side effects of interferon-beta in multiple sclerosis.

Psychiatric disorders, especially depression, are frequent in patients with multiple sclerosis (MS). They are attributed both to the psychosocial impact of a chronic, usually progressive, disabling illness and to cerebral demyelination. Besides, drugs such as corticosteroids and possibly interferon (IFN) may also have depressogenic effects. Major depressive disorders and/or suicidal ideation are a major concern and efforts to identify and minimize these reactions are of much importance. Psychiatric side effects, particularly depression, are widely reported with IFN-alpha and have been suspected with IFN-beta but are not yet fully established. Our review of the literature revealed that most studies discard an association between IFN-beta and depression or suicide. However, few patients, especially those with a history of depression, might be at higher risk for depression when treated with IFN-beta. Overall, considering the uncertainty of a link between IFN-beta and depression and/or suicide, as well as the complete remission of psychiatric complications after IFN discontinuation and/or antidepressant treatment, physicians should closely monitor the psychiatric status of patients, but should not refrain from including them in IFN-beta treatment programs, even when they have past or present depression.

[Food avoidance emotional disorder in 3 to 10-year-old children: a clinical reality]. / Evitement alimentaire et trouble affectif chez l'enfant.

We underline the clinical importance of a specific eating disorder in 3 to 10 years old children, when the majority of the works about the prepubertal eating disorders focus either on the period just preceding adolescence (often between 10 and 13 years), or on the second half of the first year of the baby. Within the eating disorders described in the literature, we compare the clinical presentation of most of these 3 to 10 years old children with the food avoidance emotional disorder described during adolescence. These problems of eating behaviour (various selective eating with or without provoked vomiting) are ignored for a long time in these young children because of quite a satisfactory growth, but these children are often seen in emergency rooms because of a brutally complete eating refusal. Therapeutic consultations allow these children to express their fears about diseases, poisoning and death, for themselves or for their close relations, in particular the mother, without endangering their body. The early recognition and care of these difficulties of conciliation between the body and the thoughts impose a narrow collaboration between paediatric and psychiatric staffs.

Acute delirium, delusion, and depression during IFN-beta-1a therapy for multiple sclerosis: a case report.

Adverse effects of interferon (IFN) treatment are common, and efforts to minimize these reactions are of considerable importance. IFN-beta-1a is an established therapy for patients with relapsing-remitting multiple sclerosis (MS). Its psychiatric side effects are debated and not yet fully established. The authors report here the case of a patient on IFN-beta-1a therapy for MS who developed acute delirium, delusion, and depression that ceased with treatment discontinuation. Although he had a history of recurrent major depressive disorder, his prior psychiatric illness had followed a course that was clinically independent of other signs of MS. This observation points out psychiatric vulnerability of patients taking IFN-beta-1a therapy for MS and suggests that IFN-beta-1a may induce or exacerbate preexisting psychotic symptoms.

[Psychiatric complication of an implanted automatic defibrillator]. / Conséquence psychiatrique après l'implantation d'un défibrillateur automatique. A propos d'un cas.

The implantable automatic defibrillator has completely changed the prognosis of potentially fatal ventricular arrhythmias by the delivery of an electric shock in the event of ventricular tachycardia or fibrillation. This vital device is sometimes poorly accepted from the psychological point of view by patients having been traumatised by experiences of sudden death from which they have been rescuscitated. Anxiety and depression are common and they have an important effect on the quality of life. The unpredictable occurrence of painful, multiple and uncontrollable electrical shocks may induce a state of acute stress with stunning, the resemblance of which to the model of learned helplessness described experimentally in the animal by Seligman, is discussed. The authors report the case of a 20 year old man whose automatic defibrillator was activated twenty times in one night. His state of stress and impotence was such that he lay prostate in his bed. Suicide seemed to be the only possible way of escaping from the electrical shocks of the device which was perceived as being dangerous. The management of this condition is not standardised but it requires the collaboration of the cardiac rhythmological and psychiatric teams. Medication with antidepressant drugs alone is not sufficient. The regulation of the sensitivity of the defibrillator gives the patient a feeling of mastering the situation: submission is not total! Research along this line should improve the patients' acceptation of the device and their quality of life.

[Bipolar affective disorder and Ekbom syndrome: apropos of a case]. / Trouble affectif bipolaire et syndrome d'Ekbom: à propos d'un cas.

A delusion of parasitosis may be seen in patients with a variety of organic and psychiatric disorders. It may also be a primary delusion often referred to as the "Ekbom syndrome". The nosological categorization of this rare condition is still under debate. We report the case of a 81 year-old woman followed in our department during more than 20 years for a bipolar affective disorder. Five years ago she developed a persistent delusion of parasitosis displaying phenomenological characteristics that are typical of the Ekbom syndrome. Given the complete independence of the respective courses of affective and delusional symptoms, we concluded in favour of a genuine comorbid association between two independent disorders. To our knowledge this association has not heretofore been described in the French or English language literature. It raises questions regarding the connections between affective disorders and delusions of parasitoris.

[Prospective study of favorable factors in follow-up of drug addicted patients--apropos of 257 patients of the Cassini Center in Paris]. / Recherche prospective de facteurs favorisant le suivi des toxicomanes--à propos de 257 patients du centre Cassini de Paris.

UNLABELLED: Assessing the effectiveness of treatment is one of the main concerns of any medical process. The different ways proposed for assuming the responsibility of drug addicts and their efficacy are greatly heterogeneous since drug-abusing takes on diverse forms. Thus, in order to closely target the request of drug addicts and adjust their follow-up, we undertook to study prospectively, for 3 months, a population of drug addicts taking medical advice for the first time at the Cassini center in Paris, with the assumption that some predictors may forecast outcomes. METHOD: Data were obtained at the admission with a structured interview about socio-economic and demographic status, psychiatric disorders (assessed clinically according to DSM III-R and with HAD and MADRS scales), substance use and prior treatment history, environmental data (as well as familial substance use or support lending). Medical and paramedical referents have been interviewed after their first contact with the patient about his expectations and his motivation. Familial attendance at this first contact was noted as well as its implication in the programme. At the end of the study, we noted length of stay, regularity of follow up and clinical changes with a last interview of the staff. RESULTS: Half the time, patients' follow up doesn't last a month, drug abuse doesn't change in 6 out of 10 cases, and we only note 14% of durable abstinence. Polydrug abuse (over 80%) is not linked, here, with pejorative outcomes, in opposition to the usual literature. Heroin is the main substance used by our population (over 80%), other opiates, sedatives and alcohol are associated by more than 30% of these patients; cocaine is associated in a quarter of the cases. More than 10% of the patients are concerned by ecstasy and LSD. Cannabis use is common. Medical complaint (mainly viral diseases) at the beginning of the programme, concerns one of two patients. Only a few are initially known as being HIV positive, suggesting a great lack of information. Over forty percent of the patients are given a DSM III-R diagnosis at the end of the first medical advice, when a doubt subsists for a third of the other patients. Major depressive disorder for the first axis and borderline personality disorder for the second axis are the main disorders we founded. We also noted a large ratio (n = 13.5%) of schizophrenic disorders. Univariate analysis: length and regularity of the programmes are key factors of their efficacy. A long follow-up is also required to improve patients' socio-economical status. Initial psychiatric disorders are linked, in our study as well as in literature, with longer stays in therapeutic programms. By revenge, psychiatric disorders at the third month (over 10%) are linked with poorer outcomes. We noted with interest that, in our sample, neither imprisonment in the past (over 40%, but we noted several imprisonments in a case out of two), or intraveinous route at any moment of the patient's life time (40%), or else a programm caused by a court (a quarter of the patients) are of wrong prognosis. Relatives' implication in the programm is linked with favorable outcomes. Multivariate analysis draws 3 independent clusters about the length of stay. One concerns patient's motivation as assessed by medical staff. An other one concerns patient's relatives' implication in the care. A third one is about the begining of the treatment: an initial medical prescrition and a psychological help are linked with favorable outcomes. About the efficacy, multivariate analysis isolates 4 independant clusters. Prior drug abuse programmes (one out of three patients) are associated with poorer outcomes, when, by revenge, familial relationship initially seen by the patient as (very) satisfying, patient's motivation, and, again, an initial medical prescription are linked with better outcomes. The study of those of the patients whose programme lasted more then 3 months but without any appreciable benefit shows that a long follow-up is successful when it is regular, when it provides a socio-economical status improvement and when the patient is given access to insight. For these patients, the (old) age is associated with better outcomes. By revenge, such a 3 months follow-up is not able to reduce drug abuse when a psychiatric disorder exists at the third month. Patients whose treatment was referred by a court don't differ from the others: their length of stay and outcomes are the same. DISCUSSION: Our study confirms our initial hypothesis according to witch subgroups in our population of drug abusers should be isolated and that some predictors of outcomes should be described. Three points seem important to be discussed. First, a medical prescription appears to be important to initiate the relationship between the patient and his practicioner. We have never see any report about this particular point. (ABSTRACT TRUNCATED)

[Neonatal death of a newborn twin]. / Le décès d'un jumeau en réanimation néonatale. La place que le psychiatre peut prendre.

In France, in 2001, 33,000 children were born from multiple pregnancies (4.2% of births). Lately, with the stimulated fertilization improvement, this number has strongly increased. These pregnancies are pretty often difficult and the hospitalizations of the twins (or other multiples) in a neonatal intensive care unit are more frequent than in a single pregnancy (48 vs. 5.3%). Newborn twin death leads the parents to face a tough mourning because of the surviving twin presence. The psychiatrist's function is crucial with the parents, the deceased child, the surviving child and the pediatric staff. Therefore, as much as possible, the psychiatrist (or the psychologist) has to gather and work through the confused feelings of the parents. Several splittings occur in this situation. Some of these splittings concern the medical staff, some others affect the children, the dead one and the living one, either rejected and disinvested or idealized and overprotected. The child psychiatrist is a preferred recipient for the different projections of the parents.The hospital staff as a whole has to understand their full significance and their important psychic sparing for the couple. As the deceased child, the psychiatrist may look bad and unsatisfying, for instance: "he doesn't answer as we would like", "he doesn't come up to the couple's expectations", "he doesn't talk enough", "he's leaving too soon", etc.In addition, the psychiatrist may be attacked as the representative of the pediatric staff, in order to preserve in a better way the others medical protagonists, still essential for the survival of the alive child. These parents are in mourning and the psychiatrist must help them in this process in order to improve the specific investment of the surviving child, the attachment and the communication with him.