La loi du 5 juillet 2011 relative aux soins sans consentement en psychiatrie (regards croisés d acteurs de proximité sur un nouveau dispositif)

La loi du 5 juillet 2011 relative aux droits et à la protection des personnes faisant l objet de soins psychiatriques et aux modalités de leur prise en charge a été fortement critiquée et souvent rejetée, avant puis lors de sa parution. Elle est appliquée depuis le mois d aout 2011. Notre étude a pour objectif de décrire et de croiser les perceptions de cette loi par des acteurs de terrain, après six mois d application, puis d en déduire des pistes d amélioration. Cette étude qualitative multicentrique (Isère et Savoie) réalisée auprès de vingt quatre acteurs de proximité, recrutés parmi des psychiatres, juges, patients et familles montre que cette loi n est pas globalement remise en cause et qu elle apporte des avantages pratiques : période d observation, regard extérieur du juge, soins rapides aux personnes isolées en cas de péril imminent, amélioration des certificats ainsi que du suivi ambulatoire. Mais la loi du 5 juillet entraine aussi de nombreuses difficultés : les moyens manquent ; certaines parties du texte ne sont pas claires ; les audiences sont problématiques car précoces, publiques, et parfois réalisées en dehors des établissements hospitalier ; les possibilités de sorties d essai de moyenne durée ont été abolies ; et les relations justice-psychiatrie sont complexes. Dix propositions ont pu être dégagées des entretiens et de leur analyse, afin d améliorer la loi et les conditions de sa mise en œuvre. Ces recommandations relèvent de modifications législatives, de la création de dispositifs complémentaires innovants, d actions de formations et de l apport de moyens supplémentaires.The Law of the 5th of July 2011 on the rights and protection of persons under psychiatric care and on modalities of their care was heavily criticized and often rejected before and since it was published. The law is now applied since August 2011. Our study aims to describe and cross the perceptions of the law by peoples concerned by the law, after six months of operation, and then to deduce possible improvements. This multicenter qualitative study (Isère and Savoie) based on twenty-four interviewee including psychiatrists, judges, patients and families, shows that this law is not totally questioned and provides practical advantages: a period observation, an outside view of the judge, efficient cares for isolated peoples with a risk of a imminent danger, improvement of certificates as well as ambulatory health care. But the act of the 5th of July leads to many problems: financial difficulties; badly explained parts of the text; problematic hearings because premature, public, and sometimes performed outside of hospitals; no authorization of get out of the hospital more than twelve hours and unaccompanied during hospitalization under constraints; and relationships between justice and psychiatry are complex. Based on interview analysis, ten proposals are presented in order to improve the law and his application. These recommendations are legislative changes, the creation of innovative organization, training actions and the provision of additional resources.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Quels sont, en médecine générale, les motifs de consultations des étudiants ? (Secondairement, évaluation de la part psychologique des motifs)

INTRODUCTION : La France comptait 2,3 millions d étudiants en 2011. Les données actuelles montrent que 37% des étudiants éprouvent du stress et 23% des troubles du sommeil. Leurs interrogations fréquentes concernent le stress et le sommeil. Aucune donnée n émerge du corps médical. Cette étude réalisée grâce au CNGE [Collège National des Généralistes Enseignants], va identifier les motifs de consultations des étudiants et en évaluer la part psychologique. METHODE : Du 01/12/2011 au 30/04/2012, 54 internes en stage ambulatoire, ont réalisé le recueil chez 128 généralistes en France. Une fois par semaine, ils relevaient les données administratives et les motifs de consultations énoncés par chaque patient. Il était requis 400 consultations par investigateur. 549 consultations d étudiants ont été analysées en utilisant la Classification Internationale en Soins Primaires. RESULTATS : L échantillon est composé de 369 femmes et de 180 hommes. L âge moyen est de 22 ans. Il y a 1127 motifs analysés. Les motifs les plus fréquents sont : contact administratif (3,8%), toux (5,1%), diarrhée (2,9%), plaintes des lombes (1,1%). Les motifs psychologiques sont en 5ème position et représentent 7,3 % des motifs: "plaintes du sommeil" (20.7%) "sensations de tristesse" (11%). CONCLUSION : Les motifs fréquents sont d ordre général, respiratoire, digestif ou ostéo-articulaires et psychologiques. La venue en consultation d un étudiant pour un banal motif devrait être l occasion d investiguer le sommeil, l état moral et d aborder les thèmes pour lesquels ils souhaitent des informations afin de préserver la santé mentale des étudiants.INTRODUCTION: There were 2.3 million students at the start of the school year 2011. The current data about their health show that 37% suffer from stress and 23% from sleep disorder. Their most frequent questions are about nutrition, stress and sleep. No analyzes emerges from the medical profession. The goal of this epidemiological study realized thanks to the CNGE is to identify students consultations motivations and to estimate the psychological proportion from them. METHOD: From 12/01/2011 to 04/30/2012, 54 internal students realized the data collection during their ambulatory internship among 128 general practitioners distributed in France. Once a week, they collected the administrative data and the consultations motivations expressed by every patient. 20 000 consultations all in all were required. Then, 550 students consultations were analyzed by using the international classification of primary care. RESULTS: The sample consists of 369 women and 180 men with 22 middle-aged years. There are 1127 analyzed consultations motivations. The most frequent are of general order or concern the respiratory, digestive and osteo-articular systems: Administrative need (3.8%), cough (5.1%), diarrhea (2.9%), complaints of loins (1.1%). Psychological motivations are on the 5th position with 7.3%. Inside, sleep complaints and sadness sensations dominate. CONCLUSION: Frequent motivations are of general, respiratory, digestive or osteo-articular order. Psychological order complaints found by the previous analyzes are present in general medicine consultations A student s consultation for a commonplace motive should be the opportunity to approach sleeping disorders, moral state and the students wonderings, to prevent students mental health.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Construction and Validation of an Analytical Grid about Video Representations of Suicide (“MoVIES”)

International audienceExposure to fictional suicide scenes raises concerns about the risk of suicide contagion. However, researchers and clinicians still lack empirical evidence to estimate this risk. Here, we propose a theory-grounded tool that measures properties related to aberrant identification and suicidal contagion of potentially harmful suicide scenes. Methods. The items of the Movies and Video: Identification and Emotions in reaction to Suicide (MoVIES) operationalize the World Health Organization's recommendations for media coverage of suicide, and were adapted and completed with identification theory principles and cinematographic evidence. Inter-rater reliability (Cohen's kappa) and internal consistency (Cronbach's alpha) were estimated and optimized for two series of 19 and 30 randomly selected movies depicting a suicide scene. The validity of the scale in predicting identification with the suicidal character was tested in nine unknowledgeable participants who watched seven suicide movie scenes each. Results. The MoVIES indicated satisfying psychometric properties with kappas measured at 0.7 or more for every item and a global internal consistency of [α = 0.05]. The MoVIES score significantly predicted participants' strength of identification independently from their baseline empathy ((β = 0.20), p < 0.05). Conclusions. The MoVIES is available to scholars as a valid, reliable, and useful tool to estimate the amount of at-risk components of fictional suicidal behavior depicted in films, series, or television shows

Decisional impulsivity and the associative-limbic subthalamic nucleus in obsessive-compulsive disorder: stimulation and connectivity.

Why do we make hasty decisions for short-term gain? Rapid decision-making with limited accumulation of evidence and delay discounting are forms of decisional impulsivity. The subthalamic nucleus is implicated in inhibitory function but its role in decisional impulsivity is less well-understood. Here we assess decisional impulsivity in subjects with obsessive compulsive disorder who have undergone deep brain stimulation of the limbic and associative subthalamic nucleus. We show that stimulation of the subthalamic nucleus is causally implicated in increasing decisional impulsivity with less accumulation of evidence during probabilistic uncertainty and in enhancing delay discounting. Subthalamic stimulation shifts evidence accumulation in subjects with obsessive-compulsive disorder towards a functional less cautious style closer to that of healthy controls emphasizing its adaptive nature. Thus, subjects with obsessive compulsive disorder on subthalamic stimulation may be less likely to check for evidence (e.g. checking that the stove is on) with no difference in subjective confidence (or doubt). In a separate study, we replicate in humans (154 healthy controls) using resting state functional connectivity, tracing studies conducted in non-human primates dissociating limbic, associative and motor frontal hyper-direct connectivity with anterior and posterior subregions of the subthalamic nucleus. We show lateralization of functional connectivity of bilateral ventral striatum to right anterior ventromedial subthalamic nucleus consistent with previous observations of lateralization of emotionally evoked activity to right ventral subthalamic nucleus. We use a multi-echo sequence with independent components analysis, which has been shown to have enhanced signal-to-noise ratio, thus optimizing visualization of small subcortical structures. These findings in healthy controls converge with the effective contacts in obsessive compulsive disorder patients localized within the anterior and ventral subthalamic nucleus. We further show that evidence accumulation is associated with anterior associative-limbic subthalamic nucleus and right dorsolateral prefrontal functional connectivity in healthy controls, a region implicated in decision-making under uncertainty. Together, our findings highlight specificity of the anterior associative-limbic subthalamic nucleus in decisional impulsivity. Given increasing interest in the potential for subthalamic stimulation in psychiatric disorders and the neuropsychiatric symptoms of Parkinson's disease, these findings have clinical implications for behavioural symptoms and cognitive effects as a function of localization of subthalamic stimulation.This work was supported by Agence Nationale de la Recherche (grant number ANR-14-CE13-0030-01 Physiobs); and University Hospital of Grenoble (Direction de la Recherche Clinique et de l’Innovation). This work was supported by a Wellcome Trust Fellowship grant to V.V. (983705/Z/10/Z)

Relationship between childhood physical abuse and clinical severity of treatment-resistant depression in a geriatric population

Introduction: We assessed the correlation between childhood maltreatment (CM) and severity of depression in an elderly unipolar Treatment-Resistant Depression (TRD) sample. Methods: Patients were enrolled from a longitudinal cohort (FACE-DR) of the French Network of Expert TRD Centres. Results: Our sample included 96 patients (33% of the overall cohort) aged 60 years or above, with a mean age of 67.2 (SD = 5.7). The majority of the patients were female (62.5%). The Montgomery and Asberg Depression Rating Scale (MADRS) and Quick Inventory Depression Scale-Self Report (QIDS-SR) mean scores were high, 28.2 (SD = 7.49) [MADRS score range: 0–60; moderate severity≥20, high severity≥35] and 16.5 (SD = 4.94) [IDS-SR score range: 0–27; moderate severity≥11, high severity≥16], respectively. Mean self-esteem scores were 22.47 (SD = 6.26) [range 0–30]. In an age- and sex-adjusted model, we found a positive correlation between childhood trauma (CTQ scores) and depressive symptom severity [MADRS (β = 0.274; p = 0.07) and QIDS-SR (β = 0.302; p = 0.005) scores]. We detected a statistically significant correlation between physical abuse and depressive symptom severity [MADRS (β = 0.304; p = 0.03) and QIDS-SR (β = 0.362; p = 0.005) scores]. We did not observe any significant correlation between other types of trauma and depressive symptom severity. We showed that self-esteem (Rosenberg scale) mediated the effect of physical abuse (PA) on the intensity of depressive symptoms [MADRS: b = 0.318, 95% BCa C.I. [0.07, 0.62]; QIDS-SR: b = 0.177, 95% BCa C.I. [0.04, 0.37]]. Preacher & Kelly’s Kappa Squared values of 19.1% (k2 = 0.191) and 16% (k2 = 0.16), respectively for the two scales, indicate a moderate effect. Conclusion: To our knowledge, this is the first study conducted in a geriatric TRD population documenting an association between childhood trauma (mainly relating to PA) and the intensity of depressive symptoms

Experience Feedback Committee: a management tool to improve patient safety in mental health

BACKGROUND: A management tool, called the Experience Feedback Committee, has been applied for patient safety and successfully used in medical departments. The purpose of this study was to analyse the functioning of an Experience Feedback Committee in a psychiatric department and to explore its contribution to the particular issues of patient safety in mental health. METHODS: We conducted a descriptive study based on all the written documents produced by the Experience Feedback Committee between March 2010 and January 2013. The study was conducted in Grenoble University Hospital in France. We analysed all reported incidents, reports of meetings and event analysis reports. Adverse events were classified according to the Conceptual Framework for the International Classification for Patient Safety. RESULTS: A total of 30 meetings were attended by 22 professionals including seven physicians and 12 paramedical practitioners. We identified 475 incidents reported to the Experience Feedback Committee. Most of them (92 %) had no medical consequence for the patient. Eleven incidents were investigated with an analysis method inspired by civil aviation security systems. Twenty-one corrective actions were set up, including eight responses to the specific problems of a mental health unit, such as training to respond to situations of violence or management of suicide attempts. CONCLUSIONS: The Experience Feedback Committee makes it possible to involve mental healthcare professionals directly in safety management. This tool seems appropriate to manage specific patient safety issues in mental health. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12991-015-0062-2) contains supplementary material, which is available to authorized users

La dépression résistante (concept théorique ou réalité clinique)

La notion de dépression résistante a vu le jour il y a 30 ans, à la suite de la généralisation de l'utilisation des antidépresseurs. Il semble bien que ce concept théorique recouvre une réalité clinique, mais la prévalence généralement annoncée dans la littérature (10 à 30 %) doit être revue à la baisse, suite à l'affinement des critères de définition et à l'élimination des pseudo-résistances. Ces pseudo-résistances sont souvent dues à des comorbidités psychiatriques ou somatiques, à rechercher systématiquement devant un tel tableau clinique. Il faut également éliminer toute association médicamenteuse délétère. La mise au point de bonnes pratiques cliniques et la hiérarchisation des différentes modalités thérapeutiques (optimisation, substitution et potentialisation des antidépresseurs notamment) semblent nécessaires pour limiter le plus possible l'évolution vers la dépression résistante et la dépression chronique. L'étude de la file active d'un service de psychiatrie générale (de Mai 2002 à Avril 2003) n'a pas mis en évidence de cas de dépression résistante. Cette constatation clinique et l'évaluation de la prévalence de la dépression résistante à moins de 5% ne doivent pas faire oublier que la dépression est une pathologie grave, souvent difficile à traiter.GRENOBLE1-BU Médecine pharm. (385162101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

L'automatisme mental de De Clérambault à nos jours (genèse du concept et évolution au travers des principaux modèles psychopathologiques des schizophrénies)

GRENOBLE1-BU Médecine pharm. (385162101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Behavioral effects of repeated electroconvulsive seizures on MAP6 knockout mice

Contexte : L électroconvulsivothérapie est reconnue comme la thérapeutique la plus efficace dans les épisodes dépressifs sévères. Ses mécanismes d action demeurent mal connus mais semblent en lien avec des effets sur la neurogenèse et la neuroplasticité. Nous évaluons ici l effet de crises électroconvulsives (ECS) répétées sur des souris knockout (KO) pour MAP6, qui présentent de multiples troubles du comportement associés à des altérations neuro-anatomiques et biochimiques, et sont considérées comme un bon modèle de troubles psychiatriques. Méthodes : Les comportements de type dépressif des souris KO MAP6 ont été évalués par un test de nage forcée (FST). Des souris KO MAP6 ont ensuite été soumises à dix séances d ECS ou d ECS factices et ont été comparées par un FST. Enfin, des souris KO MAP6 et des souris sauvages (WT) ont été soumises à des ECS répétées et leurs comportements d interaction sociale ont été comparés par un test résident-intrus. Résultats : Avant ECS, les comportements des souris KO MAP6 au cours d un FST sont similaires à ceux de souris WT conditionnées pour présenter des comportements de type dépressif. Les ECS répétées améliorent significativement les comportements de type dépressif des souris KO MAP6 par rapport aux ECS factices. Cet effet disparaît après huit jours. Après dix séances d ECS, la différence significative qui existait dans le test d interaction sociale entre souris KO MAP6 et souris WT disparaît. Cette différence réapparaît à J21 et J30. Conclusions : Les ECS répétées corrigent temporairement les troubles du comportement que présentent les souris KO MAP6 dans le test de nage forcée et le test résident-intrus.Background: Electroconvulsive therapy is documented as the most efficient therapy for severe depression and other psychiatric conditions. Yet, its mechanisms of action remain largely unclear. An increase in neurogenesis and neuroplasticity seems to be linked to therapeutic effects. Electroconvulsive seizures (ECS) have been mostly studied on healthy animals or on stress-induced models of depression. We propose here to evaluate the behavioral effects of repeated ECS on MAP6 knockout mice, which display multiple behavioral disorders, associated with neuro-anatomical and biochemical alterations, and are thus considered a good model of psychiatric disorders. Methods: MAP6 knockout mice were assessed for depression-like behaviors in a forced swim test (FST). They were also subjected to either ECS or sham ECS for ten days, then depression-like behaviors during a FST were compared. Secondly, MAP6 knockout and wild-type (WT) mice were subjected to repeated ECS and their social behaviors were compared using the modified resident-intruder test. Results: Without ECS, the behaviors of MAP6 knockout mice during a FST are similar to those of a learned helplessness model of depression. The behaviors of MAP6 knockout mice subjected to ECS or sham ECS are significantly different on day 1, but not on day 8. After ten ECS, there is no significant difference between the social interaction of MAP6 knockout and WT mice during the first nine days, and there is one on days 21 and 30 as before ECS. Conclusions: Repeated ECS temporarily correct the behavioral disorders displayed by MAP6 knockout mice in the FST and the resident-intruder test.GRENOBLE1-BU Médecine pharm. (385162101) / SudocSudocFranceF

Schizophrénie et maladie bipolaire du sujet âgé (évaluation au moyen d'une batterie neurocognitive courte)

GRENOBLE1-BU Médecine pharm. (385162101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF