Managing acutely aggressive or agitated people in a psychiatric setting: a survey in Lebanon

Background: Violent patients constitute 10% of all psychiatric admissions. Treatment options and clinical practice interventions vary across the globe and no survey of practice in a Middle Eastern setting exists. Surveying treatments in Lebanon will show treatment interventions used in this part of the world and, most importantly, provide the treatment options that could potentially be used for clinical trials pertaining to emergency psychiatry. Methods: A survey of clinicians’ opinions and practice was conducted between July and August 2017 at the largest psychiatric hospital in Lebanon. Results: Five of seven experienced psychiatrists provided opinions when interviewed of their preferred intervention when dealing with an emergency psychiatric episode. Whilst this varied in detail, there was a consistent view that there should first be verbal control, then use of medications, and finally physical restrain of the patient. A total of 39 emergency episodes (28 people) occurred in the one month (64% men in their 30s). Bipolar disorder was the most frequent single diagnosis behind the aggression (n=16, 41%; 12 people 43%) but the combined schizophrenia-like illnesses underlay 18 of the 39 episodes (46%; 13/28 people 46%). In clinical life, we found evidence of high family involvement, but little attempts made at initial verbal control in the hospital. All 39 episodes involved administration of pharmacological interventions. Medications were used in 29 of cases (74%) and non-medication interventions used in the remaining 10/39 (26%). Conclusion: This survey provides some evidence that clinicians’ preferences may not fully reflect clinical practice but also that experienced clinicians are using several clearly effective techniques to manage these very difficult situations. However, as for other parts of the world, treatment in Lebanon has limited or no underpinning by evidence from well-designed, conducted and reported evaluative studies

“With every passing day I feel like a candle, melting little by little.” experiences of long-term displacement amongst Syrian refugees in Shatila, Lebanon

Abstract Background Long term displacement and exposure to challenging living conditions can influence family dynamics; gender roles; violence at home and in the community and mental well-being. This qualitative study explores these issues as perceived by Syrian refugees who have been living in Shatila, a Palestinian camp in South Beirut, Lebanon, for at least 2 years. Methods Twenty eight in-depth interviews with men and women were conducted between February and June 2018. Women were recipients of mental health services, and men were recruited from the local community. Interviews were conducted in Arabic, translated, transcribed, coded and analysed using thematic content analysis. Results Our results show patterns of harsh living conditions similar to those described earlier in the course of the Syrian refugee crisis. Lack of infrastructure, overcrowding, cramped rooms and violence were all reported. Participants also described a lack of social support, discrimination and harassment within the host community, as well as limited social support networks within their own Syrian refugee community. Family dynamics were affected by the increased responsibilities on men, women and children; with additional economic and employment demands on men, women assuming the roles of ‘mother and father’ and children having to work and contribute to the household. Participants discussed several types of violence, including parental violence against children and violence in the community. Violence against women was also reported. Reported mental health issues included depression, anxiety, sadness, frustration, hopelessness, self-neglect and a loss of sense of self and self-worth. Some participants expressed a wish to die. Conclusions This study describes experiences of changing gender roles, family dynamics, violence and mental health after long-term displacement in in Shatila camp, South Beirut as perceived by Syrian refugees. A lack of safety and security coupled with economic hardship rendered refugees even more susceptible to exploitation and harassment. Parental violence was the most commonly reported type of domestic violence

Study protocol for a randomised controlled trial of haloperidol plus promethazine plus chlorpromazine versus haloperidol plus promethazine for rapid tranquilisation for agitated psychiatric patients in the emergency setting (TREC-Lebanon)

Background: Agitated and aggressive behaviours are common in the psychiatric setting and rapid tranquilisation is sometimes unavoidable. A survey of Lebanese practice has shown that an intramuscular haloperidol, promethazine and chlorpromazine combination is a preferred form of treatment but there are no randomised trials of this triple therapy.Methods: This is a pragmatic randomised trial. Setting - the psychiatric wards of the Psychiatric Hospital of the Cross, Jal Eddib, Lebanon. Participants - any adult patient in the hospital who displays an aggressive episode for whom rapid tranquilisation is unavoidable, who has not been randomised before, for whom there are no known contraindications. Randomisation – stratified (by ward) randomisation and concealed in closed opaque envelope by independent parties. Procedure – if the clinical situation arises requiring rapid tranquilisation, medical residents overseeing the patient will open a TREC-Lebanon envelope in which will be notification of which group of treatments should be preferred [Haloperidol + Promethazine + Chlorpromazine (HPC) or Haloperidol + Promethazine (HP)], along with forms for primary, secondary and serious adverse effects. Treatment is not given blindly. Outcome - primary outcome is calm or tranquil at 20 minutes post intervention. Secondary outcomes are calm/tranquil at 40, 60 and 120 minutes post intervention, asleep, adverse effects, use of straitjacket and leaving the ward. Follow-up will be up to two weeks post randomisation.Discussion: Findings from this study will compare the HPC versus HP combination used in Lebanon’s psychiatry emergency routine practice.Trial registration: ClinicalTrials.gov NCT03639558. Registration date, August 21, 2018

The bi-focal model : An integration of diagnostic and transdiagnostic approaches

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Correlates of severity in a clinical staging model of schizophrenia: a cross-sectional study among 158 subjects

Abstract Background Clinical staging has been widely used to predict and optimize the treatment of medical disorders. Different models have been proposed to map the development, progression, and extension of psychiatric disorders over time, mainly for schizophrenia. The primary objective of this study was to classify patients with psychosis according to the McGorry staging model and compare factors between the different stages. Methods This was a cross-sectional study, collecting data from 158 patients hospitalized for schizophrenia/psychosis. The survey included the Mini International Neuropsychiatric Interview (MINI), Positive and Negative Symptom Scale (PANSS), Montgomery-Asberg Depression Rating Scale (MADRS), Yong Mania Rating Scale (YMRS), Clinical Global Impression (CGI) scale, and the McGorry staging model. Results Patients have been classified into three clinical stages: relapse of psychotic disorder (43%), multiple relapses (47.5%), and persistent and severe illness (9.5%). A higher mean duration of hospitalization, psychotic symptoms (PANSS total scale and subscales), chlorpromazine equivalent dose, and number of antipsychotic treatments were found among participants in Stage 4 as compared to the other groups. However, a significantly higher mean GAF scale was found among participants in stage 3b as compared to the other groups. Conclusion Each stage in the McGorry staging model of schizophrenia is associated with well-defined clinical presentations, which help decide the appropriate treatment. Using such models in psychiatry can improve the diagnostic process and potential therapeutic interventions for patients suffering from mental disorders

Factors associated with overweight and obesity in Lebanese male patients with schizophrenia

International audiencePurpose: To assess the influence of lifestyle factors, antipsychotic medications, and psychosis symptoms on obesity in a group of male patients with schizophrenia in Lebanon.Design/methods: A cross-sectional study conducted between May and July 2018 enrolling 149 male patients with chronic schizophrenia.Results: We found that 59.1% of the patients were obese/overweight. Older age and higher negative and total positive and negative syndrome scale scores were significantly associated with lower body mass index values.Practice implications: This study shed light on some factors associated with obesity in male patients with schizophrenia, which may be targeted for the prevention and management of obesity. Some interventions were proposed such as focusing on patients' physical health, psychiatric treatment, and maintaining a healthy diet and a healthy lifestyle

Role of estuarine habitats for the feeding ecology of the European eel (Anguilla anguilla L.)

This study aims to characterize and compare the feeding ecology of the European eels (Anguilla anguilla L.) during the continental phase (i.e. yellow and silver) along a salinity gradient (i.e. lower, middle and upper) in six northern France estuaries (i.e. brackish water). The diet and stable isotopic (i.e. δ15N and δ13C values) compositions of eels collected with a fyke net in six estuaries (Slack, Wimereux, Liane, Canche, Authie and Somme estuaries) located along the French coast of the eastern English Channel per season over a year were described by combining gut content and stable isotope analyses. Eel guts were dominated by typical BW prey, Malacostraca and Actinopterygii (54% and 40%, respectively), with the gammare Gammarus zaddachi and the green crab Carcinus maenas (38% and 14%, respectively), and smaller yellow eels of A. anguilla and juvenile European flounder, Platichthys flesus (19% and 14%, respectively) being the most frequently found in their guts. The δ13C values of a majority of eels confirmed the sea- and brackish water-specific carbon resources. Dietary and isotopic niche revealed no clear change between total length, silvering stages and seasons, but a significant difference between salinity gradients and estuaries. Eels δ13C values showed significant enrichment from upper to lower along the estuaries while the δ15N values showed an inverse effect, with the lowest values in the lower part and highest in the upper part. Higher variability in δ13C values in larger estuaries suggested that eels feed on a wide range of food sources than in smaller estuaries. While eels in the smaller estuaries fed mainly on Actinopterygii prey, eels in the larger ones had a lower trophic level (i.e. δ15N values) and fed mainly on Malacostraca prey. This spatial difference in dietary and isotopic niche is discussed in relation to biological structure of eel and environmental variables

PLASTIC-Seine research project: Microplastic Flux and Impact on biota in the Seine estuary.

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Évaluation de la contamination et des effets écotoxiques des microplastiques en estuaire de Seine ; les premiers enseignements du projet Plastic-Seine

International audienceLe bassin versant de la Seine peut être considéré comme représentatif des bassins hydrographiques fortement impactés par l'activité humaine et à ce titre présente une forte pression de pollution. La pollution chimique constitue une menace supplémentaire pour des écosystèmes aquatiques déjà trèsfragiles tels que les estuaires et les zones marines côtières. Peu d'études se sont concentrées sur la contamination et l'impact des microplastiques (MP, taille < 5 mm) dans les écosystèmes estuariens et aucune à ce jour en estuaire de Seine. Le projet Plastic-Seine (GIP Seine-Aval et CPIER Vallée de Seine) vise d’une part à quantifier la présence et le flux de MP dans l'estuaire de la Seine et d’autre part à évaluer leur devenir et leur impact sur différentes espèces du réseau trophique. Plusieurs campagnes de terrain ont été menées depuis mars 2017 sur le continuum eau douce-eau salée à différentes saisons pour échantillonner les eaux de surface, les sédiments et sept espèces du réseau trophique (poissons, crustacés, mollusques, annélides) représentatives de l'écosystème estuarienne de la Seine. Les premiers résultats indiquent une contamination modérée (1,8-5,1 fragments/m3) mais généralisée des différents compartiments abiotiques et biotiques par des MP comprenant principalement des fibres et des fragments. Des MP ont été identifiés dans toutes les espèces analysées, quel que soit le site ou la saison de prélèvement. Des expositions à des MP environnementaux en conditions contrôlées de laboratoire ont démontré l’ingestion mais aussi l’égestion très rapide de ces MP par les annélides et la sole commune (les analyses sont en cours sur les copépodes). Des premiers effets significatifs des MP sur la survie et la reproduction du copépode E. affinis et sur le comportement des soles ont été observés. Ce projet devrait fournir d’ici 2020 une première évaluation de la distributionet du flux de microplastiques dans l'estuaire de la Seine et de la faune aquatique associée