Paradoxe et changement dans la relation de soins en psychiatrie

" Comment induire un changement spontané chez un patient ? ". Face à ce paradoxe, le thérapeute répond par un autre paradoxe : apprendre au patient la spontanéité dans la contrainte. C'est l'utilisation des tactiques paradoxales thérapeutiques, dérivées des travaux de M. H. Erickson, G. Bateson et sa théorie de la double contrainte puis de P. Watzlawick et sa pragmatique de la communication. Malgré son apparence innovante, cette approche trouve ses origines dans diverses sagesses orientales, la religion, la littérature et la philosophie...domaines où viennent s'immiscer les paradoxes, démontrant ainsi leur nature intemporelle et universelle. Ce travail a pour objectif de montrer, à travers quelques vignettes cliniques, l'intérêt de l'utilisation des paradoxes de la communication comme levier thérapeutique afin de bloquer les tentatives de solution développées par le patient face à un problème, source de sa pérennisation. L'utilisation de ces techniques, par la confusion et l'effet de surprise qu'elles suscitent, imposent au thérapeute de bâtir une alliance thérapeutique solide, respectant les objectifs et les valeurs du patient.NANTES-BU Médecine pharmacie (441092101) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Combining Postcards, Crisis Cards, and Telephone Contact Into a Decision-Making Algorithm to Reduce Suicide Reattempt

International audienceBACKGROUND:There is growing evidence in the literature that brief contact interventions (BCIs) might be reliable suicide prevention strategies.OBJECTIVE:To assess the effectiveness of a decision-making algorithm for suicide prevention (ALGOS) combining existing BCIs in reducing suicide reattempts in patients discharged after a suicide attempt.METHODS:A randomized, multicenter, controlled, parallel trial was conducted in 23 hospitals. The study was conducted from January 26, 2010, to February 28, 2013. People who had made a suicide attempt were randomly assigned to either the intervention group (ALGOS) or the control group. The primary outcome was the rate of participants who reattempted suicide (fatal or not) within the 6-month study period.RESULTS:1,040 patients were recruited. After 6 months, 58 participants in the intervention group (12.8%) reattempted suicide compared with 77 (17.2%) in the control group. The difference between groups (4.4%; 95% CI, -0.7% to 9.0%) was not significant (complete-case analysis, P = .059).CONCLUSIONS:These results may help researchers better integrate BCIs into routine health care and provide new insights concerning personalized suicide prevention strategies.TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT01123174

Rilpivirine in HIV-1-positive women initiating pregnancy: to switch or not to switch?

International audienceBackgroundSafety data about rilpivirine use during pregnancy remain scarce, and rilpivirine plasma concentrations are reduced during second/third trimesters, with a potential risk of viral breakthroughs. Thus, French guidelines recommend switching to rilpivirine-free combinations (RFCs) during pregnancy.ObjectivesTo describe the characteristics of women initiating pregnancy while on rilpivirine and to compare the outcomes for virologically suppressed subjects continuing rilpivirine until delivery versus switching to an RFC.MethodsIn the ANRS-EPF French Perinatal cohort, we included women on rilpivirine at conception in 2010–18. Pregnancy outcomes were compared between patients continuing versus interrupting rilpivirine. In women with documented viral suppression (<50 copies/mL) before 14 weeks of gestation (WG) while on rilpivirine, we compared the probability of viral rebound (≥50 copies/mL) during pregnancy between subjects continuing rilpivirine versus those switching to RFC.ResultsAmong 247 women included, 88.7% had viral suppression at the beginning of pregnancy. Overall, 184 women (74.5%) switched to an RFC (mostly PI/ritonavir-based regimens) at a median gestational age of 8.0 WG. Plasma HIV-1 RNA nearest delivery was <50 copies/mL in 95.6% of women. Among 69 women with documented viral suppression before 14 WG, the risk of viral rebound was higher when switching to RFCs than when continuing rilpivirine (20.0% versus 0.0%, P = 0.046). Delivery outcomes were similar between groups (overall birth defects, 3.8/100 live births; pregnancy losses, 2.0%; preterm deliveries, 10.6%). No HIV transmission occurred.ConclusionsIn virologically suppressed women initiating pregnancy, continuing rilpivirine was associated with better virological outcome than changing regimen. We did not observe a higher risk of adverse pregnancy outcomes