What is the impact of physical effort on the diagnosis of concussion?

Objective: Sport-related concussion commonly occurs in contact sports such as rugby. To date, diagnosis is based on the realization of clinical tests conducted pitch-side. Yet, the potential effect of prior physical effort on the results of these tests remains poorly understood. The purpose of this study was to determine whether preceding physical effort can influence the outcome of concussion assessments. Design: Prospective observational study. Setting: University Medicine Center Patients: A cohort of 40 subjects (20 rugby players and 20 athletes from a range of sports). Intervention: A concussion assessment was performed immediately following physical activity. Following a period of 6 months and under the same experimental conditions, the same cohort performed the same tests in resting conditions. Main outcome measure: Results of concussion tests. Results: In both cohorts, the comparison for post-exercise and rest assessments demonstrated a most likely moderate-to-very large increase in the number of symptoms, severity of symptoms and BESS score. In the rugby cohort, scores for concentration, delayed memory and SAC, likely-to-most likely decreased following completion of physical activity compared to baseline values. The between-cohort comparison showed a greater impact post-exercise in the rugby players for delayed recall (0.73±0.61, 93/7/1) and SAC score (0.75±0.41, 98/2/0). Conclusion: Physical activity altered the results of concussion diagnostic tests in athletes from a range of sports and notably in rugby players. Therefore, physical efforts prior to the concussion incident should be accounted for during pitch-side assessments and particularly during rugby competition and training

Exploring venlafaxine pharmacokinetic variability with a phenotyping approach, a multicentric french-swiss study (MARVEL study).

It is well known that the standard doses of a given drug may not have equivalent effects in all patients. To date, the management of depression remains mainly empirical and often poorly evaluated. The development of a personalized medicine in psychiatry may reduce treatment failure, intolerance or resistance, and hence the burden and costs of mood depressive disorders. The Geneva Cocktail Phenotypic approach presents several advantages including the "in vivo" measure of different cytochromes and transporter P-gp activities, their simultaneous determination in a single test, avoiding the influence of variability over time on phenotyping results, the administration of low dose substrates, a limited sampling strategy with an analytical method developed on DBS analysis. The goal of this project is to explore the relationship between the activity of drug-metabolizing enzymes (DME), assessed by a phenotypic approach, and the concentrations of Venlafaxine (VLX) + O-demethyl-venlafaxine (ODV), the efficacy and tolerance of VLX. This study is a multicentre prospective non-randomized open trial. Eligible patients present a major depressive episode, MADRS over or equal to 20, treatment with VLX regardless of the dose during at least 4 weeks. The Phenotype Visit includes VLX and ODV concentration measurement. Following the oral absorption of low doses of omeprazole, midazolam, dextromethorphan, and fexofenadine, drug metabolizing enzymes activity is assessed by specific metabolite/probe concentration ratios from a sample taken 2 h after cocktail administration for CYP2C19, CYP3A4, CYP2D6; and by the determination of the limited area under the curve from the capillary blood samples taken 2-3 and 6 h after cocktail administration for CYP2C19 and P-gp. Two follow-up visits will take place between 25 and 40 days and 50-70 days after inclusion. They include assessment of efficacy, tolerance and observance. Eleven french centres are involved in recruitment, expected to be completed within approximately 2 years with 205 patients. Metabolic ratios are determined in Geneva, Switzerland. By showing an association between drug metabolism and VLX concentrations, efficacy and tolerance, there is a hope that testing drug metabolism pathways with a phenotypical approach would help physicians in selecting and dosing antidepressants. The MARVEL study will provide an important contribution to increasing the knowledge of VLX variability and in optimizing the use of methods of personalized therapy in psychiatric settings. ClinicalTrials.gov NCT02590185 (10/27/2015). This study is currently recruiting participants

Electroconvulsive therapy-induced volumetric brain changes converge on a common causal circuit in depression

Neurostimulation is a mainstream treatment option for major depression. Neuromodulation techniques apply repetitive magnetic or electrical stimulation to some neural target but significantly differ in their invasiveness, spatial selectivity, mechanism of action, and efficacy. Despite these differences, recent analyses of transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS)-treated individuals converged on a common neural network that might have a causal role in treatment response. We set out to investigate if the neuronal underpinnings of electroconvulsive therapy (ECT) are similarly associated with this causal depression network (CDN). Our aim here is to provide a comprehensive analysis in three cohorts of patients segregated by electrode placement (N = 246 with right unilateral, 79 with bitemporal, and 61 with mixed) who underwent ECT. We conducted a data-driven, unsupervised multivariate neuroimaging analysis Principal Component Analysis (PCA) of the cortical and subcortical volume changes and electric field (EF) distribution to explore changes within the CDN associated with antidepressant outcomes. Despite the different treatment modalities (ECT vs TMS and DBS) and methodological approaches (structural vs functional networks), we found a highly similar pattern of change within the CDN in the three cohorts of patients (spatial similarity across 85 regions: r = 0.65, 0.58, 0.40, df = 83). Most importantly, the expression of this pattern correlated with clinical outcomes (t = -2.35, p = 0.019). This evidence further supports that treatment interventions converge on a CDN in depression. Optimizing modulation of this network could serve to improve the outcome of neurostimulation in depression

Depressed patients’ preferences for type of psychotherapy: a preliminary study

Antoine Yrondi,1 Julie Rieu,1 Claire Massip,1 Vanina Bongard,2 Laurent Schmitt1 1Department of Psychiatry and Medical Psychology, 2Public Health Service, CHU Toulouse, Toulouse, France Background: The treatment recommendations for depressed patients by the American Psychiatric Association encourage a focus on the patient’s preferences. The focus of this study was the preference of depressed inpatients for the type of psychotherapy. Methods: Twenty-nine subjects of both sexes who were hospitalized with a major depressive episode were interviewed at 5-day intervals with the same questions after the depressive episode resolved, as indicated by a score less than 7 on the Hamilton Depression Rating Scale (HDRS). The selection of items was performed by expert consensus. Results: The supportive psychotherapy scores were the highest, followed by psychodynamic psychotherapy and cognitive behavioral therapy. The two sessions conducted at 5-day intervals showed no significant difference, which reflected the stability of choices and preferences of patients. Conclusion: In this study, the patients preferred supportive psychotherapy as first-line therapy compared to psychodynamic psychotherapy and cognitive behavioral therapy. Keywords: depression, depressive disorder, psychodynamic psychotherap, supportive psychotherapy, cognitive behavioral therap

Évolution de l’activité d’électro-convulsivo-thérapie en France depuis le début de la pandémie COVID-19

International audienc

Recommandations pour une reprise progressive et contrôlée de l’électroconvulsivothérapie en France en période de levée du confinement et de pandémie COVID-19 liée au SARS-CoV-2

International audienceThe COVID-19 pandemic has had major consequences for the organization of care. In France and around the world, centers practicing electroconvulsive therapy (ECT) have seen their activity decrease, or even stop for many reasons. In this context, maintaining or resuming this essential therapeutic activity for many patients suffering from psychiatric disorders requires material, human and logistical adaptations that should be supervised. The objective of this collective and national work is to offer simple recommendations that can be applied immediately by any healthcare establishment, public or private, practicing ECT. They are the result of feedback from multiprofessional and inter-establishment experiences. Declined in three stages, these recommendations are accompanied by a practical sheet which describes in detail the necessary conditions and prerequisites for any resumption of ECT activity

Clinical Pharmacy in Psychiatry: Towards Promoting Clinical Expertise in Psychopharmacology.

Although clinical pharmacy is a discipline that emerged in the 1960s, the question of precisely how pharmacists can play a role in therapeutic optimization remains unanswered. In the field of mental health, psychiatric pharmacists are increasingly involved in medication reconciliation and therapeutic patient education (or psychoeducation) to improve medication management and enhance medication adherence, respectively. However, psychiatric pharmacists must now assume a growing role in team-based models of care and engage in shared expertise in psychopharmacology in order to truly invest in therapeutic optimization of psychotropics. The increased skills in psychopharmacology and expertise in psychotherapeutic drug monitoring can contribute to future strengthening of the partnership between psychiatrists and psychiatric pharmacists. We propose a narrative review of the literature in order to show the relevance of a clinical pharmacist specializing in psychiatry. With this in mind, herein we will address: (i) briefly, the areas considered the basis of the deployment of clinical pharmacy in mental health, with medication reconciliation, therapeutic education of the patient, as well as the growing involvement of clinical pharmacists in the multidisciplinary reflection on pharmacotherapeutic decisions; (ii) in more depth, we present data concerning the use of therapeutic drug monitoring and shared expertise in psychopharmacology between psychiatric pharmacists and psychiatrists. These last two points are currently in full development in France through the deployment of Resource and Expertise Centers in PsychoPharmacology (CREPP in French)

Les échelles anticholinergiques : usage en psychiatrie et mise à jour de l’échelle d’imprégnation anticholinergique

National audienceLes effets anticholinergiques sont bien connus des prescripteurs, notamment en psychiatrie, à la fois comme des stratégies thérapeutiques pour les syndromes extrapyramidaux, mais également comme une source d’effets indésirables. Nous proposons ici une revue narrative de la littérature décrivant successivement : (i) la pharmacologie cholinergique et les effets anticholinergiques ; (ii) l’importance des effets anticholinergiques en psychiatrie ; (iii) les échelles anticholinergiques existantes avec la pertinence et les limites de leur usage en psychiatrie et ; enfin, (iv) une mise à jour de l’échelle d’imprégnation anticholinergique, développée pour la psychiatrie française. Les effets anticholinergiques peuvent se manifester autant au niveau périphérique, qu’au niveau central. Schématiquement, les effets anticholinergiques/antimuscariniques sont aisément attribués parmi les psychotropes : à certains antipsychotiques, aux traitements correcteurs qualifiés d’anticholinergiques, et aux antidépresseurs tricycliques. Afin d’évaluer la charge anticholinergique, des outils appelés des échelles d’évaluation des effets anticholinergiques ont été développés au cours des deux dernières décennies (13 échelles répertoriées en 2021), mais trois seulement bénéficient d’une utilisation réellement importante : l’Anticholinergic Drug Scale (ADS), l’Anticholinergic Risk Scale (ARS) et l’Anticholinergic Cognitive Burden scale (ACB). Ces échelles présentent plusieurs limites : une faible concordance entre elles, une difficulté à prédire les effets centraux en raison de classements ne différenciant pas, ou mal, la capacité des traitements à passer à la barrière hématoencéphalique, enfin, un manque de pondération de la puissance des effets anticholinergiques par la posologie. Nous proposons, à l’issue de cette revue, une mise à jour de l’échelle d’imprégnation anticholinergique développée spécifiquement pour la psychiatrie française