Search

Objective: Describe and analyse the experience of family physicians in managing current psychiatric disorders to obtain a better understanding of the underlying reasons of under-detection and inadequate prescribing identified in studies. Methods: A qualitative study using in-depth interviews. Sample of 15 practicing family physicians, recruited by telephone from a precedent cohort (Sesame1) with a maximum variation: sex, age, single or group practice, urban or rural. Qualitative method is inspired by the completed grounded theory of a verbatim semiopragmatic analysis from 2 experts in this approach. Results: Family physicians found that current psychiatric disorders were related to psychological symptoms in reaction to life events. Their role was to make patients aware of a psychiatric symptom rather than establish a diagnosis. Their management responsibility was considered in contrasting ways: it was claimed or endured. They defined their position as facilitating compliance to psychiatrist consultations, while assuring a complementary psychotherapeutic approach. Prescribing medication was not a priority for them. Conclusions: The identified under-detection is essentially due to inherent frontline conditions and complexity of clinical forms. The family physician role, facilitating compliance to psychiatrist consultations while assuring a support psychotherapy is the main result of this study. More studies should be conducted to define more accurately the clinical reality, management and course of current psychiatric disorders in primary care.

INTRODUCTION: Toxoplasma gondii is the most common protozoan parasite in developed nations. Up to 43% of the French population may be infected, depending on eating habits and exposure to cats, and almost one third of the world human's population may be infected. Two types of infection have been described: a congenital form and an acquired form. Although the medical profession treats these latent cases as asymptomatic and clinically unimportant, results of animal studies and recent studies of personality profiles, behavior, and psychomotor performance have led to reconsider this assumption. PRECLINICAL DATA: Among rats: parasite cysts are more abundant in amygdalar structures than those found in other regions of the brain. Infection does not influence locomotion, anxiety, hippocampal-dependent learning, fear conditioning (or its extinction) and neophobia in rats. Rats' natural predator is the cat, which is also T. gondii's reservoir. Naturally, rats have an aversion to cat urine, but the parasite suppresses this aversion in rats, thus influencing the infection cycle. Tachyzoites may invade different types of nervous cells, such as neurons, astrocytes and microglial cells in the brain, and Purkinje cells in cerebellum. Intracellular tachyzoites manipulate several signs for transduction mechanisms involved in apoptosis, antimicrobial effectors functions, and immune cell maturation. Dopamine levels are 14% higher in mice with chronic infections. These neurochemical changes may be factors contributing to mental and motor abnormalities that accompany or follow toxoplasmosis in rodents and possibly in humans. Moreover, the antipsychotic haloperidol and the mood stabilizer valproic acid most effectively inhibit Toxoplasma growth in vitro with synergistic activity. CLINICAL DATA: The effects of the parasite are not due to the manipulation in an evolutionary sense but merely due to neuropathological or neuroimmunological effects of the parasite's presence. Toxoplasmosis and schizophrenia: epidemiological studies point to a role for toxoplasmosis in schizophrenia's etiology, probably during pregnancy and early life, this association being congruent with studies in animal models indicating that animal exposures of the developing brain to infectious agents or immune modulating agents can be associated with behavioral changes that do not appear until the animal reaches full maturity. Psychiatric patients have increased rates of toxoplasmic antibodies, the differences between cases and controls being greatest in individuals who are assayed near the time of the onset of their symptoms. The increase of dopamine in the brain of infected subjects can represent the missing link between toxoplasmosis and schizophrenia. Toxoplasmosis and Obsessive Compulsive Disorder (OCD): the seropositivity rate for anti-T. gondii IgG antibodies among OCD patients is found to be significantly higher than the rate in healthy volunteers. Infection of basal ganglia may be implicated in the pathogenesis of OCD among Toxoplasma seropositive subjects. Toxoplasmosis and personality: infected men appear to be more dogmatic, less confident, more jealous, more cautious, less impulsive and more orderly than others. Conversely, infected women seem warmest, more conscientious, more insecure, more sanctimonious and more persistent than others. It is possible that differences in the level of testosterone may be responsible for the observed behavioral differences between Toxoplasma-infected and Toxoplasma-free subjects. CONCLUSION: In the future two major avenues for research seem essential. On one hand, prospective studies and research efforts must still be carried out to understand the mechanisms by which the parasite induces these psychiatric disorders. On the other hand, it has not yet been demonstrated that patients with positive toxoplasmic serology may better respond to haloperidol's or valproic acid's antiparasitic activity. These results may appear as a major issue in the drug's prescribing choices and explain variability in response to the treatment of patients with schizophrenia that is not explained by the genetic polymorphism.

International audience; Apathy, described as impaired motivation and goal-directed behavior, is ă a common yet often overlooked multidimensional psychopathological state ă in schizophrenia. Its underlying cognitive processes remain largely ă unexplored. Data was drawn from a longitudinal hospital study of ă patients with a DSM-IV diagnosis of schizophrenia; 137 (82.5%) ă participated at the 1-month follow-up and 81 (59.1%) at the 1-year ă follow-up. Apathy was assessed with the Lille Apathy Rating Scale, ă validated in French and in schizophrenia. Severe apathy, overall (total ă score > -13) and on 4 previously identified distinct dimensions, was ă considered. Episodic verbal learning was assessed with the California ă Verbal Learning Test, executive functioning with the Trail Making Test, ă the Six Element Test and the Stop Signal Paradigm and working memory ă with the Letter-Number Sequencing Test. After controlling for ă confounding variables, only episodic verbal learning was associated with ă severe overall apathy in the cross-sectional study. At 1 year, working ă memory was associated with an increased risk of severe overall apathy, ă adjusting for baseline apathy. Using a dimensional approach to apathy, ă specific types of cognition were found to be associated with specific ă dimensions of apathy. Our findings confirm the need for a ă multidimensional approach of negative symptoms in schizophrenia. ă Moreover, cognitive functioning could be a risk factor for developing ă severe apathy. Cognitive remediation may thus be a useful ă non-pharmacological intervention for treating apathy in schizophrenia ă patients.

Objectifs: L'objectif principal a été de mener la validation française de la Scale to Assess Unawareness of Mental Disorder (SUMD) auprès d'une population souffrant de schizophrénie. Méthode: Cent patients souffrant de troubles schizophréniques ont été inclus. Nos analyses statistiques ont évalué la fidélité inter-juges, la validité théorique, la validité convergente ou divergente. Finalement, une analyse factorielle exploratoire a été conduite. Résultats: Nos résultats montrent que la version francophone de la SUMD possède de bonnes qualités métrologiques. La fidélité inter-juges (CCI variant de 0,68 à 1,00) et la cohérence interne des facteurs (α de Cronbach > 0,70) sont satisfaisantes. La validité convergente ou divergente a été confirmée par des corrélations élevées entre les scores de la SUMD et le score G12 de l'échelle des syndromes positif et négatif (PANSS). Nous ne rapportons que peu de liens entre les scores de la SUMD et les variables cliniques. Enfin, nos analyses factorielles ACP confirment l'hypothèse de deux dimensions distinctes de l'insight (conscience, attribution) dans leurs aspects actuel et passé. Conclusion: La version française de la SUMD est une mesure fiable et valide de l'insight dans la schizophrénie. L'importance de mesurer l'insight et le développement d'interventions psychosociales afin d'améliorer l'insight des personnes souffrant de schizophrénie sont discutés.

Au cœur d’une societe ou les valeurs sont en mutation, le malade irresponsable, jusqu’alors ecarte des procedures, se voit integre dans le processus judiciaire penal. Meme si le Code penal et le Code civil sont a ce jour inchanges, le Code de procedure penale connait un remaniement majeur. Le Code de sante publique pourrait egalement connaitre une revision prochaine. Ainsi, si la loi du 25 fevrier 2008 clot une quinzaine d’annees de reflexion et d’evolution autour de la notion de l’irresponsabilite penale pour trouble psychique, elle ouvre parallelement tout un champ de nouvelles pratiques. La presence du patient psychiatrique lors du proces pose une difficile question d’equilibre. Pour le malade d’abord, entre respect de ses particularites et de son statut de citoyen a part entiere qui doit repondre de ses actes lorsque son etat le permet. Pour les victimes ensuite : equilibre entre le respect de leur place nouvelle si durement acquise au coeur des procedures judiciaires et le sens fondamental de l’action judiciaire qui ne peut considerer que les interets individuels. Ces remaniements nous font nous interroger sur le role du medecin psychiatre aupres du malade et de la societe.

Resume Le modele de la conscience des troubles dans les troubles mentaux graves propose par Amador et Strauss et le developpement corollaire de la Scale to Assess Unawareness of Mental Disorder (SUMD) constituent la reference theorique et clinique dans l’approche multidimensionnelle de l’insight. Neanmoins, cette approche repose essentiellement sur une analyse phenomenologique de ce concept. Dans la seconde partie de cette revue, nous nous proposons d’exposer l’evolution des modeles explicatifs qui tentent d’en rendre compte. Quatre approches seront decrites comme suit : les troubles de l’insight comme resultant, soit de mecanismes de defense ou d’adaptation aux stresseurs environnementaux, qui sont les premiers modeles explicatifs, de biais cognitifs de traitement de l’information, de deficits fonctionnels neuropsychologiques lies a des anomalies cerebrales notamment, prefrontales ou plus recemment, comme etant la consequence de deficits metacognitifs. Il ressort des differentes etudes qu’aucune explication unique ne semble pouvoir expliquer les deficits de l’insight. Les explications psychologiques en terme de mecanismes de defense ou d’adaptation (mecanismes de coping) aux consequences de la maladie ont ete peu etudiees et meriteraient d’etre davantage explorees. Cependant, cette approche se confronte au fait que la litterature ne rapporte aujourd’hui aucun argument en faveur d’un lien entre severite de la symptomatologie ou de l’etat emotionnel du patient schizophrene et la presence ou l’absence de la conscience des troubles. A l’oppose, les recherches en neuropsychologie et en psychologie cognitive presentent des resultats consistants permettant d’impliquer cognitivement un deficit des fonctions executives et anatomiquement des anomalies des lobes frontaux. De nouvelles etudes concernant les distorsions du traitement de l’information et la cognition sociale ouvrent actuellement de nouvelles perspectives dans ce phenomene multidimensionnel et multidetermine qu’est la conscience des troubles dans la schizophrenie.

International audience; What leads healthy individuals to abnormal feelings of contact with schizophrenia patients remains obscure. Despite recent findings that human bonding is an interactive process influenced by coordination dynamics, the spatiotemporal organization of the bodily movements of schizophrenia patients when interacting with other people is poorly understood. Interpersonal motor coordination between dyads of patients (n = 45) or healthy controls (n = 45), and synchronization partners (n = 90), was assessed with a hand-held pendulum task following implicit exposure to pro-social, non-social, or anti-social primes. We evaluated the socio-motor competence and the feeling of connectedness between participants and their synchronization partners with a measure of motor coordination stability. Immediately after the coordination task, all participants were also asked to rate the likeableness of their interacting partner. Our results showed greater stability during interpersonal synchrony in schizophrenia patients who received pro-social priming, inducing in their synchronization partner greater feelings of connectedness towards patients. This greater feeling of connectedness was positively correlated with stronger motor synchronization between participants suggesting that motor coordination partly underlies patients' social interactions and feelings of contact with others. Pro-social priming can have a pervasive effect on abnormal social interactions in schizophrenia patients.

Aricle disponible en ligne à l'adresse : http://www.nature.com/articles/srep08156; International audience; What leads healthy individuals to abnormal feelings of contact with schizophrenia patients remains obscure. Despite recent findings that human bonding is an interactive process influenced by coordination dynamics, the spatiotemporal organization of the bodily movements of schizophrenia patients when interacting with other people is poorly understood. Interpersonal motor coordination between dyads of patients (n = 45) or healthy controls (n = 45), and synchronization partners (n = 90), was assessed with a hand-held pendulum task following implicit exposure to pro-social, non-social, or anti-social primes. We evaluated the socio-motor competence and the feeling of connectedness between participants and their synchronization partners with a measure of motor coordination stability. Immediately after the coordination task, all participants were also asked to rate the likeableness of their interacting partner. Our results showed greater stability during interpersonal synchrony in schizophrenia patients who received pro-social priming, inducing in their synchronization partner greater feelings of connectedness towards patients. This greater feeling of connectedness was positively correlated with stronger motor synchronization between participants suggesting that motor coordination partly underlies patients' social interactions and feelings of contact with others. Pro-social priming can have a pervasive effect on abnormal social interactions in schizophrenia patients.

Introduction – Les troubles neuro-psychiatriques constituent une des principales causes de morbidite et d'incapacites liees au vieillissement. Le projet Esprit a pour but d'etudier l'etiologie complexe des troubles psychiatriques chez le sujet âge pour une meilleure prise en charge. Objectifs – 1) determiner la prevalence (en actuel et au cours de la vie) et l'incidence des troubles psychiatriques en population generale âgee ; 2) evaluer les facteurs de risque de ces troubles, leur poids relatif et leurs interactions ; 3) etudier l'heterogeneite clinique ; 4) estimer les probabilites de transition vers un etat subsyndromique ou vers la maladie ; 5) construire des modeles etiologiques predictifs. Methode - L'etude longitudinale Esprit porte sur 1863 personnes non institutionnalisees de 65 ans et plus, recrutees par tirage au sort sur listes electorales. Depuis l'inclusion en 1999, ces sujets ont deja ete revus deux fois a 2 ans d'intervalle. Ils ont ete soumis a differents questionnaires (socio-demographiques, antecedents medicaux, incapacites, expositions, survenue d'evenements traumatiques), examens neurologiques ainsi qu'a un enregistrement polysomnographique a domicile. Une DNAtheque et une serotheque ont ete constituees et certains parametres biochimiques doses (lipides, cortisol...). La pathologie psychiatrique a ete evaluee au cours d'un entretien structure, le MINI (fonde sur les criteres diagnostiques du DSM IV), la symptomatologie depressive par la CES-D et le niveau d'anxiete via l'echelle de Spielberger. D'autres questionnaires ont ete utilises afin d'evaluer la personnalite colerique (Spielberger-anger), l'impulsivite (Barratt), l'agressivite (Buss-Durkee) et la survenue de traumatismes dans l'enfance. Resultats - Les troubles psychiatriques sont frequents chez les sujets âges et au cours de leur vie ils ont touche pres d'une personne sur deux. La prevalence des troubles actuels est elevee notamment pour les phobies (10,7%), l'anxiete generalisee (4,6%) et les ideations suicidaires (9,8%). Pour la plupart des troubles psychiatriques, les prevalences sont pres de 2 fois plus elevees chez la femme. Nos premieres analyses montrent l'importance de certains facteurs de risque jusque-la peu explores, facteurs environnementaux comme les evenements de vie traumatiques ou facteurs biologiques comme le statut hormonal au cours de la vie reproductive ou le role des systemes de regulation du stress (e.g. activite secretoire de l'axe HPA). L'insomnie est egalement un facteur de risque de troubles depressifs ou anxieux. Conclusion - L'etude longitudinale Esprit constitue une base de donnees relativement exhaustive sur les troubles psychiatriques en population generale francaise âgee. L'approche multifactorielle (prenant en compte facteurs environnementaux, psychosociaux, biologiques, genetiques, pharmacologiques ou cliniques et leurs interactions) devrait permettre la construction de modeles etiologiques complexes susceptibles d'etre valides au sein d'etudes cliniques et ouvrir de nouvelles perspectives dans le champ de la sante mentale du sujet âge.

BackgroundFrance has high rates of psychotropic drug consumption and suicide in the elderly population, but it has not yet been possible to determine whether this is due to exceptionally high morbidity rates.AimsTo describe the first longitudinal population study of psychiatric disorder undertaken in France, and to estimate current and lifetime prevalences and age of onset of psychiatric disorder.MethodA study group of 1873 non-institutionalised persons aged 65 years and over was randomly recruited from the Montpellier district electoral rolls. The Mini International Neuropsychiatric Interview was used to assess current and lifetime symptoms. Cases identified by the application of DSM–IV criteria were reexamined by a clinical panel.ResultsForty-six percent of the study population had experienced a mental disorder in their lifetime, and 3.7% had made a suicide attempt. Lifetime prevalence of major depression was 26.5% and 30% for anxiety disorders. Current prevalence rates were 14.2% for anxiety disorders, 10.7% for phobia, 3% for major depression and 1.7% for psychosis.ConclusionsResults show very high rates of lifetime but not current major depression. Rates of current phobia and suicidal ideation in the very elderly are also high compared with other studies. The rates reported are likely to be underestimates.

We screened 124 individuals for single nucleotide polymorphisms of the alpha1, beta3 and gamma2 genes of the GABA(A) receptor in the regions corresponding to the ligand-binding domains on the protein level. In a patient with chronic insomnia, a missense mutation was found in the gene of the beta3 subunit. This mutation results in the substitution of the amino acid residue arginine for histidine in position 192 (beta3(R192H)). The patient was found to be heterozygous for this mutation. Functional analysis of human alpha1beta3(R192H)gamma2S GABA(A) receptors using ultra fast perfusion techniques revealed a slower rate of the fast phase of desensitization compared with alpha1beta3gamma2S GABA(A) receptors. Additionally, current deactivation [a major determinant of inhibitory postsynaptic current (IPSC) duration] was faster in the mutated receptors. This raises the possibility of decreased GABAergic inhibition contributing to insomnia, as some members of the patient's family also suffer from insomnia. The mutation beta3(R192H) might, therefore, be linked to this condition. The intron/exon boundaries of the alpha1 subunit gene were also established and three additional variants were found in the alpha1 and beta3 genes.

International audience; Poor insight is found in up to 80% of schizophrenia patients and has been associated with multiple factors of which cognitive functioning, social and environmental factors. Few studies have explored associations between patient insight and that of their biological parents', and the influence of parental factors. Insight was assessed in 41 patients and their biological parents with Amador's Scale for the assessment of Unawareness of Mental Disorder (SUMD). Parents' knowledge about schizophrenia and critical attitudes were assessed with validated self-report questionnaires. Both groups underwent cognitive assessments for working memory and executive functioning. Insight in patients and their parents was not associated for any of the SUMD dimensions but a significant correlation was found between patient and parent awareness of treatment effect for patient-parent dyads with frequent daily contact. Low parental critical attitude was associated with higher patient awareness of symptoms and a high parental memory task score with high patient insight. Our study is the first to suggest a possible influence of parental factors such as critical attitudes and cognitive performance on patient insight.

International audience; Semantic priming tasks are classically used to influence and implicitly promote target behaviors. Recently, several studies have demonstrated that prosocial semantic priming modulated feelings of social affiliation. The main aim of this study was to determine whether inducing feelings of social affiliation using priming tasks could modulate nonverbal social behaviors in schizophrenia. We used the Scrambled Sentence Task to prime schizophrenia patients according to three priming group conditions: pro-social, non-social or antisocial. Forty-five schizophrenia patients, diagnosed according to DSM-IV-TR, were randomly assigned to one of the three priming groups of 15 participants. We evaluated nonverbal social behaviors using the Motor-Affective subscale of the Motor-Affective-Social-Scale. Results showed that schizophrenia patients with pro-social priming had significantly more nonverbal behaviors than schizophrenia patients with antisocial and non-social priming conditions. Schizophrenia patient behaviors are affected by social priming. Our results have several clinical implications for the rehabilitation of social skills impairments frequently encountered among individuals with schizophrenia.

This study assessed the efficacy, tolerability and safety of vortioxetine versus placebo in adults with recurrent major depressive disorder. This double-blind, randomized, placebo-controlled study included 608 patients [Montgomery-Åsberg Depression Rating Scale (MADRS) total score ≥ 26 and Clinical Global Impression - Severity score ≥ 4]. Patients were randomly assigned (1 : 1 : 1 : 1) to vortioxetine 15 mg/day, vortioxetine 20 mg/day, duloxetine 60 mg/day or placebo. The primary efficacy endpoint was change from baseline in MADRS total score at week 8 (mixed model for repeated measurements). Key secondary endpoints were: MADRS responders; Clinical Global Impression - Improvement scale score; MADRS total score in patients with baseline Hamilton Anxiety Rating Scale ≥ 20; remission (MADRS ≤ 10); and Sheehan Disability Scale total score at week 8. On the primary efficacy endpoint, both vortioxetine doses were statistically significantly superior to placebo, with a mean difference to placebo (n = 158) of -5.5 (vortioxetine 15 mg, P0.0001, n = 149) and -7.1 MADRS points (vortioxetine 20 mg, P0.0001, n = 151). Duloxetine (n = 146) separated from placebo, thus validating the study. In all key secondary analyses, both vortioxetine doses were statistically significantly superior to placebo. Vortioxetine treatment was well tolerated; common adverse events (incidence ≥ 5%) were nausea, headache, diarrhea, dry mouth and dizziness. No clinically relevant changes were seen in clinical safety laboratory values, weight, ECG or vital signs parameters. Vortioxetine was efficacious and well tolerated in the treatment of patients with major depressive disorder.

le document est disponible en ligne : http://www.sciencedirect.com/science/article/pii/S0165178113002266; International audience; Recent research has established that schizophrenia patients have difficulties envisioning the future. Although mental simulations have a clear adaptive value, little is known about the function of simulating future episodes, particularly emotional events. The aim of this study was to explore the relationships between apathy and future projection in schizophrenia. Twenty-five schizophrenia patients and 25 healthy controls were asked to imagine pleasant and unpleasant episodes that might happen to them in the future. Verbal descriptions were scored for specificity, and participants also completed the Memory Characteristics Questionnaire, which assesses phenomenal characteristics of imagined future events. Apathy was assessed with the Lille Apathy Rating Scale and the apathetic/social withdrawal item of the Positive and Negative Syndrome Scale. Results showed that schizophrenia patients’ pleasant and unpleasant imagined future events were less specific and contained fewer phenomenal characteristics (e.g., amount of sensory details) than those of controls. In the schizophrenia group, difficulties imagining future pleasant events, and particularly poor self-referential information for future pleasant events, were specifically associated with apathy, even after controlling for working memory. These results suggest that episodic future thinking impairments, especially for future events of pleasure, may partly underlie the motivational deficits characteristic of schizophrenia.

International audience; UNLABELLED: Frequent attenders in family practice are known to have higher rates of mental disorder. However little is known about specific psychiatric disorders and whether this behavior extends to specialist services, in an open access fee-for-service health care system. METHODS: 1060 patients from 46 family practices completed the Patient Health Questionnaire and the Client Service Receipt Inventory. During the consultation, family practitioners blind to the questionnaire responses rated the severity of mental health and physical disorders. The 10% of patients with the highest number of 6-month consultations in six age and sex stratified groups were defined as frequent attenders. RESULTS: After adjustments for sociodemographic variables, physical health and other psychiatric diagnoses, patients with a somatoform disorder were more likely to be frequent attenders, with an odds ratio of 2.3 (95% CI: 1.3-3.8, p=.002). CONCLUSION: When adjusting for confounders, among the four psychiatric diagnoses investigated only somatoform disorders remain significantly associated with frequent attendance. Physical health and chronic disease were no longer associated with frequent attendance which does not support the hypothesis that in an open access fee-for-service system, patients will consult for a wider range of health problems. Greater investigation into unexplained somatic symptoms could help reduce the frequency of attendance in both primary and secondary care, as this behaviour appears to be a general health-seeking drive than extends beyond family practice.

International audience; It has been demonstrated that motor coordination of interacting people plays a crucial role in the success of social exchanges. Abnormal movements have been reported during interpersonal interactions of patients suffering from schizophrenia and a motor coordination breakdown could explain this social interaction deficit, which is one of the main and earliest features of the illness. Using the dynamical systems framework, the goal of the current study was (i) to investigate whether social motor coordination is impaired in schizophrenia and (ii) to determine the underlying perceptual or cognitive processes that may be affected. We examined intentional and unintentional social motor coordination in participants oscillating hand-held pendulums from the wrist. The control group consisted of twenty healthy participant pairs while the experimental group consisted of twenty participant pairs that included one participant suffering from schizophrenia. The results showed that unintentional social motor coordination was preserved while intentional social motor coordination was impaired. In intentional coordination, the schizophrenia group displayed coordination patterns that had lower stability and in which the patient never led the coordination. A coupled oscillator model suggests that the schizophrenia group coordination pattern was due to a decrease in the amount of available information together with a delay in information transmission. Our study thus identified relational motor signatures of schizophrenia and opens new perspectives for detecting the illness and improving social interactions of patients.

Since the middle of the last century, there has been a transition in almost all Western countries toward a policy of reduced periods of hospitalization for patients with severe mental illness. While initially not evidence based, a number of observational studies have suggested that patients returning to the community show better quality of life and have larger friendship networks, lower mortality rates, and reduced dependence on pharmacotherapies than those remaining in institutions.1 This policy assumes, however, that community care is well organized and places increasing burden in particular on primary caregivers. While there has been considerable research on community mental health care in general in preventing relapse, relatively little attention has been paid to the interface with general practitioners, although it is estimated that 25% of patients with psychosis lose all contact with mental health services and are followed and cared for entirely within general practice.2,3 Patients discharged from the hospital following a psychotic episode frequently discontinue medication and often have multiple pathologies as well as social and professional difficulties. Antipsychotic medication also has numerous side effects that require monitoring. Adequate medical follow-up therefore assumes not only knowledge of these disorders on the part of primary care practitioners, but also an efficient interface between hospital practitioners and primary caregivers at discharge. There are many studies on pathways to care in first-episode psychosis4–7 and general practitioner management of early psychosis.8–12 Few studies, however, have examined care pathways of specific patients13 and particularly the influence of length of hospital stay on postdischarge community care. In France, public psychiatric care is organized into sectors that cover well-defined geographical areas of approximately 70,000 inhabitants.14 Each sector is Clinical Points ♦There is a need for greater recognition of the role of the general practitioner in managing first-episode psychotic patients after hospital discharge, specifically for the management of psychiatric symptoms in the case of early discharge. ♦Communication between general practitioners and psychiatrists needs to be improved. responsible for providing inpatient and outpatient care. Care is largely hospital based, the amount provided at a community level being limited overall, although it varies widely from one sector to another depending on the care organization and internal policy. Psychiatrists have few guidelines and protocols to follow with managerial targets to meet, resulting in different care models working alongside. There are long appointment delays for consulting private psychiatrists, many of whom offer psychoanalytic therapy only.15–17 Although general practitioners are the main primary care providers, they are not actively integrated into the community mental health team and seldom receive referrals from psychiatric services. General practitioners work mainly alone with no ancillary staff and limited collaboration with specialists, especially hospital psychiatrists.18 Changes were introduced in 2004, with patients strongly encouraged to register with a general practitioner of their choice whose role it is to coordinate care and refer patients if necessary to specialists (all except ophthalmologists, gynecologists, pediatricians, and psychiatrists for those patients under 26 years old). Those who bypass general practitioner referral can be financially sanctioned with lower reimbursements.19,20 In France there is still considerable variation in length of stay; our previous findings (D.C., unpublished data, 2011) confirm this, with length of stay varying from 4 to 371 days for first-episode psychotic patients within the same hospital. Our results suggest that this variation is not determined by clinical differences in patients at admission but rather by changes in medication during hospitalization, symptomatology at discharge (less negative but more positive symptoms for short-stay patients), and ward policy (length of stay being significantly shorter in services where the head psychiatrist declared being in priori more in favor of shorter [≤30 days] than longer stays [>30 days]). With regard to care plans at discharge, one-third (32.5%) of patients with a short length of stay were “referred” to care by a private psychiatrist compared to 12.5% of long length of stay patients; the remaining patients received community care or day hospital care (52.5% and 15%, respectively, for short length of stay patients; 44.4% and 43.1%, respectively, for long length of stay patients). Length of stay may also have an impact on the role of the general practitioner in providing postdischarge care and on the collaboration between general practitioners and specialists. However, there are to our knowledge no studies specifically on this topic. Furthermore, findings on service use specific to one health care organization are difficult to extrapolate to other settings. The aim of the present study was thus to describe the role of the general practitioner in providing postdischarge care to patients with first-episode psychosis in terms of frequency and type of consultation and the extent of collaboration with hospital-based specialist services. We then sought to determine whether decreasing length of stay was accompanied by a modification in this role. Although community psychiatric care remains largely underdeveloped and hospital based in France,14 it was hypothesized that short-stay patients would be more likely to consult their general practitioner after discharge than long-stay patients, most of whom stay “within” the system.

International audience; BACKGROUND: Doctor-shopping may reflect unmet patient needs and places a significant burden on health resources; however little is known about its underlying reasons and how it relates to mental illness and its recognition in an open access fee-for-service setting. METHODS: In 2003-2004, consecutive patients of 46 French general practitioners (GPs), completed in the waiting room the self-report Patient Health Questionnaire and reported on service use in the past six months. During the consultation, GPs rated the severity of any physical and psychiatric disorders. RESULTS: Of 1079 patients, those rated by the GP as having a common mental disorder were significantly more likely to be doctor-shoppers but only if visiting another GP because of dissatisfaction with previous care (OR=2.3, 95% CI: 1.4-3.7). A similar trend is observed for those identified as having a common mental disorder by the Patient Health Questionnaire. Among patients with a common mental disorder, 'dissatisfied' doctor-shoppers were significantly more likely to be recognised as cases by the GP, adjusting for covariates (OR=6, 95% CI: 2.1-17.2). This was not the case for those doctor-shopping for practical reasons alone. CONCLUSION: Doctor-shopping behaviour is associated with higher rates of mental illness and, among cases, an increased likelihood of recognition by the GP, only however for doctor-shoppers dissatisfied with previous care. This suggests a benefit to letting patients choose their GP as is the case in France and change if not satisfied.

International audience; BACKGROUND: Lipids appear to mediate depressive vulnerability in the elderly; however, sex differences and genetic vulnerability have not been taken into account in previous prospective studies. METHODS: Depression was assessed in a population of 1040 women and 752 men aged 65 years and older at baseline and after 7-year follow-up. Clinical level of depression (DEP) was defined as having either a score of 16 or higher on the Centre for Epidemiology Studies Depression scale or a diagnosis of current major depression on the Mini-International Neuropsychiatric Interview. Lipid levels, apolipoprotein E, and serotonin transporter linked promoter region (5-serotonin transporter gene linked promoter region) genotypes were evaluated at baseline. RESULTS: Multivariate analyses adjusted by sociodemographic and behavioral variables, measures of physical health including ischemic pathologies, and genetic vulnerability indicated gender-specific associations between dyslipidemia and DEP, independent of the use of lipid-lowering agents or apolipoprotein E status. Men with low low-density lipoprotein cholesterol levels had twice the risk of prevalent and incident DEP, whereas in women low high-density lipoprotein cholesterol levels were found to be significantly associated with increased prevalent DEP (odds ratio = 1.5) only. A significant interaction was observed between low low-density lipoprotein-cholesterol and 5-serotonin transporter gene linked promoter region genotype, men with s/s or s/l genotype being at increased risk of DEP (odds ratio = 6.0 and 2.7, respectively). No significant gene-environment interaction was observed for women. CONCLUSIONS: DEP is associated with higher atherogenic risk in women (low high-density lipoprotein cholesterol), whereas the reverse is observed in men (low low-density lipoprotein cholesterol). Late-life depression may have a complex gender-specific etiology involving genetic vulnerability in men.

International audience

Whereas new pharmacological treatments are developed for cognitive impairments in schizophrenia, self-assessment of cognitive dysfunctioning besides their objective validity could be of interest in evaluating patients' motivation to engage in rehabilitation program. Nevertheless insight into symptoms is severely impaired in schizophrenia and is negatively linked with poor compliance. But it is yet unknown if patients with poor insight into their symptoms could have some insight into their cognitive impairments. The aim of this study was to explore the relationships existing between the cognitive complaint and the level of awareness of the disease in patients with schizophrenia. A total of 101 patients with DSM-IV schizophrenia or schizoaffective disorder and 60 control participants were recruited. Insight was assessed using the Scale to assess Unawareness of Mental Disorder (SUMD) and cognitive complaint intensity was assessed with the Scale to Investigate Cognition in Schizophrenia (SSTICS). Participants with schizophrenia displayed the same level of cognitive complaint when compared to healthy controls. Strong correlations were observed between SSTICS total score and duration of illness, levels of depression and state anxiety. Patients with a good insight into the therapeutic effects achieved with medication expressed a more important cognitive complaint. No correlations were found between the four others SUMD insight dimensions and total SSTICS score. The partial overlap of insight into illness and cognitive complaint suggests that insight is modular in schizophrenia. Assessment of cognitive complaint and awareness of illness need to be assessed before engagement in rehabilitation program.

International audience; BACKGROUND: Cortisol hypersecretion is characteristic of acute clinical depression, but little is known in fully recovered, non-treated elderly persons with a lifetime history of depression. This study was designed to examine patterns of diurnal cycle of cortisol in an elderly cohort without current depression or treatment for depression according to whether the person has or has not experienced a previous episode of depression or co-morbid depression with anxiety. METHODS: Cortisol secretion was evaluated in 162 community-dwelling elderly on a stressful and a non-stressful day (basal level). Past depression and anxiety disorders were assessed using a standardized psychiatric examination based on DSM-IV criteria (the Mini International Neuropsychiatric Interview). RESULTS: Antidepressant-free persons with a history of non-co-morbid major depression (6.8% of the sample) showed basal cortisol hypersecretion compared to those with depression and anxiety (8.6%) or controls. Several hours after exposure to a stressful situation, controls showed a sustained increase in cortisol secretion, which was not observed in persons with a history of depression. Persons with a history of depression with anxiety showed a similar cortisol secretion at baseline to controls but a heightened response to stressful situation; a pattern comparable to that observed in subjects with pure anxiety disorders (16.7%). CONCLUSION: An abnormal HPA response persists even after effective treatment for depression. A history of co-morbid depression and anxiety gives rise to changes characteristic of anxiety alone. Our findings suggest that cortisol abnormalities may be trait markers for vulnerability to depression and for the differentiation of depression and depression with co-morbid anxiety.

International audience; BACKGROUND: Cortisol secretion in elderly persons with anxiety disorders exposed to common stressful situations has not been evaluated. METHODS: Salivary-free cortisol levels were evaluated at 8, 15, and 22 h, in 201 elderly subjects during stressful and non-stressful days. Psychiatric symptomatology was assessed by a standardized psychiatric examination (MINI). RESULTS: Elderly subjects without psychiatric disorder showed a sustained increase in cortisol secretion several hours after the exposure to a stressful situation. In comparison, subjects with anxiety disorders showed a greater increase in cortisol secretion in the stressful situation, with lowered recuperation capacity. This effect was dose-dependent as a function of anxiety co-morbidity. Persons reporting lifetime major trauma with intrusions exhibited lowered continuous basal cortisol associated with efficient recuperation capacity. Independently of psychopathology, women appeared more reactive to stressful environmental conditions. LIMITATIONS: Exclusion of institutionalized persons and benzodiazepine users may have led to sampling of less severe anxiety symptoms. CONCLUSIONS: Dysregulation of the hypothalamic-pituitary-adrenal axis was observed in elderly persons with anxiety disorders experiencing environmental stress. A common pattern of up-regulated diurnal cortisol secretion was observed in anxious subjects with lifetime and current anxiety disorder irrespective of sub-type (generalized anxiety, phobias) suggesting a stable trait and a common "core" across disorders. Elderly persons who had experienced trauma with subsequent intrusions showed a distinct pattern with down-regulated activity.

International audience; Introduction: In France, general practice is playing an increasing role in the management of common mental disorders. This is due to a variety of factors, among which the way general practice and specialised mental health services have evolved over time. Methods: A description of the status quo in France, with a comparison between France, the UK and the Netherlands. A review of reasons for the present position. Results: the general practitioner (GP) is often the only medical carer to be contated in cases of psychological distress and over 80% of psychotropic medications are prescribed in this setting. Although most common forms of mental disorder can be managed at the primary care level, GPs need to be able to refer patients rapidly to specialised mental health services. Yet there are delays for consultations with both private and public psychiatrists along with difficulties in finding beds for full-time hospitalisation. The situation is predicted to get worse with the reduction in the number of psychiatrists and GPs forecasted for the coming years. ‘Psychiatric sectorisation' has led to a substantial development of community mental health care services, yet this has not compensated fully for the reduction in full-time hospital beds. Furthermore, community mental health care services remain relatively isolated from other community health services with very limited exchanges with general practice. Conclusions: GPs report an urgent need for training in mental health. Along with improving their ability to accurately detect and treat mental disorders, it is crucial also to improve communication between GPs and psychiatrists and increase shared case-management. Structural changes are also necessary to ensure a quicker and easier access to specialised mental health care services.

International audience; OBJECTIVES: The objectives of this study were to establish provisional psychiatric diagnoses using the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PHQ) and to describe family practitioner (FP) case recognition, survey-day prescription of anxiolytic and antidepressant medications and overall consumption rates (medication use). METHODS: Between October 2003 and April 2004, 1151 consecutive patients (> or = 18 years old) of 46 FPs practicing in and around the city of Montpellier, France, completed the PHQ. During the consultation, FPs rated the severity of any psychiatric disorder. RESULTS: PHQ prevalence rates (FP case recognition percentages are given in parentheses) were as follows: 10.9% (36%) for probable alcohol abuse/dependence; 11.3% (40%) for somatoform disorder; 9.1% (75%) for major depression; 7.4% (42%) for other depressive disorders; 7.5% (69%) for panic disorder; and 6% (69%) for other anxiety disorders. The prescription rate for all study patients was 11.3%, ranging from 6.2% for those without a PHQ disorder to 30.3% for those with a PHQ diagnosis of anxiety or depression to 48.2% for FP-recognized cases. The estimated survey-day consumption rate for these medications was 19.4%. CONCLUSIONS: High consumption of anxiolytic and antidepressant medications in France is confirmed but not explained either by higher prevalence rates of psychiatric disorders as compared with other locations or by unusually high survey-day prescription rates. A possible explanation would be the organization of the French health care system, which has multiple sources for obtaining medication.

Residual symptoms of variable intensity often persist following pharmaco/or psychotherapeutic interventions for treatment of major depression (MD). In several studies, such persistent symptoms have been clearly shown to be associated with a higher risk of relapse, chronicity and functional impairment, but their true nature is still controversial. Several authors consider that these symptoms belong to the range of depression proper and thus indicate that the current episode has been inadequately treated, a hypothesis reinforced by their frequent similarity with the symptoms preceding the full-blown picture of MD. However, in the current state of research, their connection with certain personality traits or comorbid disorders—notably anxiety disorders—cannot be completely ruled out. This article reviews the main data from the literature concerning residual symptoms and their treatment, as well as the issues related to their psychopathological meaning. In practice, once the state of a patient has been stabilized in partial remission of the depressive syndrome, the clinician should revise the current therapeutic strategy and seek to find how to return as fully as possible to the previous euthymic state.

Attenders (n = 124, response rate 84%) of five GPs in Montpellier completed questionnaires on health (reason for visit, cause of problem, GHQ-12), disability (WHODAS II) and service use (CSRI). For each patient, the GP filled in a brief form including a rating of severity of physical and psychological illness. Overall 30.6% of patients were classified as GHQ cases indicating probable non-psychotic psychiatric morbidity and 58.9% were rated as having a physical illness by the GP. Patients with psychiatric morbidity showed as high levels of disability as those with a physical illness, with however a greater number of domains of life affected. They also had a greatly increased number of disability days and used services to a greater extent than those without psychiatric morbidity, these links being stronger than with physical illness. Use of the WHODAS II and the CSRI has not been previously reported in France. This study shows that they could be useful instruments for depicting disability and service use in general practice. The findings from this initial study indicate the need for greater research in primary care focusing on accurate detection and treatment of patients so that disability and excess service use associated with psychiatric morbidity might be reduced.

Le relai de la pédopsychiatrie à la psychiatrie d’adulte est un processus de transition au sein du parcours de soins qui devrait s’inscrire dans une continuité respectant le développement individuel du patient. Il représente une étape fondamentale mais délicate du fait des différences d’organisation entre la psychiatrie infanto–juvénile et la psychiatrie d’adulte. Le risque principal est la rupture thérapeutique. Cette étape s’inscrit dans les priorités du plan stratégique de santé de l’Agence régionale de santé du Languedoc-Roussillon publié en avril 2011. Au centre hospitalier de Montpellier, nous avons étudié rétrospectivement la mise en œuvre de 31 relais réalisés entre 2008–2009 afin de les comparer aux recommandations de la littérature et de proposer des axes d’amélioration. Les patients de l’étude ont en moyenne 16 ans lors de la transition et c’est d’ailleurs ce critère d’âge qui motive à lui seul 51 % des demandes de relai. Les ruptures thérapeutiques sont rares (6 %), cependant un délai de 3 mois sans suivi entre les deux prises en charge est retrouvé pour 48 % des patients. Les praticiens expriment régulièrement des difficultés pour communiquer et pour organiser les relais. Les principaux critères de qualité manquants et donc à améliorer sont :– une période de soins parallèles avec un travail conjoint entre les soignants de pédopsychiatrie et de psychiatrie d’adulte (critère absent dans 81 % des cas) ;– une rencontre impliquant les deux équipes et le patient avec sa famille (critère absent dans 87 % des cas). Un protocole local de mise en œuvre des relais a été validé sur le pôle de psychiatrie suite à cette étude et sera diffusé auprès des psychiatres d’enfants et d’adultes afin d’améliorer leur collaboration. L’objectif serait de faire tomber les barrières organisationnelles et d’âge pour centrer le processus de transition sur les spécificités cliniques et environnementales de chaque patient.

Une mauvaise satisfaction vis-à-vis des soins peut entraîner une mauvaise compliance et donc une prise en charge non optimale. Dans la littérature, le diagnostic de schizophrénie est lié à un faible niveau de satisfaction vis-à-vis des soins. L’idée que peu d’insight ou que des soins sans consentement sont associés à une mauvaise satisfaction est largement répandue, bien que jamais étudiée dans la littérature. L’objectif de cette étude pilote est d’évaluer si l’insight et les soins avec ou sans consentement sont impliqués dans la satisfaction vis-à-vis des soins chez des patients souffrant de schizophrénie. 20 patients souffrant de schizophrénie ou de trouble schizo-affectif et suivis en hôpital de jour ont été inclus. La satisfaction des soins a été évaluée à l’aide de la version française de la Verona Service Satisfaction Scale (VSSS-54) adaptée pour l’hôpital de jour. L’insight a été évalué à l’aide de la Scale to assess Unawareness of illness in Mental Disorder (SUMD). Les résultats montrent d’une part une absence de corrélation entre la satisfaction vis-à-vis des soins et le degré d’insight. D’autre part, il n’est pas retrouvé de différence significative concernant la satisfaction vis-à-vis des soins entre un groupe de patients recevant des soins sans consentement et un groupe recevant des soins avec consentement. Enfin, l’ensemble des patients présente un score médian de satisfaction globale supérieure à la moyenne (99 sur 130). L’insight et les soins avec ou sans consentement ne modifient pas la satisfaction vis-à-vis des soins dans cette population. Ces observations cliniques, malgré la petite taille de l’échantillon, permettent de remettre en cause certaines idées reçues. Il s’agit alors d’appréhender sous un autre angle la satisfaction vis-à-vis des soins chez les patients souffrant de schizophrénie afin d’améliorer nos prises en charge.

Les symptômes négatifs dans la schizophrénie, le plus souvent chroniques et prédictifs du fonctionnement actuel et futur des patients, restent actuellement difficiles à traiter tant sur le plan médicamenteux que psychothérapique. Or, il s’agit d’un groupe de symptômes vaste et hétérogène qu’il est difficile d’étudier dans son ensemble. C’est pourquoi, nous avons choisi de nous intéresser à l’un d’entre eux : l’apathie à la fois symptôme cardinal dans les descriptions précoces de la schizophrénie et symptôme transnosographique. Dans la schizophrénie, il est également admis qu’il existe des troubles de la motivation qui entrent dans la description des symptômes négatifs. Les données de la littérature suggèrent qu’il existerait uniquement sur un plan conceptuel un lien entre motivation et apathie. L’objectif principal de cette étude transversale est de rechercher s’il existe une association entre motivation et apathie chez des patients souffrant de schizophrénie. Soixante-quinze patients hospitalisés ayant un diagnostic de schizophrénie selon les critères du DSM IV, âgés de 18 à 60 ans ont été inclus. Les critères de jugement principaux sont :– l’Apathie évaluée par deux échelles dont la « Lille Apathy Rating Scale » (LARS) ;– la Motivation explorée par la BIRT Motivation Questionnaire (BMQ), par une échelle de sensibilité à la punition et à la récompense et par une tâche d’apprentissage par renforcement.Les résultats montrent que les patients apathiques sont significativement moins motivés et plus sensibles à la punition que les patients non apathiques, et présentent une corrélation positive significative entre les scores obtenus à la LARS et à la BIRT (p < 0,001). Il existe donc une association entre motivation et apathie chez des patients souffrant de schizophrénie montrant que plus les patients sont apathiques, moins ils sont motivés. Une meilleure compréhension de cette symptomatologie négative doit permettre le développement de stratégies thérapeutiques spécifiques.

There is compelling evidence that serotonin system dysfunction is associated with certain behavioral disorders, such as suicidal behavior and impulsive aggression. A functional polymorphism in the promoter region of the serotonin transporter gene (5-HTTLPR) was recently identified and the presence of the short allele found to be associated with a lower level of expression of the gene, lower levels of 5-HT uptake, suicidal behavior and anxiety-related traits. We genotyped 51 West European Caucasians who had made violent suicide attempts and 139 controls of the same ethnic origin, with no history of suicidal behavior. The frequencies of the S allele and the SS genotype were significantly higher in the violent suicide attempters than in the controls. The odds ratio for the SS genotype vs the LL genotype was 3.63 (95% CI (1.27--10.40)). This suggests that a change in expression of the gene encoding the 5-HT transporter may be involved in violent suicidal behavior.

Tryptophan hydroxylase (TPH) is the rate-limiting enzyme of serotonin synthesis. In this case-control study, we investigated whether the TPH gene was a susceptibility factor for suicidal behavior. Seven polymorphisms spanning the entire gene were studied in a case-control study including 231 individuals who had attempted suicide and 281 controls. Significant associations were found between variants in introns 7, 8 and 9 (chi(2) = 11.2, df = 1, P< 0.0008 for the allele distribution; these loci are in complete linkage disequilibrium) and in the 3' noncoding region (chi(2) = 30.94, P = 0.0014) and suicide attempt. The association was strongest for subjects who had attempted suicide by violent means and who had a history of major depression. No significant association was observed between suicide attempts and polymorphisms in the promoter, intron 1 and intron 3. The results presented here, and those of previous studies, suggest that a genetic variant of the 3' part of the TPH gene may be a susceptibility factor for a phenotype combining suicidal behavior, mood disorder and impulsive aggression.

BackgroundLipids appear to mediate depressive vulnerability in the elderly, however, sex differences and genetic vulnerability have not been taken into account in previous prospective studies.MethodsDepression was assessed in a population of 1040 women and 752 men aged 65 years and over at baseline and after 7-year follow-up. Clinical level of depression (DEP) was defined as having either a score of 16 and above on the Centre for Epidemiology Studies Depression scale or a diagnosis of current major depression on the Mini International Neuropsychiatric Interview. Lipid levels, apolipoprotein E and serotonin transporter linked promoter region (5-HTTLPR) genotypes were evaluated at baseline.ResultsMultivariate analyses adjusted by socio-demographic and behavioral variables, measures of physical health including ischemic pathologies, and genetic vulnerability indicated gender-specific associations between dyslipidemia and DEP, independent of the use of lipid lowering agents or apolipoprotein E status. Men with low LDL-cholesterol levels had twice the risk of prevalent and incident DEP whereas in women low HDL-cholesterol levels were found to be significantly associated with increased prevalent DEP (OR = 1.5) only. A significant interaction was observed between low LDL-cholesterol and 5-HTTLPR genotype, men with s/s or s/l genotype being at increased risk of DEP (OR = 6.0 and 2.7, respectively). No significant gene-environment interaction was observed for women.ConclusionsDEP is associated with higher atherogenic risk in women (low HDL-cholesterol), whereas the reverse is observed in men (low LDL-cholesterol). Late-life depression may have a complex gender-specific etiology involving genetic vulnerability in men.

Even if schizophrenia is known to affect social interaction, reasons of such impairment remain unclear. Social motor coordination has been suggested as being an important embodiment of healthy social exchanges. Therefore, we examined whether social motor coordination is affected by schizophrenia. Investigating patients unintentionally and intentionally coordinated with control participants, we found that schizophrenia decreased intentional but not unintentional coordination. A model is proposed to describe and understand such impairments.

Obsessive compulsive-disorder (OCD) is a group of highly debilitating condition characterized by intrusive troubling thoughts, repetitive, compulsive behaviors or mental rituals. A notable percentage of patients are refractory to pharmacological treatment and cognitive behaviour therapy. Increasing attention has been paid to the efficacy of Deep Brain Stimulation (DBS) therapies in alleviating pharmacoresistant psychiatric disorders including OCD.ObjectivesThe aim of this prospective study was to determine the efficacy of DBS using several targets in a pharmacoresistant OCD population with heterogeneous symptoms.MethodsFive patients (3 males) have been included in the study. Patients were classified according to their prominent features as follows: contamination/cleaning, symmetry/checking, exactness/counting and forbidden thoughts.The entire surgical procedure was performed under general anaesthesia. Direct targeting based on stereotactic MRI without microelectrode recordings was done. A combination of two of the following targets was simultaneously implanted for all patients: subthalamic nucleus, accumbens nucleus and bed nucleus of stria terminalis, limbic globus pallidus internus.Patients were assessed pre-and postoperatively using the Yale-Brown Obsessive Compulsive Scale.ResultsMean age at surgery was of 42.6±12.68 years. Mean follow-up with DBS was of 21±14.88 months.Mean preoperative Y-BOCS scores was 31.6±2.70 and of 11±7.97 (p=0,057, Wilcoxon signed Rank test).ConclusionSubthalamic nucleus and accumbens nucleus targets seem to be comparable in alleviating several subtypes of compulsions (checking, cleaning, counting) as well as obsessions. Further investigations are required to assess the role of limbic globus pallidus in improving pharmacoresitant OCD. Implanted system was well accepted without triggering new obsessions.

PurposeThis randomised, double-blind fixed-dose study compared the efficacy of escitalopram and paroxetine in the long-term treatment of patients with severe MDD.Methods:Patients with DSM-IV-defined MDD and baseline Montgomery-Asberg Depression Rating Scale (MADRS ≥30) were randomised in a 1:1 ratio to 24 weeks of double-blind treatment with either escitalopram (20mg) or paroxetine (40mg). The primary analysis of efficacy was an analysis of covariance of change from baseline to Week 24 in MADRS total score using the last observation carried forward (LOCF) method.Results:At endpoint (24 weeks), the mean change from baseline in total MADRS score was -25.2 for escitalopram-treated patients (n=228) and -23.1 for paroxetine-treated patients (n=223), a difference of 2.1 points (p