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Background: Opioid use disorder (OUD) poses a global health challenge, and despite medications for opioid use disorder (MOUD) and psychosocial interventions, relapse remains a significant concern. Comorbid psychiatric disorders, including attention deficit hyperactivity disorder (ADHD), are one of the major factors associated with poor OUD treatment outcome. We aimed to estimate the frequency of probable ADHD (in childhood and in adulthood) in patients with OUD; to assess the factors associated with this comorbidity; and to explore the factors that mediate the relationship between ADHD and OUD treatment outcome., Methods: We conducted an observational study using a sample of 229 patients aged 18 years and older who were diagnosed with OUD and had received MOUD for at least six months. Participants were assessed through a structured interview and self-report questionnaires. Multivariate logistic regressions and a mediation analysis were performed., Results: Almost half of the participants reported probable ADHD in childhood, and ADHD persisted into adulthood among two-thirds of the patients. The factors associated with poor OUD treatment outcome included earlier onset of OUD, lower education, and greater impulsivity. There was no direct effect of probable ADHD in childhood on OUD treatment outcome, but there was an indirect effect through negative urgency, the tendency to respond impulsively to negatively connoted emotional experiences., Conclusions: The findings suggest that ADHD symptoms, particularly impulsivity, may contribute to vulnerability in opioid use and play a crucial role in treatment outcomes for this population., Trial Registration: ClinicalTrials identifier NCT01847729., (© 2024. The Author(s).)

Background: In recent years, many studies have explored the associations among impulsivity, history of abuse, the emergence of eating disorders with episodes of binge eating (EDBE) and their severity. Nevertheless, factors associated with successful clinical outcomes of EDBE are still unknown. Our study aimed to test the hypothesis that a history of abuse is associated with unsuccessful clinical outcomes of EDBE through an effect mediated by impulsivity., Methods: We assessed patients older than 15 years, 3 months with EDBE at inclusion and at 1 year. Recovery was defined as the absence of eating disorders at 1 year. A mediation analysis was performed by means of structural equation modelling., Results: We included 186 patients in our analyses (54% bulimia nervosa, 29% anorexia nervosa binge eating/purging type and 17% binge-eating disorder); 179 (96%) were female. One-third ( n = 63) of patients reported a history of abuse, and recovery was observed for 20% of the sample ( n = 38). Contrary to our assumption, a history of abuse was not associated with the absence of recovery of EDBE at 1 year. Factors unfavourable for achieving recovery were anxiety disorders (odds ratio [OR] 0.41), vomiting (OR 0.39), physical hyperactivity (OR 0.29), negative urgency and a lack of perseverance (OR 0.85 for both). Only positive urgency was positively associated with recovery (OR 1.25)., Limitations: We excluded 219 patients lost to the 1-year follow-up., Conclusion: Our findings may help to deconstruct the empirical belief that traumatic events may interfere with the successful course of treatment for eating disorders. A high level of positive urgency may be associated with more receptivity to care., Competing Interests: Competing interests: None declared., (© 2023 CMA Impact Inc. or its licensors.)

Introduction: Since the first description of sex addiction (SA) by Carnes, research on this problematic behaviour has continued to grow, and the association with attention-deficit hyperactivity disorder (ADHD) appears to be frequent. This study aimed to estimate the frequency of a history of probable ADHD in a population of patients with SA and to explore the factors associated with it., Methods: One hundred 85 patients referred to the Nantes University Hospital for SA between 2011 and 2020 were included. Patients completed the Sexual Addiction Screening Test (SAST) or its revised version (SAST-R) to establish the presence of SA. As the SAST-R was not validated in French, we conducted a validation study for the French version. ADHD was screened using the Wender-Utah Rating Scale in childhood and the Adult ADHD Self-Report Scale in adulthood. A multivariate logistic regression model was used to identify factors associated with the presence of a history of probable ADHD., Results: Childhood ADHD was identified in 36% of patients with SA. Factors associated with the presence of a history of probable ADHD were a low education level, an earlier age of onset of problematic sexual behaviour, another addictive disorder, an anxiety disorder, impulsivity (high negative urgency score), and high scores on harm avoidance and novelty-seeking temperament scales. Furthermore, the French version of the SAST-R displayed good psychometric properties, especially excellent sensitivity., Conclusion: The frequency of a history of probable ADHD among patients with SA is consistent with the literature and close to the highest range. Specific personality traits in patients with both SA and a history of probable ADHD could induce lasting problems of adaptation, which may precipitate the development of SA or maintain it., (© 2023 S. Karger AG, Basel.)

Introduction: Dual diagnosis (DD) is defined as the co-occurrence of at least a psychiatric disorder and at least an addictive disorder. Most studies about DD considered substance use disorders. In 2018, gaming disorder (GD) was recognized as a formal disorder and integrated into the category of addictive disorders in the 11th version of the International Classification of Diseases. Our objectives were to measure DD prevalence among GD patients and to assess factors associated with the presence of DD., Methods: As part of the EVALuation of behavioral ADDictions (EVALADD) cohort, 92 patients with GD were included in the present study. Psychiatric disorders, including anxiety, mood, and psychotic disorders, were explored with the Mini International Neuropsychiatric Interview (MINI 5.0.0). Probable adult attention-deficit/hyperactivity disorder (ADHD) was screened with the Wender Utah Rating Scale (WURS) in childhood and with the ADHD Self-Report Scale-V1.1 (ASRS) in adulthood. Finally, personality was assessed using the 125-item version of the Temperament and Character Inventory (TCI-125), motives for gaming with the Videogame Motives Questionnaire (VMQ) and attachment styles with the Relationship Scales Questionnaire (RSQ). To measure the prevalence of DD among GD patients, we considered the occurrence of current GD with current anxiety, mood, or psychotic disorders, or with probable current ADHD. We also performed a multivariate analysis to identify independent factors associated with DD., Results: More than half (55.4%) of GD patients suffered from DD. We found a high prevalence of probable ADHD (38%) and anxiety disorders (29% suffering from generalized anxiety disorder, social, agoraphobia or panic disorder). Four variables were significantly associated with DD: suicidal thoughts [odds ratio (OR) = 6.83, 95% confidence interval (95%CI) (1.66-28.09)], VMQ "coping" scores [OR = 1.18, 95%CI (1.01-1.38)], TCI-125 "harm avoidance" scores [OR = 1.04, 95%CI (1.01-1.07)] and "novelty seeking" scores [OR = 1.03, 95%CI (1.00-1.06)]., Discussion: The prevalence of certain psychiatric disorders among GD patients far exceeded that observed in the general population. Both ADHD and suicidal ideations should particularly be screened among GD patients. Specific interventions targeting personality dimensions associated with DD but also on the management of negative affect should represent new treatment opportunities., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Barrangou-Poueys-Darlas, Cabelguen, Garrouste, Leboucher, Rocher, Challet-Bouju and Grall-Bronnec.)

Background and Aims: Since June 2018, gaming disorder (GD) has been recognized as a disease. It is frequently associated with attention deficit hyperactivity disorder (ADHD), as there are common vulnerability factors and bidirectional interactions between the two disorders. This study aims to evaluate the presence of ADHD symptoms and predictive factors of ADHD among patients with GD., Methods: Ninety-seven patients ≥16 years old referred to the University Hospital of Nantes between 2012 and 2020 for GD were included. The diagnosis of GD was given a posteriori in accordance with the new ICD-11 GD definition. ADHD was screened using the Adult-ADHD Self-Report Scale and the Wender-Utah Rating Scale. A multivariate logistic regression model was used to identify explanatory factors for ADHD-GD comorbidity., Results: The rate of GD patients who screened positive for ADHD was 39%. Predictive factors of ADHD-GD comorbidity were impulsivity (higher score on the negative urgency dimension) and low self-esteem., Discussion: The rate of ADHD found among patients with GD is consistent with that from the literature on internet GD but higher than that found for other behavioural addictions. The identification of a higher negative urgency score and low self-esteem as predictive factors of AHDH-GD comorbidity indicates that gaming could be considered a dysfunctional way to cope with emotional dysregulation in ADHD or to virtually escape., Conclusions: Comorbid ADHD must be taken into consideration to minimize its functional impact on GD patients and gaming-related damage. In contrast, the evaluation of gaming habits in patients with ADHD could be useful for both prevention and care.

Objectives: Relapses and recurrence remain the greatest risks posed by patients with severe mood disorders after discontinuation of electroconvulsive therapy (ECT). To date, despite a wide range of literature on ECT, little is known about the rate of recurrence of depression after maintenance ECT (mECT) discontinuation specifically. This study sought to address this lacuna, confronting literature data to the results of a retrospective case study., Methods: A comprehensive review was conducted, followed by a retrospective analysis of 18 cases of mECT discontinuation between January 2011 and June 2016 involving patients with affective disorders., Results: The comprehensive review revealed that only 3 studies have assessed recurrence rate after c/mECT discontinuation. In our retrospective analysis, mean (SD) mECT duration was 12.69 (12.16) months. A new mood event (usually a depressive state) was observed in 50% of the cases, and 44% of those recurrences occurred during the first 6 months after discontinuation., Discussion: Given that high recurrence rates are observed after mECT discontinuation, the authors discuss the advantages of long-term mECT and the choice of concomitant pharmacotherapy for severe and complex affective disorders.

Background: Depression is a debilitating and costly disease for our society, especially in the case of treatment-resistant depression (TRD). Repetitive transcranial magnetic stimulation (rTMS) is an effective adjuvant therapy in treatment-resistant unipolar and non-psychotic depression. It can be applied according to two therapeutic strategies after an initial rTMS cure: a further rTMS cure can be performed at the first sign of relapse or recurrence, or systematic maintenance rTMS (M-rTMS) can be proposed. TMS adjuvant to treatment as usual (TAU) could improve long-term prognosis. However, no controlled study has yet compared the cost-effectiveness of these two additional rTMS therapeutic strategies versus TAU alone., Methods/design: This paper focuses on the design of a health-economic, prospective, randomized, double-blind, multicenter study with three parallel arms carried out in France. This study assesses the cost-effectiveness of the adjunctive and maintenance low frequency rTMS on the right dorsolateral prefrontal cortex versus TAU alone. A total of 318 patients suffering from a current TRD will be enrolled. The primary endpoint is to investigate the incremental cost-effectiveness ratio (ICER) (ratio costs / quality-adjusted life-years [QALY] measured by the Euroqol Five Dimension Questionnaire) over 12 months in a population of patients assigned to one of three arms: systematic M-rTMS for responders (arm A); additional new rTMS cure in case of mood deterioration among responders (arm B); and a placebo arm (arm C) in which responders are allocated in two subgroups: sham systematic M-rTMS and supplementary rTMS course in case of mood deterioration. ICER and QALYs will be compared between arm A or B versus arm C. The secondary endpoints in each three arms will be: ICER at 24 months; the cost-utility ratio analysis at 12 and 24 months; 5-year budget impact analysis; and prognosis factors of rTMS. The following criteria will be compared between arm A or B and arm C: rates of responders; remission and disease-free survival; clinical evolution; tolerance; observance; treatment modifications; hospitalization; suicide attempts; work stoppage; marital / professional statues; and quality of life at 12 and 24 months., Discussion: The purpose of our study is to check the cost-effectiveness of rTMS and we will discuss its economic impact over time. In the case of significant decrease in the depression costs and expenditures associated with a good long-term prognosis (sustained response and remission) and tolerance, rTMS could be considered as an efficient treatment within the armamentarium for resistant unipolar depression., Trial Registration: ClinicalTrials.gov, NCT03701724. Registered on 10 October 2018. Protocol Amendment Version 2.0 accepted on 29 June 2019.

Attention deficit with or without hyperactivity disorder (ADHD) is one of the most frequent neuropsychiatric disorders, and affects 2-4% of adults. In contrast with many European countries, the identification and management of adult ADHD remains underdeveloped in France, and a subject of controversy. This review provides a practical update on current knowledge about ADHD in adults for French-speaking professionals who have to detect or manage adult patients with ADHD. ADHD is classified as a neurodevelopmental disorder in the recent update of the international diagnostic classification. While symptoms and impairment due to ADHD are frequently severe during childhood, they often evolve as children grow older, with frequent persistent disabilities in adulthood. In adulthood, the clinical presentation, as in childhood, involves the symptom triad of inattention, hyperactivity and impulsivity. However, differences are noted: hyperactivity is more often internalized, symptoms of inattention may be masked by anxiety symptoms or obsessive-like compensation strategies. ADHD is often diagnosed during childhood, but it is not rare for the diagnosis to be made later. Failure to recognise symptoms resulting in misdiagnosis, or alternatively well-developed compensation factors could be two underlying reasons for the long delay until diagnosis. Other symptoms, such as emotional deregulation or executive function-related symptoms are also usually observed in adults. In addition, in adults, ADHD is often associated with other psychiatric disorders (in 80% of cases); this makes the diagnosis even more difficult. These disorders encompass a broad spectrum, from mood disorders (unipolar or bipolar), to anxiety disorders, and other neurodevelopmental disorders and personality disorders, especially borderline and antisocial personality disorder. Substance-use disorders are very common, either as a consequence of impulsivity and emotional dysregulation or as an attempt at self-treatment. Sleep disorders, especially restless leg syndrome and hypersomnolence, could share common pathophysiological mechanisms with ADHD. ADHD and comorbidity-related symptoms are responsible for serious functional impairment, in various domains, leading to academic, social, vocational, and familial consequences. The impact on other psychiatric disorders as an aggravating factor should also be considered. The considerable disability and the poorer quality of life among adults with ADHD warrant optimal evaluation and management. The diagnostic procedure for ADHD among adults should be systematic. Once the positive diagnosis is made, the evaluation enables characterisation of the levels of severity and impairment at individual level. A full examination should also assess medical conditions associated with ADHD, to provide personalized care. In recent years, a growing number of assessment tools have been translated and validated in French providing a wide range of structured interviews and standardized self-report questionnaires for the evaluation of core and associated ADHD symptoms, comorbidities and functional impairment. The treatment of ADHD in adults is multimodal, and aims to relieve the symptoms, limit the burden of the disease, and manage comorbidities. The most relevant and validated psychological approaches are psycho-education, cognitive-behavioural therapy and "third wave therapies" with a specific focus on emotional regulation. Cognitive remediation and neurofeedback are promising strategies still under evaluation. Medications, especially psychostimulants, are effective for alleviating ADHD symptoms with a large effect size. Their safety and tolerance are satisfactory, although their long-term clinical benefit is still under discussion. In France, methylphenidate is the only stimulant available for the treatment of ADHD. Unfortunately, there is no authorization for its use among adults except in continuation after adolescence. Hence the prescription, which is subject to the regulations on narcotics, is off-label in France. This article aims to provide practical considerations for the management of ADHD and associated disorders in adults, in this particular French context., (Copyright © 2019 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Depression is among the most widespread psychiatric disorders in France. Psychiatric disorders are associated with considerable social costs, amounting to €22.6 billion for treatment and psychotropic medication in 2011. Treatment as usual (TAU), mainly consisting of pharmacotherapy and psychotherapy, is effective for only a third of patients and in most cases fails to prevent treatment resistance and chronicity. Transcranial direct current stimulation (tDCS) consists in a non-invasive and painless application of low-intensity electric current to the cerebral cortex through the scalp. Having proved effective in depressed patients, it could be used in combination with TAU to great advantage. The objective is to compare, for the first time ever, the cost-utility of tDCS-TAU and of TAU alone for the treatment of a depressive episode that has been refractory to one or two drug treatments., Methods and Analysis: This paper, based on the DISCO study protocol, focuses on the design of a prospective, randomised, controlled, open-label multicentre economic study to be conducted in France. It will include 214 patients with unipolar or bipolar depression, assigning them to two parallel arms: group A (tDCS-TAU) and group B (TAU alone). The primary outcome is the incremental cost-effectiveness ratio, that is, the ratio of the difference in cost between each strategy to the difference in their effects. Their effects will be expressed as numbers of quality-adjusted life-years, determined through administration of the EuroQol Five-Dimension questionnaire over a 12-month period to patients (EQ-5D-5L). Expected benefits are the reduction of treatment resistance and suicidal ideation as well as social and professional costs of depression. Should depression-related costs fall significantly, tDCS might be considered an efficient treatment for depression., Ethics and Dissemination: This protocol has been approved by a French ethics committee, the CPP--Est IV (Comité de Protection des Personnes-Strasbourg). Data are to be published in peer-reviewed medical journals., Trial Registration Number: RCB 2018-A00474-51; NCT03758105., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Due to its ease of use, tolerance, and cost of acquisition, transcranial direct current stimulation (tDCS) could constitute a credible therapeutic option for non-resistant depression in primary care, when combined with drug management. This indication has yet to receive official recognition in France. The objective of this study is to evaluate the production cost of tDCS for the treatment of depression in hospitals, under realistic conditions., Methods: The methodology adopted is based on cost accounting and was validated by a multidisciplinary working group. It includes equipment, staff, and structural costs to obtain the most realistic estimate possible. We first estimated the cost of producing a tDCS session, based on our annual activity objective, and then estimated the cost of a 15-session treatment program. This was followed up with a sensitivity analysis applying appropriate parameters., Results: The hospital production cost of a tDCS depression treatment program for a single patient was estimated at €1555.60 euros: €99 in equipment costs, €1076.95 in staff costs, and €379.65 in structural costs., Conclusion: This cost analysis should make it possible to draw up pricing proposals in compliance with regulations and health policy choices and to develop health-economic studies. This would ultimately lead to official recognition of tDCS treatment for depression in France and pave the way for studying various scenarios of coverage by the French national health insurance system., (Copyright © 2018. Published by Elsevier Masson SAS.)

Borderline personality disorder (BPD) is a severe and frequent disorder characterized by a pervasive pattern of instability affecting impulse control, emotional regulation, cognitive processing, self-image and interpersonal relationships. Patients' personal histories are often marked by stressful or traumatic experiences, either unique or repeated. Moreover, while clinical signs of the disorder include both chronic and acute features, acute features are mostly triggered by acute stressful situations. Such features include transient cognitive distortion, intense anger, uncontrollable impulsivity, and self-harm behavior - including suicide - and contribute to the burden of the disease. In this paper, we review the various aspects (epidemiological, clinical, and physiological) contributing to the relationship between BDP and stress. In particular, we explore the statistical association between stress exposure and the emergence of BPD while taking into account other psychopathologies, such as post-traumatic stress disorder. Then, the different aspects of stress responses (namely, the phenomenological, behavioral, hormonal, neuro-vegetative and neural responses) are reviewed in BPD patients. Pathophysiological hypotheses are formulated to explain the differences in responses between BPD patients and healthy subjects and their relation to BPD symptoms. Although the pathogenesis remains uncertain, our conclusions seem to reflect a specific biological and neural pattern of altered stress perception and regulation in BPD.