[Validation of the French language version of the Parkinson's Disease Questionnaire - PDQ-39]. / Validation en langue française d'un questionnaire de qualité de vie dans la maladie de Parkinson: le Parkinson's Disease Questionnaire - PDQ-39.

After Alzheimer's disease, Parkinson's disease (PD) is the second most frequent degenerative disease of the central nervous system. The consequences of PD at the functional, social and emotional levels warrant a better understanding the patient's perceptions as measured using a specific instrument rather than restricting the medical approach to the clinical evaluation of the motor component. In 1996, we began implementation of a project to transculturally validate the single specific instrument that had been published and was available at that time: PDQ-39. The scale consists in a 39-item questionnaire enabling determination of an overall quality-of-life score and scores for 8 specific dimensions: mobility, activities of daily living, emotional well-being, stigma, social support, cognitions, communication and bodily discomfort. Eighty-nine patients taking part in an open-label study of the safety of a combination of pergolide and dopa therapy were included and followed up on D15 and after 8 weeks. The process of "Forward-Backward" translation, conducted in close liaison with the authors, enabled semantic and linguistic validation of the French language version. The content was validated by PD experts. At baseline, the patients presented quality-of-life scores that were particularly impaired for the dimensions exploring Mobility, Emotional well-being and Bodily discomfort. The main metric properties of the scale were confirmed. The PDQ-39 scores were closely correlated with the related concepts investigated by generic scale, SF-36. The PDQ-39 scores were correlated with the "Mental and Mood Status", "Everyday Activities" and "Motor Status" dimensions determined by the UPDRS. The reliability, expressed by Cronbach coefficients alpha, showed strong consistency of the instrument, very similar to the data for the original version. In contrast to what was observed with SF-36, the scale was particularly sensitive to clinical changes. The initial results make PDQ-39 a precious tool for the optimization of management of patients presenting with PD.

The long-term effectiveness of preventive strategies for osteoporosis in postmenopausal women: a modeling approach.

Based on data from the literature, we have developed a computer-based simulation model to compare the long-term effectiveness of different preventive strategies of osteoporotic fractures. The Markov model comprises 25 states, including states which describe women distributed according to three levels of fracture risk, fractures states, post-fracture states and a death state. We chose eight standard preventive strategies, which we compare with the 'No Treatment' reference strategy. The first two strategies consist in treating all 50-year-old women for 5 or 10 years with hormone replacement therapy (HRT). Strategies 3 and 4 aim at assessing a 5-year course of treatment with bisphosphonates in osteopenic and osteoporotic 65- or 75-year-old women. Strategies 5 and 6 combine 5 years of HRT in all 50-year-old women with 5 years of bisphosphonates in osteopenic and osteoporotic women at 65 or 75 years. The last two strategies simulate 10 years of HRT in all 50-year-old women, followed by strategy 3 or strategy 4. Simulated life expectancy and mean ages of fracture occurrence fit well with the observed data. All the preventive strategies tested reduced the number of fractures. Early 10-year HRT in all women, plus 5 years of bisphosphonates in women at risk of fractures at 65 or 75 years, are the most effective strategies, with an 18.4-19.0% reduction in all fractures, and a 25.6-26.1% reduction in the number of hip fractures. Strategy 2 has a similar outcome, thus demonstrating the value of treatment started early and sustained over a long period. The strategies implemented later, S3 and S4, only concern women at risk (i.e., osteopenic or osteoporotic), and are less effective, with a 1.5-2.1% decrease in all fractures. The combined strategies, S5 and S6, produce intermediate results: a 12.9-13.5% reduction in the number of all fractures and a 17.5-17.9% reduction in hip fractures.

[Frequency and costs of hospital stays for hypoglycemia in France in 1995]. / Fréquence et coûts des séjours hospitaliers pour hypoglycémie en France en 1995.

OBJECTIVES: Diabetes is a highly prevalent chronic disease causing serious complications. Hypoglycemia is the most frequent, the most serious, and the most feared by patients and families. Hospitalization may be necessary and can be costly. The main objective of this study was to determine the number of cases of hypoglycemia cared for annually in France in an inpatient setting and to estimate the annual financial impact of hospitalizations. PATIENTS AND METHODS: The number of hypoglycemias seen annually by physician s in France and the frequencies of hospitalizations for hypoglycemia were determined from a literature search. Complementary data on costs were obtained from the national PMSI mission. Our sample included 817 hospital stays between 1994 and 1995. RESULTS: In 1992, physicians in France cared for 40,000 episodes of hypoglycemia. There were 10,800 hospitalizations. In 9 out of 10 cases, the hospital stay lasted several days and, despite hospitalization, 1.9% of the patients died. Mean total medical cost of a hospital stay for hypoglycemia was 14,000 FF ($2,100) (median 10,000 FF, range 1,200-120,000 FF). Mean length of stay was 6.6 days. DISCUSSION: Mean unit cost for hospital stays for hypoglycemia is high. Based on the 1993 SESI survey, the probable annual cost for the society for hospital care of patients with hypoglycemia was an estimated 108 to 151 million FF ($16-22 million) in 1995. This figure only takes into account the visible cost of caring for hypoglycemia patients. Ambulatory care was not taken into consideration. Education, for the patient and family, is fundamental for the prevention and treatment of hypoglycemia. CONCLUSION: It is important to have this estimation due to the absence of a medicoeconomic study on ambulatory and hospital care for hypoglycemia. Complementary studies should be conducted to estimate the total annual cost of hypoglycemia in France.

Patterns of neuroleptic drug prescription: a national cross-sectional survey of a random sample of French psychiatrists.

AIMS: To describe the psychiatric indications of neuroleptics (especially the relative share of schizophrenic and other psychotic disorders) and the usage patterns of these drugs (dose, duration, coprescriptions). METHODS: A one-day national cross-sectional survey in a random sample of 723 French psychiatrists was carried out in 1996. Each psychiatrist was asked to complete a standardized questionnaire for the first three patients seen the day of the survey to whom at least one neuroleptic was prescribed (initiated or renewed). RESULTS: One thousand seven hundred and fifty-four questionnaires were returned. Three quarters of the patients (74%) were psychotic (664 with schizophrenia, and 636 other psychosis), 19. 3% were depressive and 6.7% had other psychiatric disorders. Phenothiazines were the most often prescribed (40.8%), followed by butyrophenones (22.5%), benzamides (15.8%), other neuroleptics (14. 8%) and thioxanthenes (6.1%). Among schizophrenic subjects, an average number of 1.54 (95% CI: 1.50-1.60) neuroleptics were prescribed per patient, compared with 1.4 (95% CI: 1.32-1.41) and 1. 2 (95% CI: 1.14-1.23) in other psychotic and depressive subjects, respectively. Regardless of the indication, non-neuroleptic psychotropic drugs were coprescribed in 75.4%, mainly benzodiazepines (75.7%). Adjuvant drugs used in prevention or treatment of side-effects were coprescribed in 46.7%, mostly anticholinergic antiparkinsonians (86.1%). CONCLUSIONS: Neuroleptics are mainly prescribed for psychotic disorders and especially schizophrenia. However, current recommendations are not always followed.

[Use of a structured diagnostic interview to identify depressive episodes in an epidemiologic study: a posteriori internal validation]. / Utilisation d'un entretien diagnostique structuré pour identifier les épisodes dépressifs dans une étude épidémiologique: validation interne a posteriori.

BACKGROUND: During these last years, many structured and standardized diagnostic interviews have been developed in order to identify psychiatric disorders in a standardized way. These tools enable a systematic investigation of these disorders according to international classifications. Their main drawback is to be long. To assess the care of depression, we used a shorter and more simple tool: the Mini International Neuropsychiatric Interview (MINI) to identify depressive subjects. METHOD: The study was conducted in the Gazel cohort from the French National Electricity and Gas Company. A stratified sample of 2394 civil servants selected in order to over-represent depressive subjects was asked to answer to the MINI interview through a phone interview. An epidemiological and statistical analysis was performed to test the MINI internal validity: prevalence of depressive disorders using different threshold of diagnosis (number of symptoms required to identify someone as depressive), frequency of different symptoms, variability between investigators and potential biases. RESULTS: Respondents to the phone interview (1108 civil servants) had more often presented depression markers for the last 5 years. Prevalence of depressive episodes changed little when we varied the threshold of diagnosis and did not stress any threshold problem. The variability between investigators was important, but the estimation of prevalence remained stable when we excluded extreme rates of prevalence. The choice of a classification system affected the prevalence estimation. Using the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) from the American Psychiatric Association, the prevalence of depressive episodes was lower and closer to the estimations shown in the literature than using the International Classification of Disease (ICD 10). Moreover, the stratification assigned very unbalanced weights to the stratification strata. By excluding depressive episodes observed in the stratum "control" (no depression "marker" from 1989 to 1994 in the database), the prevalence was very lower, whatever the classification was. Finally, factors which appeared linked to care of depression with the ICD definition remained the same when the DSM diagnosis definition was used, and relative risks were quite similar. CONCLUSION: The MINI appears to be a short and simple tool, suited to the epidemiological studies. This analysis does not highlight any failure in the internal consistency of the MINI. The remaining question is what the MINI really measures, particularly comparing to a psychiatrist's diagnosis.

[Economic comparison of olanzapine versus haloperidol in treatment of schizophrenia in France]. / Comparaison économique de l'olanzapine versus halopéridol dans le traitement de la schizophrénie en France.

PURPOSE: The purpose of this study is to provide an economic comparison of olanzapine-treated and haloperidol-treated patients from the subset of French patients who participated in a large, international, randomised clinical trial in schizophrenia. METHODS: Patients were evaluated from randomisation until discontinuation, drop out or completion of the 52-week study. The primary clinical measure was "clinically important response" (derived from BPRS total scores). The secondary measure was "clinically important improvement" (derived from CGI severity of illness scores). The primary economic measure was mean per diem, per patient total direct medical costs. RESULTS: A total of 275 French patients where included in the study. Demographics and other baseline differences between olanzapine- and haloperidol-treated patients were not statistically significant. Olanzapine-treated patients (205 +/- 142 days) experienced significantly (p < 0.001) longer evaluation periods than haloperidol-treated patients (132 +/- 129 days). Olanzapine-treated patients (54%) were significantly (p = 0.03) more likely to experience a clinically important response than haloperidol-treated patients (40%). Olanzapine-treated patients (69%) were significantly (p = 0.02) more likely to experience clinically important improvement than haloperidol-treated patients (54%). The mean per diem, per patient total direct medical cost was statistically lower (p = 0.033) for olanzapine-treated patients (FF619 +/- 509) compared to haloperidol-treated patients (FF756 +/- 478). CONCLUSION: Olanzapine treatment was associated with significantly better clinical outcomes and per diem total direct medical cost than haloperidol treatment. The findings indicate that olanzapine is dominant compared to haloperidol for the treatment of schizophrenia, in the context of analysed data. These findings produce increased relevance in France to the existing evidence supporting olanzapine's cost and effectiveness profiles.

[What is the meaning of "stabilization" in schizophrenic patients?]. / Que recouvre le terme "stabilisation" des patients schizophrènes?

UNLABELLED: The notion of stabilization in schizophrenia has been investigated, in France, through a survey of 875 psychiatrists. This survey, which has been conducted on the 9th, 10th and 11th of December 1997, looked into the clinical, therapeutic and socio-demographic variables, and the means of patient management, which are used by psychiatrists to ascertain that their patients are stabilized. The data was collected by each psychiatrist by way of a questionnaire administered to his or her next three patients, either at the hospital or in private practice (2,464 questionnaires were completed). RESULTS: 65% of the patients seen during this survey were considered stabilized by their psychiatrist (n = 1,597). The most common clinical presentation was of the paranoïd type. An insiduous onset of disease seems to be correlated with an absence of stabilization. Stabilization appears to be estimated at a given time rather than over a time period, since over half the patients who were considered stabilized had suffered at least one relapse over the last 2 years, and had been rehospitalized an average of 2.4 times over that period. In terms of drug therapy, they received 1.4 neuroleptic drugs, which does not differ markedly from the 1.5 neuroleptics administered to patients who were considered non stabilized. Co-prescriptions of anticholinergic medications, benzodiazepines and antidepressants were very common in these patients considered stabilized (49.9%, 39.8% and 24.8% respectively), which is similar to that observed in their non-stabilized counterparts (47.6%, 45%, 8% and 26.4%, respectively). Patient follow-up remained above an average of 1 patient visit per month (an average of 8.9 visit over the last 6 months), despite the fact that patients were considered stabilized. Two primary criteria were used by psychiatrists to determine that a patient was stabilized: treatment compliance and the absence of positive symptoms. However, 43% of the patients which were considered stabilized still presented with positive symptoms. Negative symptoms were also very prevalent in these patients (65%), as well as concomitant depressive signs (36%) and anxiety (64%). CONCLUSION: Even though the concept of stabilization remains difficult to define, it appears that schizophrenic patients are considered by their psychiatrist as stabilized on the grounds of good treatment compliance and decreased positive symptoms. Therefore, even in these so-called stabilized patients, enhancements are still possible, as symptoms remain present.

Which patients receive antidepressants? A 'real world' telephone study.

INTRODUCTION: The use of antidepressants has been questioned with respect to both undertreatment and inadequate prescription. The present investigation was therefore launched to assess the psychopathology profiles of antidepressant users. METHODS: A representative sample was constituted on the basis of usual antidepressant consumption, and ICD 10 compatible diagnoses were obtained after telephone administration of a structured psychiatric interview. RESULTS: The most often used drugs were fluoxetine, followed by tricyclic antidepressants. Coprescription existed in slightly less than two thirds of antidepressant users. ICD 10 diagnoses were compared to currently available prescription guidelines. Fluoxetine prescription, as compared to other drugs, was found to be significantly more compliant with these guidelines; conversely, in 22% of antidepressant users, no complete ICD 10 diagnosis could be documented. These results are discussed in the light of report accuracy and anecdotal or 'heterodox' indications of antidepressants. CONCLUSION: Altogether, the present study confirms previous doubts regarding appropriate use of antidepressants and stresses the need for more explicit and comprehensive clinical guidelines. It does not substantiate, however, any evidence for a 'recreational' use of these products.

[Pharmaco-epidemiologic study of the use of antidepressant drugs in the general population]. / Etude pharmaco-épidémiologique de la consommation des antidépresseurs en population générale.

The objective of this study was to evaluate the mode of prescription and the users of antidepressant agents. It consisted of an initial phase (survey of the general population), aimed at selecting a representative sample of antidepressants users by a mail questionnaire, without asking prescribers in order to avoid the bias inherent to such an approach. Results showed a current incidence of use of 2.75 % for the 8 main antidepressants, i.e. more than one million adults in France. The distribution of antidepressants showed Prozac in first place, followed by Anafranil, and Laroxyl, then Stablon, Athymil, Survector and Ludiomil. In more than 50 % of cases, antidepressants have been taken for a year or more, continuously of intermittently. They were prescribed by a general practitioner in 60 % of cases and a psychiatrist in 30 %. A second survey phase (telephone) undertaken by psychiatrists and involving a sample of this population enabled determination of the pathophysiological profile of consumers at the time of prescription of antidepressant treatment, using a validated diagnostic tool, the MINI. Taking all drugs together, results showed that prescription was within Marketing Authorization approved indications in about 65 % of cases (existence of depression 61 %, dysthymia 3 %, OCD 1 %). This study shows that, in 23 % of cases, antidepressants are not used in patients with one of the psychiatric diseases identified by the MINI but nevertheless suffering from pathophysiological symptoms (subsyndronic syndrome). It can be concluded that, in some subjects, antidepressants are used in non-identified disorders. It must also be recognized that, with 3 % of users, the population of individuals treated by antidepressants is less than that of patients suffering, in the general population, from depression (5 to 10 % per year, according to studies).