Factors related to treatment compliance in bipolar disorder.

BACKGROUND: Medication non-adherence is a major problem in patients with bipolar disorder as it is associated to poor clinical outcomes with frequent relapses and consequently poor quality of life. The reasons that patients are non adherent with medication are not well understood by clinicians who often consider it as related to the illness itself.    AIMS: To assess sociodemographic, clinical and therapeutic factors related to medication compliance in bipolar disorder. METHODS: A cross-sectional study was conducted at the department of psychiatry of FarhatHached Hospital of Sousse. We included 50 outpatients with bipolar disorder type I or II according to the criteria of the DSM-IV TR. The sociodemographic, clinical and therapeutic data were collected and adherence was evaluated with the Medication Adherence Report Scale (MARS) of Thompson. RESULTS: The mean age of our patients was of 31.9 years. The most frequent diagnosis was the bipolar disorder type I (60 %). Most of the participants were single (n=30; 60%), unemployed and living with their families. Factors associated to medication non-adherence were: young age, addiction, complexity and adverse effects of medications, lack of information about the disease and utility of treatments, low income and type I of bipolar disorder. CONCLUSION: Improving medication compliance strategies in bipolar patients must take into account psycho education of patients about their disease and simplification of prescriptions that must be also well tolerated mainly in young subjects, having addictive behaviors and low income.

[Prevalence of alcoholism in primary care in the governorate of Sousse]. / Prevalence de l'alcoholisme en première ligne dans le gouvernorat de Sousse.

BACKGROUND: The prevalence related to alcohol use disorders in adults is 1.7%. It varies around the world. In Tunisia, as in most Arab and Muslim countries, alcohol consumption is still a taboo and little studied. AIMS: To estimate the prevalence of alcohol abuse and dependence Band to assess associated socio-demographic factors in primary care patients in Sousse governorate. METHOD: It's a descriptive study carried out between June and November 2006. The sample included 30 primary care units in Sousse governorate, chosen by a stratified random method. We used the Composite International Diagnostic Interview (CIDI 2.1) translated and validated in Tunisian dialect. RESULTS: Our sample included 2577 participants. The lifetime prevalence of alcohol abuse and during the last 12 months were 2.8% and 1%. Those of alcohol dependence were respectively 0.7% and 0.3%. Only one case of alcohol abuse was found among women and no cases of dependence have been noticed. For men's, the prevalence of alcohol abuse at the lifetime and during the last 12 months were 12.8 % and 4.5 %. For men's alcohol dependence, prevalence rates were 3% and 1.6 %. Associated factors with abuse or alcohol dependence were studied in men's sample (n=560). Alcohol abuse was more common after multivariate logistic regression in the age group betwen18 and 34 years and in those with a diploma. Alcohol dependence was associated with only high level of education. CONCLUSION: Our study provides further evidence that alcohol abuse and dependence in primary care remain low compared to other international studies and highlights the role of primary care physicians in the screening of these health problems especially among men.

Eosinophilia and parotitis occurring early in clozapine treatment.

CASE PRESENTATION: Mr. S is a 32-year-old male with schizophrenia. Due to poor responses to various antipsychotic medications, he was started on clozapine with the dose titrated to 300 mg/day during a 4-week period. The weekly checks of the complete blood cell count showed gradual increases in the eosinophil count from normal values to 4320 per mm(3). Mr. S did not have any symptoms except some increased salivation. Clozapine was suspended, and eosinophils gradually began to decline to the normal range. Clozapine was subsequently re-started and there were no changes in eosinophil counts. Mr. S exhibited improvement of symptoms but complained of acute auricular pain and increased salivation, 8 weeks after clozapine rechallenge. He also developed a swelling of his both parotid glands. The diagnosis of clozapine-induced parotitis was suggested. Symptomatic medication was prescribed with a favorable outcome. CONCLUSION: We report a case of a patient who developed eosinophilia shortly after clozapine use, and then developed parotitis. There is debate in the literature over how to manage these complications of clozapine treatment. Generally they do not warrant clozapine discontinuation.

Relationships between pharmacokinetic parameters of carbamazepine and therapeutic response in patients with bipolar disease.

This study aimed to assess the relationship between plasma levels of carbamazepine and its active metabolite 10,11-epoxide-carbamazepine, and the therapeutic response in patients with bipolar disease. Thirteen patients were kept on a fixed individual dose of carbamazepine for 19 weeks under psychiatric care. Steady-state plasma concentrations of carbamazepine and its metabolite 10,11-epoxide-carbamazepine were measured at weeks 4, 12, and 20 by HPLC essay. Simultaneously, the psychopathologic state was assessed using the Brief Psychiatric rating scale (BPRS). Upon correlational analysis, mean BPRS scores did not correlate with the plasma levels of carbamazepine, whereas both mean plasma levels of 10, 11-epoxide-carbamazepine concentrations and 10,11-epoxide-carbamazepine to plasma carbamazepine ratio were closely correlated with mean values of BPRS scores (r = 0.80, p =10(-4), r= -0.89, p =10(-3) respectively). Optimum therapeutic response was observed among patients who had a plasma metabolite level of 1.4 µg/mL and a plasma carbamazepine concentrations of 7 µg/mL simultaneously. These results suggest that both plasma carbamazepine and 10,11-epoxide-carbamazepine levels must be fixed to achieve optimum therapeutic response. In order to reach these conditions, inhibitor drugs (such as valproic acid) or inductor drugs (such as phenobarbital) of epoxyde-hydrolase might be coadministered with the carbamazepine in order to adapt the plasma level of 10,11-epoxide-carbamazepine.

Life events and quality of life in female patients with dermatitis artefacta: a comparative study with siblings and controls.

BACKGROUND: If the severity of dermatitis artefacta (DA) is accepted by most authors, few published studies have sought to clarify its etiology and impact. It is in this context that this work aimed to compare Life Events (LE) and quality of life (QoL) scores in patients with DA, in their siblings and in control patients with other chronic dermatological diseases. METHODS: This is a descriptive and comparative cross-sectional study carried out in the dermatology department of Farhat Hached hospital in Sousse, Tunisia. Thirty female patients diagnosed with DA according to DSM-IV criteria were retrospectively recruited. For each patient with DA, one of her sisters, the closest in age, was enrolled in the siblings group. The control group consisted of thirty female patients with other chronic dermatological diseases, matched with DA patients for age and duration of disease progression. Assessment was based on Paykel inventory for LE and on SF-36 for QoL. RESULTS: Compared to both control groups, DA patients reported more LE with more objective negative impact of these events and had a lower score and more often impaired mean global score of QoL. CONCLUSIONS: LE would have a role in the pathogenesis of DA which seems to alter the QoL of patients. These results could help to improve the understanding of DA and incite clinicians to focus not only on the diagnosis and treatment of DA but also on the impact of this disease.

Translation into Arabic and validation of the Schedule for the Assessment of Insight-Expanded Version (SAI-E) for use in Tunisia.

BACKGROUND: The Schedule for the Assessment of Insight-Expanded Version (SAI-E) consists of 11 items that encompass: awareness of having a mental illness, ability to rename psychotic phenomena as abnormal, and compliance with treatment. AIMS: To translate into Arabic and validate the Tunisian version of this instrument. METHOD: The Arabic translation of the SAI-E was obtained by the "forward/backward translation" method. Adaptations were made after a pilot study involving 20 outpatients with schizophrenia and after taking account the opinions of 15 experts in psychiatry. For validation, 150 outpatients suffering from schizophrenia were recruited by a random drawing in the psychiatric department in Sousse (Tunisia). For factor analysis, principal components analysis and Varimax rotation were adopted. Convergent validity was assessed by correlating the translated scale with the G12 item (lack of judgment and awareness of the disease) of the positive and Negative Syndrome Scale (PANSS). Internal consistency was assessed by Cronbach alpha coefficient and inter-rater reliability was assessed by the use of intra-class correlation coefficient (ICC). RESULTS: Regarding construct validity, factor analysis revealed three factors that were responsible for 70.2% of the variance. As for concurrent validity, we found a negative correlation between the score of the SAI-E and that of the G12 item of the PANSS (r=- 0.82 and p<10(-3)). The study of internal consistency between the 11 items was found to be good (α=0.82). The test-retest reliability was satisfactory (r=0.8, p<10(-3)), and so was inter-rater reliability (ICC=0.84). CONCLUSION: In the Tunisian cultural context, the SAI-E presented three factors with good consistency and an inter-rater reliability compatible with the insight dimensions that are intended to be evaluated.

Validation of the Arabic version of the Comprehensive Assessment of At Risk Mental States (CAARMS) in Tunisian adolescents and young adults.

AIM: The study aimed to examine whether the Arabic version of the Comprehensive Assessment of At Risk Mental States (CAARMS) has good construct validity, concurrent validity and reliability. METHODS: Validity was established on a sample of 58 Tunisian adolescents and young adults aged between 16 and 30 years. These subjects were divided into three groups according to the CAARMS scores: ultra-high risk positive subjects (UHR (+) ) (n = 22), ultra-high risk negative subjects (UHR (-) ) (n = 25) and subjects meeting the criteria of a first-episode psychosis (FEP) (n = 11). For construct validity, we used the convergent validity. We used the Positive and Negative Syndrome Scale (PANSS) concomitantly with the CAARMS. For concurrent validity, we studied the correlation between symptoms of the CAARMS and their equivalents in the PANSS. The CAARMS reliability was conducted by the study of interrater reliability. RESULTS: The UHR (+) group was shown with intermediate scores of PANSS between the two groups UHR (-) and FEP. That confirms a good construct validity of the Arabic version of the CAARMS. We noted a correlation between the scores in positive and negative sections measured by the CAARMS and their corresponding level of the PANSS. These results show that the CAARMS has a good concurrent validity with the PANSS. For the reliability study, we noted a good correlation between the two raters with a Pearson coefficient ranging from 0.55 to 0.90. CONCLUSION: Analysis of the results of construct validity, concurrent validity and reliability of the CAARMS indicates that this version translated into Arabic is valid and reliable.

[Prévalence et facteurs associés du panique et des troubles phobiques dans les structures de première ligne]. / Prevalence and associated factors of panic and phobic disorders in primary care.

BACKGROUND: Panic and phobic disorders are the most common anxiety disorders in the general population. They can be a source of suffering, disability and are often complicated by other psychiatric disorders. AIMS: To estimate the prevalence of panic disorder, agoraphobia, social phobia and specific phobia and to assess associated sociodemographic characteristics in primary care patients in Sousse governorate. METHODS: A systematic sample of 1246 adults who presented to 30 different primary care units in Sousse for a medical appointment was recruited in a cross- section epidemiological study. The Composite International Diagnostic Interview (CIDI 2.1) was used to diagnose the concerned anxiety disorders. RESULTS: The lifetime prevalence of panic disorder, agoraphobia, social phobia and specific phobia were respectively 1.3%, 2.5%, 6.2% and 24.6%. The female gender was significantly predominant in social and specific phobia. The young age was found significantly in subjects with social phobia. These anxiety disorders were significantly predominant in rural areas, except for social phobia. All of these disorders have a chronic course with an index of chronicity ranging from 71 to 80%. CONCLUSION: Our study provides further evidence of the high prevalence of anxiety disorders in primary care and highlights the particular need for general physicians to diagnose and treat correctly these disorders.

Life events in bipolar patients: a comparative study with siblings and healthy controls.

BACKGROUND: While many studies have focused on life events in depressive disorders, data regarding them in bipolar disorder are scant. The aim of this work was to explore the characteristics of life events in bipolar patients. METHODS: Sixty bipolar patients have been included in our study. The evaluation focused on the sociodemographic and clinical characteristics with a standardized measurement of life events using Paykel's interview. The results were compared with those of siblings and healthy controls groups. The three groups were matched for age and sex. RESULTS: Compared to the controls, bipolar patients and their siblings had a higher global score of life events and more events in the fields of work, socio-family events and health. Bipolar patients reported more desirable events compared with their siblings and controls. The siblings reported higher scores of uncontrollable and undesirable events than patients and controls, and a higher score of controllable events than patients. LIMITATIONS: The Paykel's interview has no validated Tunisian version, which could be a methodological bias in the assessment of life events. Moreover, the assessment of the life events was made during the euthymic phase of the bipolar disorder; however, there was no standardized measure of mood symptoms, to confirm this euthymia. CONCLUSION: Our findings could help in the identification of the etiopathogeny of bipolar disorder and would contribute to improve the understanding and management of these patients focusing on the psychosocial aspect which is often overlooked.

General psychopathology, anxiety, depression and self-esteem in couples undergoing infertility treatment: a comparative study between men and women.

OBJECTIVE: To compare measures of psychological distress between men and women undergoing ART in the Unit of Reproductive Medicine "UMR" in the Department of Obstetrics and Gynecology at "Farhat Hached" Hospital in Sousse, Tunisia. STUDY DESIGN: We conducted a gender comparative study of psychological profile in infertile couples. Recruitment was done during period from January to May 2009. 100 infertile couples with primary infertility were recruited. Scores of general psychopathology, depression, anxiety and self-esteem were evaluated. We administrated questionnaires on psychological factors among infertile couples before starting a new infertility treatment cycle. Psychological factors included the symptom check-list (SCL-90-R), the hospital anxiety and depression scale (HAD-S) and the Rosenberg self-esteem scale (RSE). RESULT(S): Infertile women had higher scores than their spouses in the three global scores of the SCL-90-R and in several items such as somatisation, obsessive symptoms, interpersonal sensitivity and phobias. Scores of HADS were higher among women for both depression and anxiety. Scores of self-esteem were lower among women. CONCLUSION(S): Women endorsed higher psychological distress than men across multiple symptoms domains: general psychopathology, anxiety, depression and self esteem.

[The physicians' perception of the general practitioner management of mental disorders: importance, difficulties and perspectives]. / Perception par les médecins du rôle du généraliste dans la prise en charge des troubles mentaux: importance, difficultés et perspectives.

BACKGROUND: Mental disorders are common in general medicine consultation. According to international studies, their prevalence in primary care varies from 34 to 54%. In Tunisia, the general practitioner role, as well as the difficulties that encountered them in the management of these disorders, are little known. AIM: The objective of this work was to pull opinions of the general doctors and the psychiatrists concerning the current role of the general doctors, the difficulties that encountered them, as well as the possible solutions in promoting mental disorder management. METHODS: It was a descriptive investigation carried out in Mars 2008, near 200 doctors (100 general practitioners and 100 psychiatrists). A questionnaire was drawn up with two parts: the first for collecting the doctors' opinions concerning general practitioner mental disorder management and the strategies of improving it. The second was devoted to the assessment of the collaboration between general practitioners and psychiatrists. RESULTS: The answer's rate was 45.5%. The majority of the general doctors qualified as secondary their role in the mental disorder management and limited to the tracking of patients with mental disorders. This modest implication of the general practitioners in the treatment and the follow-up of patients with mental disorders could be explained by the lack of competence and training recognized by them and also reported by the majority of psychiatrists. Doctors in this investigation have proposed to set up training programs for managing mental diseases and to organize regularly common scientific conferences between general practitioners and psychiatrists in order to improve their collaboration. CONCLUSION: This investigation has permitted to identify reciprocal expectations of general practitioners and psychiatrists. They both agreed upon the need of a more important implication of the general practitioners in the mental disorder management and the necessity of psychiatrists' involvement in the general practitioners training and information.

[Comorbid personality disorders in major depressive disorder: a comparative study in 160 Tunisian female inpatients]. / Comorbidite trouble depressif majeur et troubles de la personnalite: etude comparative dans un groupe de 160 patientes hospitalisees.

BACKGROUND: Major Depressive Disorder (MDD) is often comorbid with personality disorders which are known to change its clinical aspects and worsen its outcome. AIM: This study aimed to compare clinical and outcome aspects of a female depressed inpatients group according to the existence or not of a comorbid personality disorder. METHODS: The study was carried in the psychiatry female inpatient unit of Farhat Hached hospital of Sousse. All entrances to the unit from January 1999 to August 2002 were retrospectively reviewed. 160, corresponding to MDD, were selected. Assessment was based on demographic characteristics, medical history, axis I comorbid disorders, clinical aspects of the index episode and outcome characteristics. RESULTS: 77 patients (48.1%) had personality disorder. Compared to those without comorbid personality disorder, these patients were younger (p < 10-4), with higher educational level (p = 0.005) and better vocational functioning (p = 0.018). They also had an earlier age at onset of their depression (p < 10-4), more previous suicide attempts (p = 0.012) and more axis I comorbid disorders (p < 10-4). Comorbid personality disorders were correlated to an impaired outcome, with higher rate of relapses (p = 0.021), more recurrences (p = 0.026), more persistent symptoms (p < 10-4) and more suicide attempts (p = 0.031).

Personality disorders in a group of psychiatric outpatients: general aspects and cluster B characteristics.

BACKGROUND: Personality disorders are common among patients seeking psychiatric care and often coexist with axis I disorders. Cluster B types are reported as being the most common in those patients. They are often correlated with specific demographic features, higher rates of axis I comorbidity and impaired outcome. AIM: This study aimed to describe general and clinical features of personality disorders types in a Tunisian outpatient psychiatric unit and to determine characteristics of cluster B personality types, compared to those of cluster A and C. METHODS: This study was held in Sousse psychiatric outpatient unit, from January 2000 to December 2004. 148 cases were retrospectively recruited and assessed according to axis I and axis II DSM-IV criteria. RESULTS: Personality disorders prevalence was 6%. 85.1% of patients had at least one current axis I disorder, which mainly consisted of depressive disorder (42.3%). Cluster B types were the most frequent (54.7%). Comorbid addictive and somatoform disorders were more frequent in cluster B. Anxiety disorders were more frequent in cluster C and psychotic disorders were more frequent in cluster A. CONCLUSION: Our results show prevalence and clinical profile of personality disorders in a Tunisian clinical population. Cluster B types were the most frequent and seem to have specific comorbid disorders. This support the idea that patients with cluster B personality types need adapted psychiatric care.

[Quality of life in oncology]. / Qualite de vie en cancerologie.

The measure of the quality of life in cancerology appears more and more as a fundamental criteria in the evaluation of therapeutic results. The study of the quality of life obeys three types of aims: descriptive, correlational and explanatory, and therapeutic. For evaluation, scales for quality of life were introduced, these scales use a quotation technique with the help of questionnaires or linear analog self assessment. Questionnaires represent the mostly used method. They are composed of several questions or items having predetermined answers for which the patient should check or circle the choice corresponding best to his state. To be useable, a questionnaire must satisfy certain criteria of quality: reliability, validity and sensitivity. In spite of the remarkable progress during recent years in the evaluation of the quality of cancerous patient life, there still exists some conceptual and practical problems that are not yet solved.