[Couples and families emergency/crisis consultation: emergency patterns and treatment assessment]. / Consultation d'urgence/crise pour couples et families: motifs d'urgence et évaluation du traitement.

Since the opening in 2003 of the Couple & Family Consultation Unit (UCCF) at Prangins Hospital, we have met urgent demands and observed that the suffering systems (i.e., couples and families) couldn't face any waiting period. So in 2007 an Emergency/Crisis Facility was created, based on the hypothesis that there is no contra-indication to systemic emergency care, if one understands and structures both crisis and treatment. We studied the suffering population in demand and the emergency/crisis issues and assessed therapy efficiency. Then we observed that treating suffering systems in emergency does produce therapeutic gain in terms of crisis resolution and patients' satisfaction. Those treatments refer to public health issues, as considered the human, social and financial cost of couples/families dysfunctions.

[Acute confusional episode--delirium in elderly patients. Definition, etiology and treatment]. / Episode confusionnet aigu--delirium chez la personne âgée: définition, étiologie et prise en charge.

Delirium, (acute confusional episode in European nomenclature) frequently occurs to elderly patients. This confusional condition is characterized by a sudden beginning and fluctuating clinical manifestations. It can bring out or showup a large number of illnesses. Generally transient and reversible, confusional state remains a medical emergency, motivating numerous consilium and psychiatric admissions. On the base of a case report, we aim to recall the high frequency of this affection in a somatic context and the importance of early diagnosis and treatment.

[Bipolar paediatric disorder early diagnosis]. / Diagnostic précoce du trouble bipolaire chez l'enfant et l'adolescent (TBEA).

The Bipolar Disorder in infants and youngsters is not very known and under-diagnosed in the concerned population. We hereby describe its clinical features, its comorbidity along with other frequent psychopathologies, such as ADHD, which enable us to describe the symptoms and the indicators of risk. According to how these indicators appear, we can establish various degrees of clinical risk. Irritability, impulsiveness, hyperactivity, intolerance to frustration and sleep disorders are the most frequent prodroms. If they present a clinic of suicidality, toxic abuse (cannabis, alcohol), or even psychotic symptoms, in the context of significant family history, the child psychiatrist should not doubt to diagnose Bipolar Disorder and start the corresponding treatment.

[Somatic disorders, factitious disorders and simulation: the subtle art of differential diagnosis]. / Troubles somatoformes, troubles factices et simulation: l'art difficite du diagnostic différentiel.

In every day practice, it is difficult, sometimes impossible, and always ethically delicate to determine the differential diagnosis between: disorders of a somatic nature, simulation and factitious disorders, as much for the psychiatrist as for the general practitioner in the front line. Our aim is to lead a reflection on this controversial theme on the basis of a clinical illustration.

[Psychiatry]. / Psychiatrie.

Introduced this year on the Swiss market, duloxetine (Cymbalta) is a new antidepressant which inhibits the reuptake of noradrenaline and serotonin. Clinical studies have shown its efficacy in depression as well as in neuropathic pains (60-120 mg/day) with a good tolerability. In this paper are also included short reviews about the two large American studies developed by the National Institute of Mental Health in the fields of the treatment for depression (STAR-D) and of the antipsychotic treatments for schizophrenia (CATIE study). Its also reviews two questions of present interest: the use of the second generation antipsychotics for the treatment of bipolar depression and the concept of bipolar disorders in children.

[Attempted suicide in Switzerland: from practice to prevention]. / Conduites suicidaires en Suisse: du terrain d la prévention.

Prevention of suicide and recurrent suicidal behaviour is actually a prior issue for the Canton de Vaud, in order to elaborate an accurate Health Management. After a brief description of the swiss and Vaud situation we report epidemiological data about attempted suicides in Morges' hospital, collected since the beginning of the activity of a Consultation-Liaison psychiatrist and we confront them with the level of functioning of the medical system. Consultation-Liaison Psychiatry, through an early intervention during such a critical period, can provide better detection and prevention of those situations. It offers also the opportunity to develop adapted plans of observation, orientation and treatment for those patients already within a somatic setting.

[Somatoform disorders: diagnosis and treatment]. / Les troubles somatoformes: diagnostics et prises en charge.

Somatoform disorders include several diagnoses, the treatment of which concerns somaticians as well as psychiatrists. This paper defines those diagnosis features, differential diagnosis, epidemiological aspects and etiology hypothesis. Regarding treatments, emphasis is stressed upon, the high level of collaboration between somaticians and psychiatrists, regarding those long term follow-up, well known for potential high-costs in terms of individual suffering and financial terms.

[Psychiatry]. / Psychiatrie.

During the year 2005 much of the attention was given to the debate on the risk of suicide during treatments with selective serotonin reuptake inhibitors. Our review concludes with a moderate increased risk of suicidal behaviour but not a risk of death by suicide. Caution, not panic, is indicated, particularly for children and adolescents given that, in this age group, benefits of these drugs have not been well established. We also report two synthesis concerning the latest developments in the fields of cognitive psychotherapy for depressive disorders (rather stimulating news) and of pharmacotherapy for borderline personality disorders (no breaking news).

[Treatment of agitation in the emergency room]. / Traitement de l'agitation aux urgences somatiques.

The treatment of agitation in the emergency room is a subject regularly treated in different studies and conferences because of the diagnosis difficulties and the psychological impact on medical teams. Differential diagnosis includes organic, toxic and psychiatric causes. Non-pharmacological means (emergency rooms' organisation, communication skills, first care teams' formation) allow resolution of some of these situations. When psychopharmacological intervention is required benzodiazepines (lorazepam) and neuroleptics (haloperidol, olanzapine) are indicated, first orally, then intramuscularly if requested by noncollaborative patient. Combination of drugs is not to be recommanded. Side effects of current medication are to be well known, that's why only a small number of molecules are to be used, after controlled studies.

[Psychiatry]. / Psychiatrie.

The main innovation of the year 2004 was the introduction of a new, second-generation antipsychotic drug with a new mechanism of action (partial dopamine agonist), encouraging first clinical results, and an advantageous clinical tolerance profile. Additionally, three new galenic forms are presented: an oral, extended-release form of methylphenidate that could be useful in the treatment of attention-deficit/hyperactivity disorders; an intramuscular depot form of a second-generation antipsychotic drug (risperidone) with the advantage of improving adherence; and an intramuscular form of a second generation antipsychotic (olanzapine) that is valuable in emergency situations. Finally, we will briefly give an update on the advantages of lamotrigine in bipolar depression.

Pharmacokinetic drug interaction potential of risperidone with cytochrome p450 isozymes as assessed by the dextromethorphan, the caffeine, and the mephenytoin test.

Two published case reports showed that addition of risperidone (1 and 2 mg/d) to a clozapine treatment resulted in a strong increase of clozapine plasma levels. As clozapine is metabolized by cytochrome P450 isozymes, a study was initiated to assess the in vivo interaction potential of risperidone on various cytochrome P450 isozymes. Eight patients were phenotyped with dextromethorphan (CYP2D6), mephenytoin (CYP2C19), and caffeine (CYP1A2) before and after the introduction of risperidone. Before risperidone, all eight patients were phenotyped as being extensive metabolizers of CYP2D6 and CYP2C19. Risperidone at dosages between 2 and 6 mg/d does not appear to significantly inhibit CYP1A2 and CYP2C19 in vivo (median plasma paraxanthine/caffeine ratios before and after risperidone: 0.65, 0.69; p = 0.89; median urinary (S)/(R) mephenytoin ratios before and after risperidone:0.11, 0.12; p = 0.75). Although dextromethorphan metabolic ratio is significantly increased by risperidone (median urinary dextromethorphan/dextrorphan ratios before and after risperidone: 0.010, 0.018; p = 0.042), risperidone can be considered a weak in vivo CYP2D6 inhibitor, as this increase is modest and none of the eight patients was changed from an extensive to a poor metabolizer. The reported increase of clozapine concentrations by risperidone can therefore not be explained by an inhibition of CYP1A2, CYP2D6, CYP2C19 or by any combination of the three.

[Antidepressants and somatic disease]. / Antidépresseurs et maladie somatique.

Depression is the most frequent psychiatric disease associated with chronic somatic disorders. Diagnosis, however, is frequently difficult to make, due on one hand to the presence of symptoms that depression and chronic somatic disorders have in common, and on the other hand to the assumption shared by the physician and its patient that depression is a normal reaction to a somatic illness. Accurate diagnosis is nevertheless necessary in order to initiate the appropriate treatment. A review of pharmacological treatments of depression related to frequent chronic somatic disorders is presented.

Pharmacokinetic consequences of a citalopram treatment discontinuation.

In this pilot study, the pharmacokinetics of citalopram (CIT) were examined in five hospitalized depressed patients after an abrupt discontinuation of a treatment with 40 mg/d of this selective serotonin reuptake inhibitor (SSRI). During the 8-day study period, clinical ratings were regularly carried out. Between days 5 and 8, the patients were treated with clomipramine (75 mg/d). The enantiomers of CIT and its metabolites, demethyl-CIT (DCIT) and CIT-propionic acid derivative (CIT-PROP), were measured repeatedly from day 0 to day 8 by a stereoselective high-performance liquid chromatography (HPLC) procedure. The following drug plasma half-lives were measured (means +/- SD): R-CIT: 66+/-11 h; S-CIT: 42+/-13 h; R-DCIT: 228+/-148 h; S-DCIT: 93+/-35 h; R-CIT-PROP: 82+/-31 h; S-CIT-PROP: 186+/-93 h.

[Withdrawal syndrome caused by selective serotonin reuptake inhibitors: apropos of a case]. / Syndrome de sevrage aux inhibiteurs sélectifs de la recapture de la sérotonine: à propos d'un cas.

During the past 4 years, several case reports have been published on the withdrawal syndrome which may be observed after acute interruption of a treatment with selective serotonin reuptake inhibiting antidepressants (SSRI). Paroxetine is the most frequently cited antidepressant in the literature, whereas fluoxetine is the less frequently cited of this type of drugs. The withdrawal symptoms appear a few days after stopping treatment or after a decrease of the dose. The typical symptoms are of the gastro-intestinal type, such as loss of appetite, nausea, vomiting, diarrhea and abdominal cramps. Other symptoms are sensation of instability, vertigo, dizziness, headache, malaise, muscular pains, asthenia, as well as a syndrome of pseudo-influenza. Brief electric shocks throughout the body, which last one or two seconds, have also been reported. A case is reported in detail by the authors, who observed some of these symptoms in a patient after stopping his treatment with paroxetine. This withdrawal syndrome may be due to a rebound phenomenon of the serotonergic systems after interruption of the treatment with SSRIs. It is, therefore, recommended that treatment with SSRIs is progressively stopped over a period of several weeks.

The association carbamazepine-mianserin in opiate withdrawal: a double blind pilot study versus clonidine.

Our clinic has fortuitously developed the therapeutic use of the association of mianserin (maximum daily dose 90 mg) and carbamazepine (maximum daily dose 400 mg) in opiate withdrawal management. If animal studies have suggested efficacy of mianserin in such indication, no human studies have been performed. To test the efficacy of such an association, a comparison was made to clonidine (maximum daily dose 0.600 mg) in a one week treatment period according to a double blind pilot study design. Thirty-two patients were included (16 in each treatment group). The two treatments did not differ in the intensity of the withdrawal, according to the rate of retention in treatment and symptoms, and the psychic distress which were auto-evaluated every other day with the Opiate Withdrawal Questionnaire and several Visual Analog Scales (VAS). The clonidine group, however, scored significantly higher (P < 0.05) on the VAS rating of the global feeling of satisfaction on the last day. The patients in the mianserin group fortuitously had a moderately lower number of daily heroin intakes but there was no significant correlation between this variable and the global OWQ scores on Days 1, 3, 5 and 7. Given the size of the groups, we cannot conclude that the association carbamazepine-mianserin is as effective as clonidine, but a real effectiveness is probable. A study versus placebo would be necessary to draw more definitive conclusions.