[Prevalence of psychiatric disorders in French general practice using the patient health questionnaire: comparison with GP case-recognition and psychotropic medication prescription]. / Prévalence des troubles psychiatriques en médecine générale selon le patient health questionnaire: adéquation avec la détection par le médecin et le traitement prescrit.

INTRODUCTION: Psychiatric disorders, mainly depression and anxiety, are frequently encountered in primary care and are a major cause of distress and disability. Nearly half of cases go unnoticed and among those that are recognised, many do not receive adequate treatment. In France, there is limited research concerning the prevalence, detection and management of these conditions in primary care. OBJECTIVES: To estimate the prevalence of psychiatric disorders, overall and for the main psychiatric diagnostic categories, encountered in primary care; to describe general practitioners' (GPs') case identification rate; to examine psychotropic medication prescription according to diagnosis, in a regionally representative sample of GP attenders. METHODS: GP practicing standard general practice in an urban area of the city of Montpellier and a nearby semi-rural region were recruited to participate. The response rate was 32.8% (n=41). Five additional GP almost exclusively offering homeopathy and acupuncture were recruited nonrandomly for convenience purposes. In each GP surgery, consecutive patients entering the waiting room were invited by a research assistant to participate until 25 patients per GP were recruited. Each participant completed self-report questionnaires in the waiting time, including the patient health questionnaire (PHQ), which yields provisional DSM-IV diagnoses. The GP completed a brief questionnaire during the consultation, giving his/her rating of the severity of any psychiatric disorder present and action taken. RESULTS: The patient response rate was 89.8%. In all, 14.9% of patients reached DSM-IV criteria for major depression or anxiety disorder on the PHQ (9.1% for major depression, 7.5% for panic disorder; 6% for other anxiety disorders). For the subthreshold categories, 7.4% met criteria for other depressive disorders, 11.8% for somatoform disorders and 10.9% for probable alcohol abuse or dependence. 66.3% of patients with DSM-IV diagnoses of major depression or anxiety disorder were identified by the GP as having a psychiatric disorder. The identification rate was 51% for all depressive disorders, anxiety and somatoform disorders. Of patients receiving a prescription for anxiolytic or antidepressant medication on the survey day, 80% were classified as cases of psychiatric disorder by the GP. Only 48.8% met criteria for major depression or anxiety disorder on the PHQ. CONCLUSION: This study highlights the frequency of psychiatric disorders in a regional study of French general practice. Overall, prevalence rates were similar to those found elsewhere, except for probable alcohol abuse and dependence, which was considerably higher than in the USA PHQ validation study. As in other countries, GP identified roughly half of psychiatric cases. Furthermore, half of patients treated by anxiolytic or antidepressant medication did not meet the diagnostic criteria on the survey day for which these medications have mainly shown their efficacy. This confirms the French paradox of one of the highest psychotropic medication consumption rates in Europe despite many cases of depression remaining untreated. The PHQ could be a rapid and acceptable diagnostic aid tool for French general practice but first needs to be validated against the diagnosis of mental health professionals in this setting.

Psychiatric morbidity, disability and service use amongst primary care attenders in France.

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.

Exposure to anaesthetic agents, cognitive functioning and depressive symptomatology in the elderly.

BACKGROUND: Anaesthesia could provoke persistent alterations in specific cognitive domains in the elderly where ageing-related neuronal changes may exacerbate pharmacotoxic effects. AIMS: To evaluate anaesthesia effects on the incidence of cognitive dysfunction after orthopaedic surgery in elderly patients. METHOD: A total of 140 patients over the age of 64 years completed a full range of computerised cognitive tests. The study takes into account effects of pre-operative cognitive dysfunction, depressive symptomatology and ability to perform activities of daily living. RESULTS: Postoperative cognitive decline persisted for up to 3 months in 56% of subjects. Dysfunction was limited to verbal, visuo-spatial and semantic abilities and secondary and implicit memory. Age, low educational level, pre-operative cognitive impairment or depression are risk factors. CONCLUSIONS: Cognitive functions are not equally affected, type of impairment being determined by the risk factors described above and anaesthesia type.

[Anesthesia and postoperative cognitive dysfunction in the elderly: a review of clinical and epidemiological observations]. / Anesthésie et troubles cognitifs postopératoires chez le sujet agé: état des connaissances cliniques et épidémiologiques.

Amnesic effects of anesthesia were first reported two hundred years ago, but the term postoperative cognitive dysfunction (POCD) has appeared only recently, covering a larger range of neuropsychological modifications resulting from surgical intervention. The clinical description of POCD is highly variable, ranging from concentration impairment to delirium. Significant short-term POCD is common in elderly persons, and can persist several months, varying both in time and intensity and affecting the full-range of cognitive functions (visual and auditory attention, primary and secondary memory, implicit memory, and visuospatial functioning). Incidence rates vary widely according to surgery type but also between studies for a given surgical procedure, as a result of methodological difficulties and limitations. Variability is largely attributable to the absence of a standardized POCD definition, the heterogeneity of procedures to measure cognitive deficits and the methods used for statistical analyses, but is also related to the disparity in targeted populations. The wide variation in study design and target populations precludes the application of formal meta-analysis procedures. We review the definition, epidemiology, etiology, pathophysiology and the clinical and public health implications of POCD. The effects of anesthetics are described in relation to ageing-related physiological changes. It is concluded that the complex interaction of etiological factors makes it difficult to determine at this point of time to what extent POCD may be attributed specifically to anesthetic agents.

Quality-of-life assessment in the old using the WHOQOL 100: differences between patients with senile dementia and patients with cancer.

INTRODUCTION: The measurement of quality of life is an increasingly important issue, particularly in regard to treatment of severe and chronic diseases. The aim of this pilot study was to assess potentially divergent profiles of quality of life in persons with two different pathologies: moderate dementia and cancer. METHOD: This pilot study was carried out in the neurology and cancer services of the medical school in Montpellier, France (Hôpital Gui de Chaulliac and CRLC Val d'Aurelle). The cumulative self-reporting test WHOQOL 100 (World Health Organization Quality of Life with 100 questions) was administered in 57 patients with either moderate senile dementia (27 cases with a Mini-Mental State Examination score >15; mean age of 73) or cancer (30 cases, mainly women with breast cancer; mean age of 53). The stability of responses was tested in a 2-week period. RESULTS: Results of the study showed clear and significant differences between the two groups in the domains of mobility and psychology. Further, eight questions and six facets with a significant difference in responses were found. Responses seemed more stable in the domains of autonomy, social relationship, and religion for the cancer group, and in autonomy and psychology for the dementia group. The age difference may be an important factor in the different quality of life measured but did not significantly influence responses to the test questions. CONCLUSION: The WHOQOL 100 seems a powerful instrument to assess quality of life in diseases such as cancer and moderate dementia. In this study, interesting differences in responses to the test questions between the two pathologic conditions were identified. Items that were unreliable on retesting are singled out. These results will be applied and reevaluated in the development of future, illness-specific and shorter versions of the WHOQOL 100.

Impact of anesthesia on the cognitive functioning of the elderly.

Exposure to general anesthesia has been suggested as a possible cause of long-term cognitive impairment in elderly subjects. The present study reviews the literature in this field in order to describe postoperative cognitive impairment in elderly populations, to determine to what extent this may be attributed to anesthetic agents, and to consider evidence of a causal relationship between anesthesia and onset of senile dementia. A systematic literature search was conducted using five bibliographic databases (PASCAL, Medline, Excerpta Medica, Psychological Abstracts, and Science Citation Index). Significant cognitive dysfunction was found to be common in elderly persons 1 to 3 days after surgery, but reports of longer-term impairment are inconsistent due to the heterogeneity of the procedures used and populations targeted in such studies. Incidence rates vary widely according to type of surgery, suggesting that factors other than anesthesia explain a significant proportion of the observed variance. Anesthesia appears to be associated with longerterm cognitive disorder and the acceleration of senile dementia, but only in a small number of cases, suggesting the existence of other interacting etiological factors.

New data on the ontogeny of the child's sleep-wake rhythm.

The present study is part of a broader body of research concerning the ontogeny and regulations of the young child's sleep-wake rhythm. It was carried out with 12 children admitted to a day-care center from 4 or 5 months of age. None of the children showed any anomalies or functional disorders. The method used in this study consisted in organizing a data collection on the alternations of wakefulness and sleep as well as on the children's behavior throughout the 24-h period, both in their family and at the day-care center from 4 to 15 months of age. The main findings are (a) the circadian rhythm of wakefulness and sleep is clearly set up as early as at 4 months of age and consolidates between 6 and 7 months; (b) some ages are characterized by significant changes in the daily distribution and duration of sleep spans: 6 to 7 months; 10 to 12 months; 13 to 15 months; (c) these changes suggest the existence of several ultradian rhythmicities which become successively prevailing from one age to the next throughout child development. The longitudinal study of the young child's sleep-wakefulness rhythm allows better evaluation of the influence of developmental factors in its structuralization and formulation of new hypotheses on its disorders and dysfunction. Individual factors are under study.

[New data on the genesis of sleep-wakefulness rhythm in children aged 4-15 months]. / Données nouvelles sur la genèse du rythme veille-sommeil de l'enfant de 4 mois à 15 mois.

The present study deals with the ontogeny of the sleep-wakefulness rhythm in 12 children from the 4th to the 15 month of age. The main findings were as follows: 1. The circadian rhythm of wakefulness and sleep is clearly sep up as of 4 months of age and is characterized by 3 main parameters: a long uninterrupted night sleep period which includes the time interval from midnight to 4 a.m. The duration of this period of time is always equal to or higher than 400 min. The periodicity of the last falling asleep before midnight and the periodicity of the first awakening after midnight are equal or very close to 24 hours. Both seem to be mutually adjusted or connected to each other. 2. Some ages are characterized by significant changes in the daily distribution of the number and duration of sleep spans. 3. These changes suggest the existence of several ultradian rhythmicities which prevail successively throughout the development period under study. 4. There are many important differences between girls and boys.

[Fluctuations of biological rhythms, behavior and intellectual activity in children in different environments]. / Les fluctuations des rythmes biologiques, des comportements et de l'activité intellectuelle de l'enfant dans ses différents environnements.

We report in this paper research data which deal with the fluctuations of biological, biopsychological and intellectual variables throughout the day and week in children and adolescents attending various educational establishments. The first chapter is devoted to the evolution of sleep-arousal alternations from the second year of life and to the relations between this evolution and behavioral and physiological variations during the day. It is divided into four parts: temporal evolution of the sleep-wake rhythm of children from 2 to 5 years of age, attending kindergarten; modifications observed in the behavior and biological rhythms of children from the last year of kindergarten to the first year of primary school; the high variability of biological rhythms from one child to another; modifications observed in intellectual performances of children attending primary and secondary school. The second chapter is devoted to the evolution of the duration of night sleep during childhood and the self-regulation phenomena that it reveals. The overall data lead to suggestions for organizing school schedules throughout the day and week.

[The demonstration of communication behaviors in children with early psychoses]. / Mise en évidence de comportements de communication chez des enfants souffrant de psychose précoce.

The authors present a research project on the ways children suffering from early psychosis communicate non-verbally. These children are studied in their regular treatment center, using a behavioral method using a set of possibilities described for a normal young child. For the three children who were studied, rather different means of non-verbal communication were highlighted, which changed and were enriched when the adult taking care of them "improved" the way his interaction with the child was organized. Our findings raise questions concerning the semiology of these conditions and it's treatment.