[Ultra-rapid detoxification of opiate dependent patients: review of the literature, critiques and proposition for an experimental protocol]. / Le sevrage ultra-rapide de patients dépendants aux opiacés: revue de la littérature, critiques et proposition d'un protocole expérimental.

UNLABELLED: Ultra-rapid opioid detoxification (UROD) is an increasingly popular technique for detoxifying patients addicted to opiates. This technique aims at reducing not only the duration but also the intensity of withdrawal by using general anesthesia coupled with a naloxone or naltrexone medication. In this paper the authors attempt to review the history of UROD and the logic of its procedure and results whilst also demonstrating its advantages and limits. METHOD: The MEDLINE database was searched from 1966 to 2000 using the terms "ultra-rapid opioid detoxification, rapid opioid detoxification under anesthesia, naloxone, naltrexone, opioid-related disorders". Additional data sources included bibliographies in textbooks on substance abuse. RESULTS: Nine studies identified in our search were analysed. The technique is based on a three-phases procedure. It consists of a medical and psychiatric selection of patients addicted to opiates, followed by the detoxification itself and finally a medical and psychosocial follow-up. A brief presentation is made of the theoretical aspects based on the use of a specific opioid receptor antagonist (naloxone and naltrexone). Only inpatients were included in the studies. The detoxification and anesthesia protocols varied. In every study all the subjects were completely detoxified. Only three studies included a control group and two used a randomized design. Three studies reported a follow-up beyond 30 days. DISCUSSION: Although this technique constitutes a safe and effective solution for opiate addicted patients, there are criticisms to be made. The absence of an animal model prior to the study of a human model, the lack of comparison with other procedures, the limitation of available literature, the cost and the risks of this technique and the lack of long-term treatment outcomes obtained from rigorous clinical trials, all call for further assessments. A more rigorous protocol based on the main areas of criticism is proposed (presentation of the inclusion and exclusion criterias, description of the three preliminary interviews, presentation of the UROD technique itself and finally a detailled nine month follow-up). CONCLUSION: Ultra-rapid opiate detoxification represents a potentially safe and effective treatment for opiate addicted patients but more rigorous research methods are needed to render this procedure entirely valid.

[Violence, desire and death. Reflections on 3 taboos in psychiatry]. / La violence, le désir et la mort. Réflexions sur trois tabous en psychiatrie.

UNLABELLED: Few studies have assessed the links of violence, desire and death with psychiatry in a scientific way. Doctors are nonetheless regularly confronted with these situations which are particularly difficult to manage. It is not evident that psychiatrists are properly prepared to deal with them. This paper proposes an original analysis of the scientific literature related to violence, desire and death, and compares the attitudes of European and American doctors. RESULTS: 1) Violence: there is definitely a relationship between violence and mental disorder. Psychiatrists are particularly at risk of being assaulted by patients, especially at the beginning of their carrier (almost 50%). Violence also includes verbal and non-verbal threats, particularly in the emergency department. Psychiatrists are poorly trained to deal with this. 2) Desire: desire is widespread in psychiatry, and can lead to sexual contact between the patient and the therapist in 7 to 10% of cases. The outpatient setting carries the greater risk. Professional associations unanimously disapprove of such conduct but the ethics of posttermination sexual contact remains controversial. Sexual harassment of female doctors by patients is another form of desire (and of violence). Psychiatrists are also poorly trained to deal with desire. 3) Death: acute death occurs in psychiatry (e.g., suicide, substance intoxication and withdrawal, delirium, neuroleptic malignant syndrome, anorexia nervosa, dementia, lethal catatonia), and there is also a link between mental disorder and a higher incidence of natural mortality. Psychiatrists may thus be confronted with death, and the inpatient setting carries the greater risk. They are nonetheless poorly trained in thanatology. DISCUSSION: Psychiatric residents need better training to manage violence, desire and death. Poor training results in their exposure to dangerous situations and in inappropriate reactions. Acute management and primary prevention are needed. Acute management should include a collegiate approach, in order to avoid being the "target" of the patient or his/her family. Primary prevention comes through the breaking of the taboos which are still too frequent in Europe, even though the situation is different from the USA. It is important to lay down limits between psychiatry and violence, desire and death. Those situations should before all be better understood, and thereby research in this field have to be stimulated. The holding of consensus conferences in Europe is also important. CONCLUSION: There is an intimate relationship between violence, desire, death and psychiatry. This relation is too often neglected, as the poor training of psychiatrists underlines. The nature of the patient-doctor relationship have to be redefined according to those considerations.

[Psychiatry of women: an new field of research in mental health]. / La psychiatrie de la femme: un nouveau domaine de recherche en sante mentale.

This paper presents the state of the art of our current knowledge in the field of female psychiatry. This domain of mental health studies the particularities of psychological distress in women. It is a new concept, and its creation is subtended by some clinical and epidemiological realities. The creation of this very interesting field of research has been promoted on the one hand because of the existence of certain female-specific psychiatric disorders (premenstrual syndrome, post-partum psychopathologies, pseudocyesis, Ferjol's syndrome and menopause-related disorders) and on the other hand because the vast majority of mental diseases may be expressing major gender-related variations (prevalence, natural history of disease, symptomatology, prognosis and treatment outcome). Research in female psychiatry has numerous goals. First of all, the sex-based differences in the prevalence of mental disorders (e.g., depression, schizophrenia, anxiety, anorexia nervosa, personality disorders) has to be understood (are they artefacts, or the expression of hormonal or genetic influence, or a consequence of social factors, or even the result of brain development?). Second, the specific nature of some of these diseases is under investigation (e.g., is postnatal depression a classical major depressive disorder or a puerperal-specific disease?). And third, treatments must be adapted accordingly. Indeed, the study of female psychiatry attempts the integration of the gender-effect in order to improve the treatment modalities.

[Sex differences relating to psychiatric treatment]. / Des variations intersexuelles relatives aux traitements en psychiatrie.

OBJECTIVE: This paper reviews the literature discussing the influence of gender factors on the efficacy of the most frequently used psychiatric treatments. It recommends taking into account patient gender in order to optimize the treatment efficacy and tolerance. METHOD: Pharmaceutical and psychotherapeutic treatments as well as other types of therapy (psychosurgery, electroconvulsive therapy [ECT]) are discussed in the overview. Each section draws intermediate conclusions. RESULTS: Literature on the subject is scarce and uneven. From a pharmaceutical perspective, gender differences are marked; they affect substance absorption, distribution, metabolism, and elimination. As a result, differences in bioavailability affect efficacy and side effects of antidepressants, neuroleptics, and lithium as well as of hypnotics, sedatives, and anxiolytics. The menstrual cycle and birth-control pills also produce significant interactions. Few studies have discussed the influence of the gender-specific effect on the outcome of psychotherapy. However, some differences might exist, and serious further research is required before repeatable conclusions can be reached. Patient gender does not seem to affect certain physical kinds of treatment such as psychosurgery or ETC as much. CONCLUSIONS: Patient gender has a definite influence on the efficacy of the treatment administered. This influence, however, is often limited and should be considered for the optimization of treatment response and tolerance. Research in this field of psychiatry should be encouraged.

["Parapsychiatry". Psychiatric paramedics: their roles, their limits...the risk of malpractice]. / La "parapsychiatrie". Les paramedicaux en psychiatrie: leurs roles, leurs limites ... le risque de derive.

This paper presents an overview of the role of paramedical workers and psychologists in psychiatry. The authors analyse their sometimes uncomfortable situation within the framework of the psychiatric unit of a general hospital. In the first part, the fundamental importance of the paramedical worker is underlined, focussing on the particularity of the management of mental disorders. The limits to the field of action of the nursing staff, the psychologist, the social worker or the ergotherapist, are also discussed. In the second part, the authors denounce the dangerous alternative approaches which sometimes tempt those paramedical workers. The negative repercussions that they inevitably create, both in the functioning of the unit and in the therapeutical objective, are developed. The competition between physicians and non-physicians in psychiatry is betraying the patient.

[Sleep during post-partum depression]. / Le sommeil durant la dépression du post-partum.

BACKGROUND: Numerous studies have been published on postnatal depression (PND) over the last 10 years. A controversy has arisen regarding the specificity of the diagnostic concept. It is based on 2 points: the hormonal environment and the course and recurrence of PND. EEG Sleep studies are also numerous, but this paper presents the first study on EEG sleep profile during PND. METHODS: 24 women suffering from major depression according to RDC were placed in 3 groups: 1) Group A (n = 8): PND; 2) Group B (n = 8): depression with a past history of PND; 3) Group C (n = 8): depression without a past history of PND. Women were age-matched and according to the Hamilton 24 item severity score. Group A patients were delivered within less that 6 months, groups B and C within a minimum of 3 years. None were pregnant or alcoholic, and none were physically ill. RESULTS: There was no difference between groups B and C. Group A was characterised by a significantly longer stage IV sleep. There was also a strong tendency to a shorter stage I sleep and a better quality of sleep (total sleep time and number of awakenings) during PND. DISCUSSION: Our study shows that, even if similar to major depression, specific polysomnographic alteration can be found during post-partum depression. This finding is relevant to the hypothesis of PND's diagnostic specificity. The perfect similarity between groups B and C strengthens this evidence. Nevertheless, the significance of SWS alterations are difficult to explain and additional studies are required. CONCLUSION: The EEG Sleep profile during PND differs from major depression of the same severity. This appears to favour the specificity of the diagnostic concept.

[Eulogy of wine?]. / L'éloge du vin?

In the literature the beneficial effects on health of drinking alcoholic beverages, especially red wine, is becoming increasingly more evident. We report an objective analysis of the advantages and the dangers of such a tendency. It appears that the daily consumption of red wine at moderate doses (200-400 ml a day) has real prophylactic effects. These are particularly marked in the prevention of coronary heart disease (CHD), but also for a possible cancer chemopreventive activity, in the prevention of type II diabetes, of ischemic stroke, of osteoporosis in older women, and of Alzheimer's disease. But, inasmuch as the consumption of alcoholic beverages always involves a potential danger (organic diseases, risk of dependence, alcoholism), from a medical point of view eulogy to wine is ethically indefensible. Similar effects may be obtained from a diet rich in fruits and fresh vegetables.

[Postpartum psychiatry]. / La psychiatrie du post-partum.

The four important syndromes that constitute postnatal psychiatry are chronologically: 1) Post-Traumatic Stress Disorder (PTSD), 2) Baby-blues, 3) Puerperal psychosis and 4) Postnatal depression. The PTSD (prevalence 1%) occurs from 24 to 48 hours after a difficult childbirth. Anxiety predominates in association with nightmares and recurrent images of the experience. Baby-blues (prevalence 80%) is a feeling of sadness that doesn't need to be treated. It occurs around the third day of post-partum. Its intensity is a predictive factor of postnatal depression. Puerperal psychosis (prevalence 0.2%) is a disturbance of psychotic or manic proportion, mainly in women with a psychiatric previous history. It occurs between the first and the third week of the post-partum period. Postnatal depression (prevalence 20%) is a major depressive state commencing four to six weeks after delivery. It is rarely diagnosed early and child abuse is one of its consequences. Prevention--the important point of the treatment--is most of the time neglected.