["What's up, doc?" The context, limitations, and issues for clinicians in evidence-based medicine]. / "What's up, doc?" Le contexte, les limites et les enjeux de la médecine fondée sur des données probantes pour les cliniciens (Evidence-Based Medicine).

BACKGROUND: The evidence-based medicine approach could be considered a new name given to the contemporary medicine dialectics between the practice of an art and the insight provided by the best scientific data. METHODS: In this 3-part article, the background is introduced, then the design limits of the approach are shown through an example of metaanalysis applied to 4 psychiatric situations, and the conclusion is left to a clinician. RESULTS: In the background, evidence-based medicine is first associated with the period of budget cuts, then with the widespread popularity of the Internet. A few snags in this seemingly flawless system are seen when the subjective items involved in metaanalysis are taken into account. There are also problems linked to unpublished data, homogenization of populations studied, and the assumption that only random studies lead to valid scientific knowledge. The clinician will probably not be surprised and will link this to the old debate between empiricists and rationalists. CONCLUSION: In its purest form, evidence-based medicine supports the necessary continuous inquiry about our practices.

[Categorical refusal of treatment by psychiatric patients: balance, survey and prospects]. / Refus catégorique de traitement des patients psychiatriques: bilan, enquête et perspective.

BACKGROUND: In his or her practice, a psychiatrist must often deal with patients who refuse treatment. In 1990, Quebec radically changed this situation by introducing a Civil Code provision imposing judicial intervention to treat an individual deemed unfit to consent, against his or her will. This paper presents an assessment and survey of patients and attending psychiatrists who have used this Code provision. METHOD: Thirty-nine subjects who explicitly refused treatment were brought to court. We asked a subgroup of these patients to be interviewed, using the Drug Attitude Inventory (DAI), the Clinical Global Impression (CGI), and 2 questionnaires specifically considering the court experience of patients and attending psychiatrists. RESULTS: The results of the survey show that patients remember their experience in court as rather uncomfortable. However, the therapeutic alliance remained unchanged, even after the legal procedure. Physicians agreed that patients would not have been clinically well enough to leave the hospital if they had not received the drug regimen resulting from the court decision. The dissociation between the perceptions of patients and physicians is compared with that found in previous studies in the United States. CONCLUSION: Even with a limited sample, this study addresses a delicate, difficult situation that professionals are increasingly likely to confront. It also proposes further research on alternatives to judicial intervention.

One hundred in-patient suicides.

BACKGROUND: The study aimed to define the characteristics and assess the clinical predictability and possible prevention of psychiatric in-patient suicides. METHOD: The coroner's files on all suicides in the Greater Montreal Region from 1 April 1986 to 31 March 1991 were examined. The medical records of each case of suspected in-patient suicide were then reviewed and rated for predictability and preventive measures taken. RESULTS: A total of 3079 suicides were recorded over this five-year period (mean annual rate of 16.4 per 100,000 inhabitants). Of these, 104 (3.4%) involved hospital in-patients. Nearly half (48%) of these in-patient suicides occurred outside the hospital setting. The methods most frequently employed were hanging (36%) and jumping from high places (24%). Patients suffering from an affective disorder (45%) or schizophrenia (35%) comprised the majority of the sample. Suicides were significantly more predictable in general hospital psychiatric wards. Suicide prevention measures did not differ significantly across settings. CONCLUSIONS: The majority of in-patient suicides were not highly predictable. For highly predictable suicides, the results underline the importance of actively treating and protecting these patients.

Suicide and mental disorders: a case-control study of young men.

OBJECTIVE: By means of the psychological autopsy method and a case-control design, the authors examined the association of specific mental disorders and comorbidity with suicide among young men. METHOD: Seventy-five men aged 18-35 years whose deaths were adjudicated as completed suicides by coroners of greater Montreal and Quebec City were matched to 75 living young men for age, neighborhood, marital status, and occupation. For each subject in both groups a key respondent best acquainted with the subject was interviewed by clinicians using standardized schedules. Information from the coroner and medical records was also collected. Two experienced psychiatrists, blind to outcome, established best-estimate DSM-III-R diagnoses. RESULTS: Six-month prevalence rates for all axis I diagnoses for the suicide and comparison groups were 88.0% and 37.3%, respectively; major depression was present in 38.7% and 5.3%, alcohol dependence in 24.0% and 5.3%, psychoactive substance dependence in 22.7% and 2.7%. Borderline personality disorder was identified in 28.0% and 4.0%, respectively. Of the suicide subjects, 28.0% had at least two of the following disorders: major depression, borderline personality disorder, and alcohol or drug dependence; the rate was 0.0% among the comparison subjects. CONCLUSIONS: In young men, completed suicide is linked to specific mental disorders, namely, major depression, borderline personality disorder, and substance abuse. Comorbidity involving any of these disorders is frequently associated with completed suicide.

[Suicide among young male adults in Quebec: psychopathology and utilization of medical services]. / Le suicide chez les jeunes adultes de sexe masculin au Québec: psychopathologie et utilisation des services médicaux.

Seventy five young male adults between the age of 18 and 35 who had committed suicide were compared with 75 male adults still alive matched for age, residence, marital and employment status. For each group a principal respondent was interviewed in order to reconstitute the psychological profile of each individual, as well as their utilisation of health services. This was completed by the study of the coroner's reports and the medical records when available. At six months the prevalence for all axis I diagnosis was 88.8% for the suicide group and 37.3% for the control group. Among the subjects who had committed suicide 38.7% were afflicted by major depression, 24% by alcohol dependency and 28.7% were dependent on drugs. Borderline personalities were present in 28% of the suicide group compared to 5% in the control group. Forty five percent (45%) of the subjects who had killed themselves had consulted a mental health professional in the year preceding the suicide compared to 5% in the control group. However, 78.5% of the suicide group had consulted during the same period a health professional compared to 73.3% of the controls.

[The doctrine of free and informed consent: its ethical and legal foundations and its applications in research and practice of psychiatry]. / La doctrine du consentement libre et éclairé: ses fondements éthiques, juridiques et ses applications dans la recherche et la pratique de la psychiatrie.

This article briefly examines the ethical and legal foundations for the doctrine of informed consent in medical research and practice. The doctrine is based upon the importance of respecting the individual's autonomy and his right to self-determination. The article also reviews the development of the doctrine of informed consent based on its recent application. The authors cite the Nuremburg Code and the Helsinki Declarations and particularly the media denunication of several scandals in the United States during the late 1960s, when Henri Beecher's name figured prominently. The effects of informed consent in psychiatry are examined specifically, as well as the consequences for psychiatric research, on subjects who are able to give their consent, as well as those who are unable to do so. As for its effects on clinical practice, the paper discusses the right of the hospitalized patient to refuse treatment, and informed consent and the risks for patients treated with neuroleptics of developing tardive dyskinesia. The authors conclude that in psychotherapy the concept of informed consent cannot be taken for granted.

[Pharmacologic interventions in agitated mentally retarded patients]. / Les interventions pharmacologiques chez les déficients mentaux agites.

Aggressive behavior of mental retardates is a frequent problem which semiological description is very polymorphic. Some psychiatric etiologies are listed, and then the different aspects of idiopathic aggressive behavior are described. These aspects give guidelines for more specific treatments which are further reviewed. Preferential indications and side effects are described for each in a way to suggest a therapeutic strategy. At the end, legal aspects involved are briefly exposed.

[Medicolegal aspects of tardive dyskinesia in the United States]. / Aspects médico-légaux des dyskinésies tardives aux Etats-Unis.

Tardive dyskinesia is by definition a neurological complication resulting from neuroleptic treatment. The exact role of neuroleptic drugs in the etiopathogenicity of this syndrome is discussed. The manifestation of dyskinesia in a patient who is under neuroleptics may involve the responsibility of a physician. The evolution of jurisprudence in the United States is analysed.

[Unemployment and mental health]. / Chômage et santé mentale.

Evidence linking unemployment with psychiatric morbidity is available since the thirties, but it is only in the seventies that a renewed research interest on this subject took place. Two research strategies seem to be emerging: an "ecological" approach establishing correlations between economical and health indicators for a given population. Another approach focuses on the psychiatric morbidity of samples of individuals who have lost their job compared to matched control groups of individuals still employed. Many of those studies did not limit themselves on the mental health of the unemployed but on the "rippling" effect of unemployment on the family and community. Many aspects of the consequences of unemployment on mental health remain to be explored such as the effects of long-term unemployment, unemployment among women. Methods of emotional supportive interventions for the unemployed need also to be explored. Furthermore the effects of a high level of unemployment on the programs of deinstitutionalization of the chronic mentally ill as well as the mentally handicapped should be evaluated.

An overview of the Canadian health care experience.

Canada's universal health insurance system is designed to assure all Canadians access to free hospital and medical treatment. Each province has had considerable latitude in administering the system within its borders. To cope with rising costs, most provinces have adopted policies that limit physician income. Others have instituted fees for service users and have allowed physicians to bill patients for charges above the benefit schedule set by the province. These latter practices have been seen as eroding access to health care, and government funding for provinces that permit them was sharply curtailed by the Canada Health Act of 1984. The law is currently being challenged by the Canadian Medical Association because of the restrictions it places on physicians' freedom of practice. Although the Canadian system has created problems for physicians, the authors believe it provides a benefit no one wants to lose: accessible medical care for all.

[Psychiatric exam under court order apropos of patients who refuse to submit to a psychiatric exam]. / Examen psychiatrique sous ordonnance de cour à propos des patients qui refusent de se soumettre à un examen psychiatrique.

In this retrospective study 52 patients who had not committed any offence were examined against their will by Court order in the emergency department of a psychiatric hospital. They were compared with a control group of patients reflecting the usual clientele attending without compulsion the emergency department of the same hospital. This research reveals it is the immediate family rather than medico-social agencies that took the initiative in arranging the Court-ordered psychiatric examination. Such patients were no different than the usual patients seen in the emergency department as to age, sex, marital status and past psychiatric history. It was at the level of symptomatology and diagnosis that such patients differed from patients in the control group. The patients refusing to submit to a psychiatric examination not only were more agitated and aggressive, but they were more disorganized, more delusional, and had more hallucinations than the patients in the control group. They were in fact grossly psychotic patients with paranoid and manic features dominating the clinical picture. Our study demonstrated that as far as Montreal is concerned flagrant abuse of civil rights is far more the exception than the rule. Furthermore, if society had to abandon compulsory measures in some cases, it would be the seriously mentally ill who would suffer.

Lithium induces rapid relief of depression in tricyclic antidepressant drug non-responders.

Eight patients suffering from a major unipolar depression and having field to respond to treatment for three weeks or more with tricyclic antidepressants were given lithium. All eight patients experienced a remarkable relief of their depression within 48 hours. This rapid antidepressant effect of lithium in "treatment-resistant' patients might be due to the enhancement of the efficacy of the central serotoninergic system, unveiling the tricyclic antidepressant-induced sensitization of the serotoninergic postsynaptic receptors.

Homicide and community-based psychiatry.

The authors studied the records of all persons convicted of homicide or found not guilty by reason of insanity during the uears 1963 through 1975, 6 years before and after the opening of the community-based psychiatric facility, in Albany County, New York. Using the Fisher Exact Probability Test, a statistically significant increase was found for those found not guilty by reason of insanity (p = .041) and those with a history of mental illness found guilty (p = .036). Other factors, including age of the perpetrator, use of alcohol, and relationship to the victim, were also examined. The authors caution against sweeping indictments of community-based psychiatry and urge that the study be repeated elsewhere.