[Altruistic kidney donation: psychological challenges]. / Don de rein altruiste: enjeux psychologiques.

Altruistic kidney donation challenges ethical principles, questions the anthropological meaning of donation and is associated with important psychological aspects. Obtaining free and informed consent is essential and requires a depth evaluation by a psychologist or a psychiatrist in order to identify the motivations which stimulate the desire of donation. By means of a psychodynamic understanding of a clinical case, we illustrate the complexity of the evaluation of consent and discuss the psychological issues associated with altruistic kidney donation.

[The community interpreter: a central role in the puzzle of the intercultural consultation]. / L'interprète communautaire: une pièce centrale dans le puzzle de la consultation interculturelle.

As a consequence of growing global migration, physicians in French speaking Switzerland often face communicational difficulties with allophone patients. This paper first discusses advantages and shortcomings of various ways of dealing with this kind of situations. The indication of using professional interpreters will be addressed, as well as some specific therapeutic, linguistic and relational features of triadic consultations involving a physician, a patient and an interpreter. Finally, useful practical information and advices are provided to clinicians in order to help them optimize their consultations with allophone patients.

[Action research and clinical governance: the example of the project "psychiatry and migrants" at the Vaudois University Medical Center]. / Recherche-action et gouvernance clinique: l'exemple du projet "psychiatrie et migrants" du CHUV.

Action research is a useful instrument for the organization health care and the clinical governance of psychiatric institutions. What this type of research offers can be illustrated by the cohort study of migrant patients without health insurance who consulted the Department of Psychiatry of the Vaudois university medical center (CHUV) in 2008. While giving greater visibilty to the psychological suffering and social distress of these patients, the study also enabled the authors to determine which clinical procedures were actually offered to these patients and the amount these procedures cost the department. The small number of cases that were identified as well as their uneven distribution amongst the different services of the department suggest that considerable efforts must still be made to improve access for this population to public psychiatric services.

[Integration processes and clinical governance in the psychiatric network]. / Processus intégratifs et gouvernance clinique dans la psychiatrie institutionnelle.

The Swiss Medical Insurance Act (LAMaL) requires the planning of psychiatric care. This necessitates a coordination between the Department of Public Health and the institutional governance. Given the difficulties to draw comparisons between a wide range of systems in a federal country, the Swiss Conference of the State Directors of Health (CDS) proposed as a first step that each canton present some of the key programs they had developed. In the canton Vaud, the implementation of mobile community treatment teams and of an early intervention program for psychosis was chosen. The main challenges faced were to go past traditional divides within the organisation of the Swiss Health system and to conciliate the requirements of public health with the needs of treating teams, in order to promote early intervention in mental health disorders.

[Psychiatry under constraint - the issue of planning in mental health care]. / Psychiatrie sous double contrainte, enjeux de la planification en santé mentale.

Given the important modifications of the "Loi sur l'Assurance maladie (LAMal)", this article gives a contribution to the hospital planification by identifying the main factors that have determined the current organisation of the psychiatric care network. We notice a gap between the orientations of these networks and the funding scheme forecast in the framework of the LAMal. In order to preserve the progressions of these last years and to avoid the negative effects of a too restrictive funding act for the assignment of the public psychiatry, the planification must result in a consensus between the state, the insurances and the multiple actors of the mental health. Otherwise, this will be done to the detriment of the activities of secondary prevention, of coordination in the network, of support to the natural helpers, and of intervention to the vulnerable populations.

[Follow-up of the cancer patient, maintaining self-identity]. / Suivi du patient oncologique, garant de la permanence de soi.

The individual facing the diagnosis of cancer is subjected to abrupt changes with regard to his inner world, his life, habits and social relationships. The patient's capacity to cope, to integrate changes in the way of living and to face the future is determined by his personal resources. However, psychological support may also be an important mean to search for and find sense to the singular experience of the illness. The narrative reconstruction within a supportive setting provides the patient a possibility to recognise his pain as an integral part of himself. A life narrative, which integrates the illness, allows the patient to re-appropriate his history again. Such a therapeutic project necessitates from the therapist a psychological and temporal availability and a capacity to create links all along the different stages of the disease.

[Qualitative study of a social and health network's expectations for community treatment of severe mental health problems]. / Etude qualitative des attentes d'un réseau sanitaire et social pour suivi des troubles psychiatriques sévères dans la communauté.

UNLABELLED: Treatment of severe mental illness in the community is gaining interest under ethical, clinical and economical pressure, which has led to mental health reform and deinstitutionalisation. However, this can lead to conflicts between all the parties involved in the community. Several countries have initiated extensive efforts to coordinate health services to enhance quality of care without increasing costs. According to Gray [Hum Relat 38 (1985) 911-936.], the first conditions facilitating interorganizational collaboration are the identification of common problems, recognition of partners (legitimacy and expertise) and interest in collaborating gains to be made from such collaboration [int J Health Plann Manage 17(4) (2002) 315-32.]. AIMS: The aims of the study were to assess the representation of problems and needs from people dealing with psychiatric patients in the community with a model of action research. The action part of the study meant to influence collaboration and objective setting in the network. The research part intended to identify the main problems experienced while dealing in the community with people suffering from severe mental illness. METHODS: In depth interviews were conducted with 25 persons involved in the community network (GPs, psychiatrists, nurses, social workers, police, judge, relatives, and users). Five open-ended questions on experienced problematic situations, network's collaboration, and expectations were asked. Content analysis of individual interviews was validated through discussion in six focus groups. Qualitative analysis used a 3 x 3 matrix model inspired from Parsons [Social systems and the evolution of action theory. Free Press; 1977, 420 p.; Health Serv Manage Res 11(1) (1998) 24-41 discussion 41-8.], and Tansella and Thornicroft [Psychol Med 28(3) (1998) 503-508.]. RESULTS: One thousand four hundred and seventy-nine propositions were grouped in 52 themes. Seventeen key problems were identified at individual, population, care-process and network levels, and were validated by the focus groups. Main problems were linked to a change in values regarding the role of psychiatric patients-from paternalistic social control to free empowered citizens-without adequate tools to deal with this in the community. Crisis management, intensive home care, and network cooperation were considered as insufficient, particularly for suicidal, dual diagnosis and difficult to engage patients. CONCLUSION: Deinstitutionalisation and more respect of patients' rights were considered as positive changes for most patients, but as a risk for the most vulnerable ones. Clearer mental health policy targets were requested for suicidal, difficult to engage and dual diagnosis patients. Collaborative efforts must focus on teaching primary care professionals for suicide and dual diagnosis patients, on direct help to welfare services for difficult to engage patients and on psychiatric services for high users. Intensive home care and liaison with primary care are viewed as key components. Identifying common targets in the network may enhance collaboration. Pathways to care need to be studied, including people involved outside a "classical" health network, such as police, welfare services and patients or carers associations.

[Improving communication skills is possible: "clinical" experience and scientific assessment]. / Améliorer les compétences communicationnelles: expérience "clinique" et evaluation scientifique.

While the importance of individualized and comprehensive care, taking into account the bio-psychosocial characteristics of the patient, has been demonstrated, this remains a considerable challenge in daily clinical practise. The Swiss Cancer League promotes since many years so called Communication Skills Training (CST). Different studies have demonstrated a positive impact of CST, illustrating that communicational competence is not only a consequence of a personal and professional development, but can be modified by an intensive and interactive training. A new scientific approach aims to elucidate the underlying mechanisms of communicational improvements, based on the hypothesis that CTS modify participants' defence mechanisms.

[Dynamic investigation and the question of early transference in a case of cancer patient]. / L'analyse du prétransfert dans une prise en charge psycho-oncologique.

Dynamic psychiatrists value the analysis of the physician-patient relationship as a crucial component of the diagnostic assessment of all cancer patients with a comorbid psychiatric disorder. Transference is a repetition. The feelings associated with figures from the past are being repeated with the psychiatrist. This premise implies that this repetition reveals a good deal about the patient's current difficulties, as an echo of past ones. This article explores the early interaction between a patient with a brain tumor and his psychiatrist, Analysis of the relationship allows to refine the diagnosis and to develop an etiological psychodynamic hypothesis. The treatment, then, aims to resolution of current symptoms but also promotes improvement of the patient's actual functioning, and avoidance of endless pathological repetitions.

[Diagnosis and treatment of depression in patients with cancer]. / Diagnostic et traitement de la dépression chez les patients souffrant de cancer.

Thirty percent of cancer patients experience depression during the course of their illness. Depression may occur at several key-moments: after diagnosis, a relapse, in the context of treatment failure. Depression is correlated with biological factors due to illness itself and its treatments, but also with inappropriate coping strategies. Diagnosis of depression is not straightforward in cancer patients. Its phenomenology is specific. Moreover, patients as well as clinicians may be reluctant to address the problem of psychological well-being. The treatment of depression has proven to increase quality of life as well as satisfaction with treatments and compliance. Antidepressants are the first line treatment. Psychotherapy and several psychological interventions are considered to be a valid alternative. In most severe cases a combined treatment is mandatory.

[What is behind the hidden agenda?]. / Que cache l'agenda caché?

The physicians often forget to ask their patients if they would like to discuss other complaints or topics. It is sometimes quite difficult to explore the patient's complaints; while the physicians tend to focus on the immediate problem, the patients may have not only one, but several hidden agendas during a visit. In a caring relation there is a clear advantage to clarify the implicit. The search for the hidden agenda is to improve the care of i) biomedical problems ii) the social quest presented to the physicians. The sentence "Oh, by the way, doctor..." should not be only understood as an information but also as a relational expression and a reaction to the imminent separation from the physician.

A prospective study of predictors of poststroke depression.

OBJECTIVE: To investigate the association between early depressive behavior after stroke onset and occurrence of poststroke depression (PSD) at 3- and 12-month follow-up evaluations. METHODS: The study prospectively included 273 patients with first-ever single uncomplicated ischemic stroke. In the stroke unit, nurses scored crying, overt sadness, and apathy daily using an observational method to include patients with comprehension deficits. The Barthel Index was used to assess disability. Follow-up evaluation at months 3 and 12 included psychiatric assessment based on the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. RESULTS: Crying (19.8%), overt sadness (50.5%), and apathy (47.6%) were observed. Of the patients observed crying, 4 showed pathologic crying, 19 emotionalism, and 12 catastrophic reactions. Crying and overt sadness, but not apathy, were associated with a subjective experience of depression (p < 0.05). Thirty of 52 (58%) patients observed crying, 12 of 19 (63%) patients with emotionalism, and 5 of 12 (41%) patients with catastrophic reactions developed PSD within the first year. Multiple logistic regression analysis showed that only severe functional disability (odds ratio [OR], 4.31; 95% CI, 2.41 to 7.69), crying behaviors (OR, 2.66; 95% CI, 1.35 to 5.27), and an age <68 years (OR, 2.32; 95% CI, 1.30 to 4.13) were (p < 0.05) predictors of late PSD development (13% of the variance). CONCLUSIONS: In the stroke unit, crying and overt sadness are more reliable indicators of depressed mood than apathy. In patients with first-ever stroke, crying behaviors soon after stroke, a younger age, and severe disability are predictors of poststroke depression occurrence within the first year after stroke onset.

[Intrauniversitary selection: a good or a bad way to identify the best medical students?]. / La selection intra-universitaire: un bon ou mauvais moyen d'identifier les meilleurs étudiants en médecine?

During their first two years at the medical faculty of the University of Lausanne, selection of medical students is based on their performance in tests in basic sciences. However, this carries the risk that scientifically talented students who perhaps do not necessarily possess the personal skills to make them a good doctor are given preferential admission to the clinical semesters. This study followed a student cohort (n = 115), which had passed the first part of their state examination at the end of the third year course. The examination included an oral examination in psychosocial medicine (PSM) that tested the student's skills with regard to patient-physician communication. The PSM grade is compared with the grade achieved in the written tests in physics and physiology taken at the end of the first year of study. The findings showed that the performance achieved in the basic science examination had no predicative value for the student's future performance in the PSM test. Moreover, it was found that the type of pre-graduate degree had no major influence on the student's progress in their preclinical years of medical school.

Results from a prospective, randomized, controlled study evaluating the acceptability and effects of routine pre-IVF counselling.

BACKGROUND: The aim of this study was to evaluate a model of routine pre-IVF counselling focusing on the narrative capacities of couples. The acceptability of counselling, the effects on emotional factors and the participants' assessments were considered. METHODS: The study included 141 consecutive childless couples preparing for their first IVF. Randomization was carried out through sealed envelopes attributing participants to counselled and non-counselled groups and was accepted by 100 couples. Another 12 couples refused randomization because they wanted counselling and 29 because they did not. Questionnaires including the State-Trait Anxiety Inventory, the Beck Depression Inventory and assessments of help were mailed to couples before IVF and counselling, and after the IVF outcome. RESULTS: Counselling was accepted by 79% (112/141) of couples. There was no significant effect of counselling on anxiety and depression scores which were within normal ranges at both times. Counselling provided help for 86% (75/87) of initially non-demanding subjects and 96% (25/26) of those initially requesting a session. Help was noted in areas of psychological assistance, technical explanations and discussing relationships. CONCLUSIONS: This model of routine counselling centred on the narrative provides an acceptable form of psychological assistance for pre-IVF couples.

Effect on mood of subthalamic DBS for Parkinson's disease: a consecutive series of 24 patients.

A series of 24 consecutive PD patients were prospectively studied prior to and within 6 months postoperatively for mood, motor, and cognitive status to investigate the effects on mood of subthalamic deep brain stimulation (DBS) in PD. In six patients (25%), mood state worsened significantly, and three were transiently suicidal despite clear motor improvement. Caregivers and patients should be educated about the potential impact of this neurosurgical procedure on mood.

[Which psychological support for couples seeking medical assistance for procreation?]. / Quelle assistance psychologique pour les couples requérant une aide médicale à la procréation?

OBJECTIVES: The objective of our qualitative study was to define modalities of psychological support to be offered to couples seeking medically assisted procreation. MATERIAL AND METHODS: Forty couples participated in a semi-structured videotaped interview, which touched on themes such as personal and family histories, the couple's relationship, etc. We focused on the "narrative mobility", that is the way in which the couples transmit their personal and family history during the interview and the interviewer's impression that he may or may not share this with the couples. RESULTS: Observed differences in narrative mobility led us to distinguish three groups of couples and to propose various types of psychological support. DISCUSSION AND CONCLUSION: This exploratory study, with its interest for the narrative mobility, concerns the couples' capacity to stand back from their own story as responsible interlocutors. We made the hypothesis that this capacity is linked to their capacity to handle their emotional stress, to act as partners to the medical team and to prepare themselves for their future parenthood.

[The health professional's approach to chronic lumbago: clinical experience at the Spinal Cord Unit at the orthopedic hospital]. / Le soignant face au patient lombalgique chronique: l'expérience clinique de l'Unité Rachis à l'Hôpital orthopédique.

The treatment of back pain patients refers to the biopsychosocial model of care. This model includes illness in patient's personal and relational life. In this context, it is not only the physical symptom of the patient which is focused but also his psychological distress often hidden by algic complain. Clinical interviews conducted with back pain patients have highlighted psychosocial aspects able to influence the relationship between health care user and provider. Taking account of psychosocial aspects implies an interdisciplinary approach that identify and assesses patients' needs through adequate tools. As a result, the different health care providers implied with back pain patients have to collaborate in a structured network.

Case complexity and clinical outcome in diabetes mellitus. A prospective study using the INTERMED.

The aim of this study was to assess a population of patients with diabetes mellitus by means of the INTERMED, a classification system for case complexity integrating biological, psychosocial and health care related aspects of disease. The main hypothesis was that the INTERMED would identify distinct clusters of patients with different degrees of case complexity and different clinical outcomes. Patients (n=61) referred to a tertiary reference care centre were evaluated with the INTERMED and followed 9 months for HbA1c values and 6 months for health care utilisation. Cluster analysis revealed two clusters: cluster 1 (62%) consisting of complex patients with high INTERMED scores and cluster 2 (38%) consisting of less complex patients with lower INTERMED. Cluster 1 patients showed significantly higher HbA1c values and a tendency for increased health care utilisation. Total INTERMED scores were significantly related to HbA1c and explained 21% of its variance. In conclusion, different clusters of patients with different degrees of case complexity were identified by the INTERMED, allowing the detection of highly complex patients at risk for poor diabetes control. The INTERMED therefore provides an objective basis for clinical and scientific progress in diabetes mellitus. Ongoing intervention studies will have to confirm these preliminary data and to evaluate if management strategies based on the INTERMED profiles will improve outcomes.