[Transition from child and adolescent to adult mental health care]. / La transition entre soins pédopsychiatriques et soins en psychiatrie adulte.

Adolescents and young adults are at particularly at-risk population in mental health. For a large majority of patients suffering from chronic psychiatric condition, the age of onset of psychiatric symptoms is less than 24 years, while the coverage in psychiatric care is the lowest between 16 and 24. Presenting a psychiatric pathology during childhood and adolescence constitutes an independent risk factor for the occurrence of adverse life events in adulthood. Furthermore, that population is at the edge between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS). Transition is the deliberate and planned movement from CAMHS to AMHS. CAMHS and AMHS struggle to achieve optimal transitions between them. Many barriers exist at the interface of the two types of structure and some young people who require continuous care during this period do not have access to it. There are also too few specific psychiatric services for the population of adolescents and young adults. Some recommendations emerge to intend to guide practices, but the literature lacks data to better define this population and build guidelines about the transition between CAMHS and AMHS and about specific services for adolescents and young adults in psychiatry.

Les adolescents et jeunes adultes constituent une population particulièrement à risque en santé mentale. Pour une grande majorité des patients souffrant d'une pathologie psychiatrique chronique, l'âge d'apparition des symptômes est inférieur à 24 ans, alors que la couverture en soin psychiatrique est la plus faible entre 16 et 24 ans. La présence d'une pathologie psychiatrique durant l'enfance ou l'adolescence constitue un facteur de risque indépendant pour la survenue d'événements de vie défavorables à l'âge adulte. Cette population se situe par ailleurs à la lisière entre soins pédopsychiatriques et soins psychiatriques adultes. La transition est le passage délibéré et planifié d'un service de pédopsychiatrie vers un service de psychiatrie adulte. Ces deux systèmes de soins peinent à s'accorder pour réaliser des transitions optimales. De nombreuses barrières existent à l'interface des deux types de structures et certains jeunes qui nécessitent une prise en charge continue durant cette période de leur vie n'y ont pas accès. Il existe également trop peu de services psychiatriques pouvant accueillir cette population de manière spécifique. Certaines pistes émergent pour tenter de guider les pratiques, mais la littérature manque de données permettant de définir cette population et de créer des guidelines en ce qui concerne la transition entre pédopsychiatrie et psychiatrie adulte ainsi que la création de dispositifs psychiatriques spécifiques pour les adolescents et jeunes adultes en psychiatrie.

[Transcranial Direct Current Stimulation (tDCS) : psychiatric use]. / La stimulation électrique transcrânienne (tDCS) : applications en psychiatrie.

Transcranial Direct Current Stimulation (tDCS) is a cheap, easy to use, and relatively safe noninvasive brain stimulation technique. It is increasingly used in several indications in psychiatry and neurology, mainly for depression, chronic pain and cognitive decline due to degenerative brain diseases. Its efficacy is probable in depression and must still be confirmed in numerous other indications. Lowcost devices for the general public are easy to find on the internet and are frequently used for non-therapeutic indications, like the improvement of video gamers' performances. A non-medical use could represent a public health hazard, due to lack of control on stimulation parameters i.e. localization, duration and intensity.

La stimulation électrique trancrânienne à courant direct (tDCS) est une technique de neuromodulation simple d'utilisation, peu coûteuse et présentant très peu d'effets secondaires. Elle connaît une popularité croissante dans une série d'applications en psychiatrie et en neurologie, principalement dans la dépression, les douleurs chroniques et les troubles cognitifs associés à des maladies dégénératives. Son efficacité est probable dans la dépression et doit encore être confirmée dans de nombreuses autres indications. Des appareils bon marché à destination du grand public sont facilement accessibles sur internet et souvent utilisés à des fins non thérapeutiques et de dopage, telles que l'amélioration des performances pour les joueurs de jeux vidéo. Une utilisation sans encadrement médical pourrait représenter un risque de santé publique en raison du non-contrôle des paramètres de stimulation (localisation, durée et intensité).

Competing Motivations: Proactive Response Inhibition Toward Addiction-Related Stimuli in Quitting-Motivated Individuals.

We examined whether addiction-related cues impact proactive inhibition (the restraint of actions in preparation for stopping) in individuals who are motivated to quit gambling or cannabis use. In Study 1, treatment-seeking individuals with cannabis use disorder and matched controls performed a stop-signal task that required them to inhibit categorizing cannabis or neutral pictures, and within varying levels of stop-signal probability. In Study 2, two groups of individuals, who applied to a voluntary self-exclusion program toward gambling, performed the stop-task following relaxation or gambling craving induction, with results compared to non-gamblers. Study 1 showed that despite being less efficient in proactive inhibition, individuals with cannabis use disorder exhibited heightened proactive inhibition toward cannabis cues. In Study 2, proactive inhibition toward gambling cues was heightened in gamblers after craving, but the degree of proactive adjustment decreased as a function of induced changes in gambling-related motivation. Present findings demonstrate that exposure to addiction-related cues can modulate proactive inhibition in individuals who are motivated to restrict their addictive behaviors.

[Are we able to measure depression?] / Peut-on mesurer la dépression ?

Etiologically and symptomatically, depression is a profoundly heterogeneous disorder. Symptoms may be classified as either emotional or cognitive. Fear, seeking and panic/grief primary emotional circuits are involved at variable intensities. Cognitive symptoms are mostly associated with executive functions' problems. Different symptoms may be linked with specific cerebral circuits dysfunctions. However, because of their heterogeneity, it seems difficult to measure depression with biological methods (cerebral imagery and evoked potentials), as if it were a one-dimensional phenomenon. Clinical impression remains the main evaluation tool for depressive patients. Psychometric scales may be useful to evaluate the efficacy of treatments and to strengthen relationship with the therapist. Hamilton Depression Scale, Montgomery and Asberg Depression Scale and Beck Depression Inventory are the most used ones. We recommend the last one, as it is reliable and easy to use in clinical settings.

La dépression est un trouble profondément hétérogène, tant dans ses causes que dans sa présentation clinique. Les symptômes qui la caractérisent peuvent être sommairement classés en émotionnels d'une part et cognitifs d'autre par t. Les principaux circuits émotionnels impliqués sont ceux de la peur, de la tristesse et du désir. Les perturbations cognitives sont pour leur part associées principalement à des troubles des fonctions exécutives. Les différentes catégories de symptômes renvoient à des perturbations de circuits cérébraux spécifiques, mais du fait de leur hétérogénéité, il semble difficile de pouvoir mesurer la dépression par des méthodes biologiques (imagerie cérébrale et potentiels évoqués cognitifs) comme s'il s'agissait d'un phénomène unidimensionnel. L'examen clinique reste l'outil principal d'évaluation du patient dépressif. Les échelles psychométriques sont une aide précieuse pour suivre l'évolution des résultats d'un traitement et pour renforcer l'alliance thérapeutique. Les 3 échelles les plus uti lisées sont cel les d'Hamilton, de Montgomery-Asberg et de Beck. Nous recommandons plus particulièrement cette dernière échelle en raison de sa fiabilité et de sa facilité d'utilisation en pratique clinique.

[Are antidepressants really effective?]. / Les antidépresseurs sont-ils réellement efficaces ?

Antidepressants are widely used for a long time and it is estimated that about 10 % of the belgian population is taking some of them each year. However, there are important controversies about their real efficacy. We review successively arguments for and against their efficacy. On the one hand, meta-analysis have shown no big efficacy differences between antidepressants and placebo. On the other hand, those meta-analysis have been criticized for their methodology. Animal models show a real effect of antidepressants on the brain and clinical observations, such as an impact on suicide prevention, the possibility of induced manic switch, and an efficacy on anxiety disorders are in favour of a real efficacy. Given our current state of knowledge about them it seems appropriate to continue to use anti-depressants in the treatment of depressive patients.

Emotional facial expression processing in depression: data from behavioral and event-related potential studies.

Behavioral literature investigating emotional processes in depressive populations (i.e., unipolar and bipolar depression) states that, compared to healthy controls, depressive subjects exhibit disrupted emotional processing, indexed by lower performance and/or delayed response latencies. The development of brain imaging techniques, such as functional magnetic resonance imaging (fMRI), provided the possibility to visualize the brain regions engaged in emotional processes and how they fail to interact in psychiatric diseases. However, fMRI suffers from poor temporal resolution and cognitive function involves various steps and cognitive stages (serially or in parallel) to give rise to a normal performance. Thus, the origin of a behavioral deficit may result from the alteration of a cognitive stage differently situated along the information-processing stream, outlining the importance of access to this dynamic "temporal" information. In this paper, we will illustrate, through depression, the role that should be attributed to cognitive event-related potentials (ERPs). Indeed, owing to their optimal temporal resolution, ERPs can monitor the neural processes engaged in disrupted cognitive function and provide crucial information for its treatment, training of the impaired cognitive functions and guidelines for clinicians in the choice and monitoring of appropriate medication for the patient.

[Treatment of depression with transcranial magnetic stimulation]. / La stimulation magnétique transcrânienne dans le traitement de la dépression.

Major depression disorder is a frequent psychiatric condition with serious consequences. Many patients don't respond to usual psychopharmacological and/or psychotherapeutic treatments. This observation has stimulated the research of alternative treatment options. Repeated transcranial magnetic stimulation (rTMS) is a recent therapeutic tool with few side effects. Its efficacy relies on stimulation of cortical networks through the application of a magnetic field on the skull. rTMS has been approved as a full therapeutic option for major depressive disorder by the FDA in 2008. It could therefore be routinely used in the future and complete the usual treatments in this condition. Our paper reviews what is currently known about the clinical use of rTMS in major depressive disorder.

[Munchausen's syndrome: a factitious disorder? A case report]. / Le syndrome de Munchausen: un trouble factice? Présentation d'un cas clinique.

Munchausen's syndrome is classified as a chronic factitious disorder with predominant physical signs and symptoms. Several symptoms are specific to this disorder, such as travelling and pseudologia fantastica. Others symptoms, such as multiple physical complaints with no organic substrate, are shared with somatoform disorders. We report a case showing how difficult it is to diagnose a Munchausen syndrome. We discuss also the opportunity to classify such a syndrome as a factitious disorder. Indeed, several authors suggest classifying Munchausen syndrome as a subtype of somatoform disorders, as those two disorders share a lot of characteristics.

[Religion and brain functioning (part 2): does religion have a positive impact on mental health?]. / Religion et fonctionnement du cerveau (partie 2): les religions jouent-elles un rôle favorable sur la santé mentale?

Religion's impact on mental health has been largely studied, but results are often difficult to interpret due to methodological concerns: definition of religion and of spirituality ; measuring issues ; identification of specific components such as social dimension, cognitive schemas influencing world perception and meditating behaviors such as prayers. Furthermore, correlations between religious dimensions and mental health variables are too often considered as evidence of causality. Despite all those methodological problems, it appears that religiosity, defined as a global concept encompassing all aspects of religious life, might be a protective factor against several mental health problems, namely substance abuse, depression, suicide and anxiety disorders. This protective property isn't likely due to religions per se, but to associated components: risky behaviors' prevention due to shared moral standards, social support, sense of meaning, purposefulness and control, and meditation habits, exercising an inhibiting influence on chronic stress.

[General practitioner burnout: risk factors]. / Le burn-out du médecin généraliste: hypothèses etiologiques.

This paper aims to review current knowledge on risk factors leading to burn-out of general practitioners, who are particularly concerned by burn-out, as 50% of them are being more or less affected. This article is based on bibliographic research covering literature between 1975 and 2010, using PUB MED software, medical books and articles. 44 articles were selected as dealing well with the aspects of the burn-out reviewed here. It seems established that stress precedes burnout symptoms. Theories investigating relationships between stress and work are presented. Exogenic stress (load and organization of work, emotional interaction with the patient, constraints, lack of recognition, conflicts between private and professional life) interacts with endogenous stress (idealism, (too much) acute feeling of responsibility, mood disorder, difficulty in collaborating, character, personality). Burn-out symptoms would appear preferentially when these two stresses coexist. Despite the wealth of publications, there is still a lack of knowledge of the causes of burn-out, requiring therefore increased research efforts, in order to improve the implementation of preventive measures, beneficial to the doctors as well as to their patients.

How cognitive assessment through clinical neurophysiology may help optimize chronic alcoholism treatment.

Alcohol dependence constitutes a serious worldwide public health problem. The last few decades have seen many pharmacological studies devoted to the improvement of alcoholism treatment. Although psychosocial treatments (e.g. individual or group therapy) have historically been the mainstay of alcoholism treatment, a successful approach for alcohol dependence consists in associating pharmacologic medications with therapy, as 40-70% of patients following only psychosocial therapy typically resume alcohol use within a year of post-detoxification treatment. Nowadays, two main pharmacological options, naltrexone and acomprosate, both approved by the US Food and Drug Administration, are available and seemingly improve on the results yielded by standard techniques employed in the management of alcoholism. However, insufficient data exist to confirm the superiority of one drug over the other, and research is ongoing to determine what type of alcohol-dependent individual benefits the most from using either medication. Available data on the application of both drugs clearly suggest different practical applications. Thus, a fundamental question remains as to how we can identify which alcoholic patients are likely to benefit from the use of naltrexone, acamprosate or both, and which are not. The aim of the present manuscript is to suggest the use of cognitive event-related potentials as an interesting way to identify subgroups of alcoholic patients displaying specific clinical symptoms and cognitive disturbances. We propose that this may help clinicians improve their treatment of alcoholic patients by focusing therapy on individual cognitive disturbances, and by adapting the pharmaceutical approach to the specific needs of the patient.

Major depression is associated with impaired processing of emotion in music as well as in facial and vocal stimuli.

BACKGROUND: The processing of emotional stimuli is thought to be negatively biased in major depression. This study investigates this issue using musical, vocal and facial affective stimuli. METHODS: 23 depressed in-patients and 23 matched healthy controls were recruited. Affective information processing was assessed through musical, vocal and facial emotion recognition tasks. Depression, anxiety level and attention capacity were controlled. RESULTS: The depressed participants demonstrated less accurate identification of emotions than the control group in all three sorts of emotion-recognition tasks. The depressed group also gave higher intensity ratings than the controls when scoring negative emotions, and they were more likely to attribute negative emotions to neutral voices and faces. LIMITATIONS: Our in-patient group might differ from the more general population of depressed adults. They were all taking anti-depressant medication, which may have had an influence on their emotional information processing. CONCLUSIONS: Major depression is associated with a general negative bias in the processing of emotional stimuli. Emotional processing impairment in depression is not confined to interpersonal stimuli (faces and voices), being also present in the ability to feel music accurately.

[Religion and brain functioning (part 1): are our mental structures designed for religion?]. / Religion et fonctionnement du cerveau (partie 1): nos structures mentales nous prédisposent-elles à la religion?

Religions are seen everywhere in the world. Two main theories are competing to explain this phenomenon. The first one is based on the assumption that our cognitive structures are predisposing us to nurture religious beliefs. Religion would then be a by-product of mental functions useful for survival. Examples of these mental functions are children credulity, anthropomorphism and teleology. The second one hypothesizes that religion is maintained trough direct adaptation benefits occurring in cooperation exchanges. In particular, religion could function as an insurance mechanism given by the religious group. It is likely that both theories are complementary and useful to explain why religion is a universal phenomenon in the human species.

Chronic alcoholism: insights from neurophysiology.

INTRODUCTION: Increasing knowledge of the anatomical structures and cellular processes underlying psychiatric disorders may help bridge the gap between clinical signs and basic physiological processes. Accordingly, considerable insight has been gained in recent years into a common psychiatric condition, i.e., chronic alcoholism. MATERIAL AND METHODS: We reviewed various physiological parameters that are altered in chronic alcoholic patients compared to healthy individuals--continuous electroencephalogram, oculomotor measures, cognitive event-related potentials and event-related oscillations--to identify links between these physiological parameters, altered cognitive processes and specific clinical symptoms. RESULTS: Alcoholic patients display: (1) high beta and theta power in the resting electroencephalogram, suggesting hyperarousal of their central nervous system; (2) abnormalities in smooth pursuit eye movements, in saccadic inhibition during antisaccade tasks, and in prepulse inhibition, suggesting disturbed attention modulation and abnormal patterns of prefrontal activation that may stem from the same prefrontal "inhibitory" cortical dysfunction; (3) decreased amplitude for cognitive event-related potentials situated along the continuum of information-processing, suggesting that alcoholism is associated with neurophysiological deficits at the level of the sensory cortex and not only disturbances involving associative cortices and limbic structures; and (4) decreased theta, gamma and delta oscillations, suggesting cognitive disinhibition at a functional level. DISCUSSION: The heterogeneity of alcoholic disorders in terms of symptomatology, course and outcome is the result of various pathophysiological processes that physiological parameters may help to define. These alterations may be related to precise cognitive processes that could be easily monitored neurophysiologically in order to create more homogeneous subgroups of alcoholic individuals.

[Neuroleptic malignant syndrome and atypical antipsychotics: a brief review]. / Antipsychotiques atypiques et syndrome malin des neuroleptiques : brève revue de la littérature.

BACKGROUND: Neuroleptic malignant syndrome (NMS) is an uncommon, but potentially life threatening complication of neuroleptic drugs. In 1960, Delay et al. [Ann Med Psychol 118 (1960) 145-152] described the "syndrome akinétique hypertonique"(hypertonic akinetic syndrome) and its cardinal symptoms: hyperthermia, extrapyramidal symptoms, altered mental status and autonomic dysfunctions. The syndrome often develops after a sudden increase in dose of neuroleptic medication or in states of dehydration. The frequency of NMS with conventional neuroleptic drugs ranges from 0.02 to 3.3%. The pathophysiology of NMS is not clearly understood. It has been suggested that the potential to induce NMS of neuroleptics is parallel to the potency of dopamine blockade in the nigrostriatal tract, mesocortical pathway and hypothalamic nuclei. It is, however, intriguing that NMS may appear with atypical antipsychotics (AA) and especially clozapine (CLZ), which is mainly characterized by its low affinity to D1 and D2 receptors. OBJECTIVE: The purpose of this study was to review cases of NMS induced by AA agents reported in the literature and to discuss the pathophysiology of this complication. METHODS: Cases of NMS related to AA were collected by means of a MEDLINE literature search between January 1986 and June 2005. As key words we used: (NMS and AA), amisulpride (AMS), clozapine (CLZ), olanzapine (OLZ), risperidone (RIS), quetiapine (QTP), ziprazidone (ZPS) and side effects. For the purpose of our review, all cases were critically examined against standard NMS diagnostic criteria according to DSM-IV. Cases involving a coprescription of classical neuroleptics were excluded. RESULTS: Our search yielded 47 cases (eight women, 39 men) of NMS associated with AA meeting DSM-IV criteria. Patients' mean age was 37 years, primary patient diagnoses were schizophrenia (n=26), schizoaffective disorder (n=9), bipolar disorder (n=3), mental retardation (n=4) and other diagnoses (n=5). Drugs involved were: CLZ (n=12), OLZ (n=18), OLZ and CLZ (n=1), OLZ and RIS (n=1), RIS (n=11), RIS and CLZ (n=2), QTP (n=3) and ZPS (n=1). No cases were reported with AMS. Twenty-nine of these 47 patients treated with AA received no other concomitant psychotropic medications; the remaining 18 patients received respectively, benzodiazepines (n=5), Valproate (n=5), lithium (n=4) and antidepressants (n=4). A lethal evolution occurred in two patients receiving in one case olanzapine, risperidone in the second, at a normal dose range. CONCLUSION: Our review indicates that atypical antipsychotics can cause NMS even when prescribed in monotherapy. The occurrence of NMS when prescribing AA and especially CLZ is, however, intriguing, given its low potency to block D2 receptors. This indicates that a low extrapyramidal syndrome-inducing potential does not prevent NMS and suggests the possible role of serotoninergic and noradrénergic receptors in the pathophysiology of NMS.

Alcoholism leads to early perceptive alterations, independently of comorbid depressed state: an ERP study.

INTRODUCTION: Alcoholism is associated with a deficit in the processing of emotional facial expressions (EFE) and with a delayed P3b component, partially mediated by earlier perceptive deficits (P100, N170). Since alcohol dependence often occurs with depression, we aim at investigating whether classical event-related potentials (ERP) alterations observed in alcoholism are modulated or not by depression. METHODS: Four groups (controls; alcoholics; depressed; alcoholics-depressed) of 12 participants performed two different discrimination tasks, a gender and an emotional one. They had to decide as quickly as possible about the gender or the emotion displayed by facial stimuli during an ERP recording session (32 channels). Reaction times (RTs), P100, N100, N170 and P3b were recorded. RESULTS: At the behavioural level, control participants discriminated EFE (but not gender) more rapidly than the three other groups. At the ERP level, the differences observed on RTs for emotional task were neurophysiologically indexed by a delayed P3b component. This delay was associated with earlier ERP alterations (P100, N100, N170), but only in participants suffering from alcohol dependence, in association or not with depression. DISCUSSION: On the one hand, individuals with alcoholism, associated or not with a comorbid depression, were impaired in the processing of EFE. This deficit was neurophysiologically indexed by early perceptive (P100, N100, N170) and decisional (P3b) alterations. On the other hand, non-alcoholic patients with depression only exhibited P3b impairment. These results lead to potential implications concerning the usefulness of the ERP for the differential diagnosis in psychiatry, notably concerning the comorbidities in alcoholism.

Is the P300 deficit in alcoholism associated with early visual impairments (P100, N170)? An oddball paradigm.

OBJECTIVE: Studies exploring chronic alcoholism with event-related potentials (ERPs) have shown delayed latency and reduced amplitude of the P300, a long-lasting positive potential reflecting decisional processing. This P300 deficit in alcoholism is generally interpreted as a disturbance in central nervous system inhibition or in memory/attention. The present study aimed at identifying if this electrophysiological deficit is already present on earlier components, and advances a new hypothesis concerning the interpretation of the P300 alteration. METHODS: Patients suffering from alcoholism and matched healthy controls had to detect, in an oddball paradigm, emotional faces among a succession of neutral faces. Behavioral performance and ERP data (recorded from 32 electrodes) were analyzed. RESULTS: In line with previous studies, data showed that alcoholism led to a P300 deficit. Moreover, we observed for the first time that this deficit begins at earlier visual (P100) and face-processing (N170) stages, and we found high positive correlations between P100, N170 and P300 for amplitude and latency values, suggesting cumulative deficits on the cognitive continuum. CONCLUSIONS: We suggest that the P300 deficit observed in chronic alcoholism could be linked to earlier visuo-spatial deficits rather than being an impairment of the specific processes linked to the P300. SIGNIFICANCE: These results call for reconsidering the interpretation of P300 impairments at a fundamental and clinical level, and shows that earlier ERP components must be taken into account in future studies.

[Panic, somatization and exercise]. / Panique, somatisation et activité physique.

Somatizations are present in many psychiatric disorders including anxiety and affective disorders, somatoform disorders and several personality disorders. Panic attacks are one of the most typical examples of somatizations: they are characterized by a focusing of attention towards physiological arousal signals and by a pathological interpretation of them as indicating an imminent danger or a serious sickness. Regular physical activity is associated with decreasing somatization, probably through adaptive mechanisms of serotonergic circuits implicated in anxiety and nociception regulation.

[Catatonic syndrome]. / Le syndrome catatonique.

Catatonia has been more studied in the past 10 years after a period of declining interest. This is due, on the one hand, to its inclusion in major psychiatric nosographic systems, and on the other hand, to the possibility to treat efficiently this condition, which was previously a fatal one. Catatonia is characterized by concurrent motor, emotional, and behavioural symptoms. This syndrome is commonly observed in persons with mood disorders, and less frequently in schizophrenia as well as in numerous neurological affections. A central dopaminergic dysfunction could explain the its apparition Catatonia is usually successfully treated by benzodiazepines and ECT.