A descriptive and follow-up study of 40 parricidal patients hospitalized in a French secure unit over a 15-year period.

Parricide is rare and represents 3% of all homicides in France, and 4% of resolved homicides in North America. Consequently, related international literature is sparse, especially concerning the evolution of offenders, and most studies concern small samples or anecdotal cases. We wished to identify the main characteristics of parricidal subjects and their victims, and to assess the socioclinical evolution of the offenders after the assault. To this end, we first studied the sociodemographic, clinical and forensic characteristics of all parricidal patients admitted to France's Henri Colin secure unit between 1996 and 2010 (40 patients). We also assessed the evolution of the 36 patients who had left the secure unit, using questionnaires sent to the psychiatric hospitals where the patients were transferred. We found most offenders to be men (97.5%), with a mean age of 28 years, who were mostly single, unemployed, living with the victim prior to the assault (77.5%), and with a history of psychiatric disorder (72.5%). The population of offenders also displayed an overrepresentation of schizophrenia (87.5%), significant toxic exposure and criminal or violent history. Some patients had attempted suicide before or right after the offense. The assault was mostly committed in the parent's house with an edged weapon, and was characterized by brutality and lack of premeditation. Precipitating factors included substance use and cessation of psychotropic medication. Matricide was more frequent than patricide. At the time of this study, half of the parricidal patients were working or attending therapeutic activities, and most were actively keeping in contact with their family, living as compliant outpatients with no signs of violent behavior. The results of our study on 40 parricidal patients are consistent with data in the literature. With regard to sample evolution, family and community reintegration was relatively effective considering the seriousness of the offense. Several biases in our study disallow the generalization of these findings, and further studies are needed.

[Dysphagia or dysphagias during neuroleptic medication?]. / Une ou des dysphagies lors d'un traitement par neuroleptiques ?

INTRODUCTION: Dysphagia is a common symptom in the general population, and even more among psychiatric patients, but rarely seen as a sign of seriousness. It is a cause of death by suffocation, and more or less serious complications, and therefore should be diagnosed and treated. Among psychiatric patients, organic and iatrogenic aetiologies, as well as risk factors are identified, which worsen this symptom when associated. It is now accepted that neuroleptics can aggravate or cause dysphagia. They act by several pathophysiological ways on the different components of swallowing, which can be identified by dynamic tests in the upper aerodigestive tract endoscopy. LITERATURE FINDINGS: This symptom is rarely reported by patients and often underestimated by caregivers. The frequency of swallowing disorders is not known. Dysphagia is a cause of complications and an increase in mortality rates among psychiatric patients. It has also been found that the average number of psychotropic drugs in patients who die by cafe coronary is significantly higher than in other patients. There are several phases in swallowing: oral, pharyngeal, and oesophageal. Swallowing disorders can affect each of these phases, or several at once: (a) Extrapyramidal syndrome: dysphagia is present in drug induced Parkinson's syndromes, but prevalence is not known. It is most often associated with another symptom of the extrapyramidal syndrome, but can also be isolated, making its diagnosis more difficult. Dysphagia is due to a slowing down in the oral and pharyngeal reflex, called bradykinesia; (b) Tardive dyskinesia: the oro-pharyngo-oesophageal dyskinesia is the most common type. Oesophageal dyskinesia causes asynchronous and random movements of the oesophagus, resulting in dysphagia. It appears mostly beyond 3 months of treatment with neuroleptics; (c) Acute laryngeal or oesophageal dystonia, associated or not with orofacial dystonia, is characterised by an impairment in the oesophageal muscle contraction and a hypertonia of the upper sphincter of the oesophagus; (d) Polyphagia or "binge eating", is frequent in psychotic patients; (e) Finally, there are risk factors for dysphagia: xerostomia, poor dental status, advanced age, neurological diseases, polypharmacy, sedative drugs, CNS depression, etc., which worsen the symptom. CASE REPORT: Mr J., aged 28, with no psychiatric history, is admitted to the Unit for Difficult Patients in Villejuif for behavioural disorder with homicide on the street. The patient was restrained by passers-by and suffers a head injury and a fracture of the transverse process of L1 vertebra. A cranial CT scan is performed in the emergency room, it is normal. The patient is not known to psychiatric services, and has never taken neuroleptics. Mr J. is homeless, known in his neighbourhood for "his noisy delirium on the street and repeated alcohol abuse." After being arrested by the police in this context, a first psychiatric examination is conducted. The medical certificate states that his condition is not compatible with custody. Mr J. remains mute; he has stereotyped gestures and strange attitudes. No delusion is verbalized. He receives vials of loxapine 50mg causing sedation. At his arrival in the department, Mr J. has the same clinical picture, with a rigid and inexpressive face, reluctance, major unconformity, poor speech. The search for drugs in urine is positive for cannabis. The diagnosis of schizophrenia is rapidly raised, motivating further prescription of loxapine 300 mg daily in combination with clonazepam 6 mg daily. From the earliest days, dysphagia to solids with choking and regurgitation is noted, aggravated by the increase of loxapine treatment of 450 mg / day to 700 mg / day, 7 days after admission. A physical examination is performed before the worsening of dysphagia, it is normal, and in particular, reveals no extrapyramidal syndrome. An anti-cholinergic corrector is introduced, without clinical improvement. A new physical examination is performed; it is normal except for sedation and a slight deviation of the uvula. Upper gastrointestinal endoscopy shows no anatomical lesion. No functional assessment of swallowing is done however. At this stage, the suspicion of neuroleptic induced dysphagia appears to be the most likely hypothesis. Treatment with loxapine is then stopped, resulting in a very rapid clinical improvement. Aripiprazole 15 mg / d is introduced. Dysphagia does not reoccur. DISCUSSION: Loxapine is an atypical antipsychotic, with a lower risk of neurological side effects than first generation of antipsychotics. These side effects are however numerous and from diverse pathophysiological mechanisms. Loxapine is an antagonist of dopamine and serotonin which is involved in the regulation of several neurotransmitters, explaining the multiple mechanisms involved in the onset of dysphagia: first, blocking dopamine D2 receptors in the striatum, causing motor side-effects of central origin, in addition to peripheral effects of the molecule, which impairs swallowing. In principle, the antagonist activity on serotonin 5-HT2A receptors increases dopaminergic activity in the striatum, reducing the risk of extrapyramidal symptoms and tardive dyskinesia, without avoiding them completely. In addition to these mechanisms, cholinergic blockade reduces oesophageal mobility and pharyngeal reflex. Moreover, the antihistamine, anti-cholinergic and adrenergic receptor blocking alpha-1 can cause sedation, which aggravates the symptom. Finally, the depression of the bulbar centres reduces the swallowing reflex and gag reflex altering the intake of food. CONCLUSIONS: The swallowing disorder caused by neuroleptics may occur regardless of the molecule or drug class to which it belongs. It can be found even in the absence of any other neurological signs. It is important to search for the aetiological diagnosis for treatment. At the crossroads of several specialties, swallowing disorders are difficult to diagnose and treat. They are frequently underestimated, partly because patients rarely complain. In our case report, the diagnosis was ascertained by the removal of the medication, without functional evidence, probably by a lack of collaboration between the physician and the endoscopist who had not performed any dynamic investigation of swallowing. This case illustrates the importance of knowing the different mechanisms underlying dysphagia in psychiatric patients, and good communication with gastroenterologists to establish a precise diagnosis of the disorder, and adapt the therapy.

[Therapeutics approach of adult patients with acute and chronic psychotic states: REALITE survey]. / Approche thérapeutique d'une population de patients présentant des troubles psychotiques aigus ou chroniques: enquête REALITE (Recherche Epidémiologique sur l'activité de la Loxapine et ses Indications en Thérapeutique quotidiennE).

A retrospective observational pharmaco-epidemiological survey was conducted during 24 weeks between October 2004 and March 2005 in metropolitan France (384 investigators) to more clearly define the use of loxapine in acute and chronic psychotic states. The objective of this national survey was to specify the clinical and therapeutic profile of patients managed by this antipsychotic in two cohorts of adult patients: one in "acute phase" (prescription of loxapine during the previous 4 weeks), the other in "maintenance phase" (prescription of loxapine for more than 8 weeks). The two groups of the recruited population (1,511 patients) presented identical sociodemographic data. Selection criteria were adapted to the data collected to ensure statistically relevant analysis: 696 patients in acute phase and 633 patients in maintenance phase. The acute phase group was predominantly composed of known patients (82% of patients had a psychotic history) with schizophrenia (47%) or mood disorders (57%) who had already presented acute episodes (an average of 5.4). The current episode consisted of a state of agitation (88%) lasting an average of two weeks, requiring hospitalization (87%), scheduled admission [HDT (admission at the request of another person) in 47.5% of cases and HO (statutory admission) in 40.8% of cases] and prescription of loxapine monotherapy (56%) at a mean daily dose of 177,3 mg. The maintenance phase group comprised a population of known patients (87.5%), schizophrenics (63%), presenting psychotic symptoms (dissociation 82%, delusions 74%) or mood disorders (71%) requiring voluntary hospitalization (78%) for a mean duration of 180 days and a prescription of loxapine monotherapy in 28% of cases at a mean daily dose of 131.6 mg. The loxapine-haloperidol combination (21%) was prescribed more frequently in the second group in the case of chronic disorders; in the other cases, loxapine was coprescribed with the main second generation antipsychotics: risperidone (16%), olanzapine (16%), amisulpride (11%). CGI assessment of the overall study population revealed a marked or very marked clinical improvement with no significant adverse effects in more than 80% of cases.

Standardized remission criteria in schizophrenia.

OBJECTIVE: Recent work has focussed on schizophrenia as a 'deficit' state but little attention has been paid to defining illness plasticity in terms of symptomatic remission. METHOD: A qualitative review of a recently proposed concept of remission [N.C. Andreasen, W.T. Carpenter Jr, J.M. Kane, R.A. Lasser, S.R. Marder, D.R. Weinberger (2005) Am J Psychiatry 162: 441] is presented. RESULTS: The proposed definition of remission is conceptually viable, and can be easily implemented in clinical trials and clinical practice. Its increasing acceptance may reset expectations of treatment to a higher level, improve documentation of clinical status and facilitate dialogue on treatment expectations. The availability of validated outcome measures based on remission will enhance the conduct and reporting of clinical investigations, and could facilitate the design and interpretation of new studies on cognition and functional outcomes. While useful as a concept, it is important to consider that remission is distinct from recovery. CONCLUSION: The introduction of standardized remission criteria may offer significant opportunities for clinical practice, health services research and clinical trials.

[Pharmaco-epidemiology of antipsychotic prescription practices for schizophrenic patients (1995 and 1998 cross sectional surveys)]. / Pharmaco-épidémiologie des pratiques de prescription d'antipsychotiques chez les patients schizophrènes (coupes transversales 1995 et 1998).

OBJECTIVE: The two cross-sectional surveys reported here concern the field of pharmaco-epidemiology of prescription practices. The objective is to describe and understand these practices in regard to antipsychotics and their evolution in all indications which go beyond the field of psychotic pathology. The research presented here only concerns schizophrenic pathology. METHODOLOGY: These 2 cross-sectional surveys were carried out in public psychiatric sectors in 1995 and 1998 applying the same methodology in the same services. On a given day, in each sector, they concern all patients aged from 18 to 64 and receiving an antipsychotic prescription. A hospital unit and a consultation unit were included to take into account practices which could be different in these two places of care. A comparison was made between the 1995 stage and the 1998 one for a better understanding of evolution in practical terms. An unvaried analysis was carried out to test the differences observed between 1995 and 1998 as well as a correlation test to evaluate evolution according to age and duration. RESULTS: The main results were as follows: the number of antipsychotics slightly decreased significantly from 1.74 (+/- 0.02) in the 1995 survey to 1.69 (+/- 0.04) in the 1998 one (p<0.05); the number of patients receiving antiparkinsonian medicines, correcting extra pyramidal effects, decreased from 60% in 1995 to 50% in 1998. The following associated factors were noted concerning prescription of antipsychotics. Women received a mean number of antipsychotics significantly lower than that of men. For each sex the mean number was lower in the 1998 survey, but not significantly so. In the two surveys, there was a positive correlation between the mean number of antipsychotics and age; it increased as the patient grew older. The mean number of antipsychotics tended to increase significantly with length of illness, in 1995 as well as in 1998. It was for the shortest periods that the mean number of antipsychotics was lowest. The mean number of antipsychotics was significantly higher in the hospital field as compared to the ambulatory. The greater was the mean number of antipsychotics, the greater was the proportion of patients who received antiparkinsonian medication. Firstly, these surveys shed light on what may underlie prescription practices such as sex and age of the patient, length of illness and the place of care. Secondly, the evolution of practices in time can be followed, taking into account the increase of knowledge concerning this subject.

[Pharmaco-epidemiological study on antipsychotic drug prescription in French Psychiatry: Patient characteristics, antipsychotic treatment, and care management for schizophrenia]. / Etude pharmaco-épidémiologique de la prescription des antipsychotiques en milieu psychiatrique en France -

UNLABELLED: In 2000, a one week national survey was conducted among 202 psychiatrists (129 participants) in France, from hospitals and clinics, private or public. The first 20 inpatients and 10 outpatients prescribed at least one antipsychotic drug (age range 18-65), were included. The diagnostic procedure was standardized with a structured interview: the Mini International Neuropsychiatric Interview (MINI). A total 2 068 patients were included, among whom 892 (43.1%) reached the criteria of schizophrenia according ICD-10. We present here data on these latter patients. Mean age was 38.8 years; with 38.8% females. Median duration of current antipsychotic treatment was 0.5 year in inpatients and 2 years in outpatients. Median duration of any antipsychotic treatment was 10 years, without difference between groups. Comorbid situations (anxiety disorder, depression and suicidal risk) were found in 33.1% of schizophrenic patients, with higher frequency among inpatients in private hospitals (54.8%) than in other groups. 46.8% patients were prescribed at least 2 neuroleptics, and 73.6% at least one non-neuroleptic drugs. Cyamemazine accounted for 16.6% of all neuroleptics drugs, and 56% of patients were prescribed an atypical antipsychotic (risperidone, olanzapine, amisulpride or clozapine). Atypical drugs accounted for 59.4% of patients who were prescribed only one neuroleptic drug. Inpatients had more neuroleptics coprescription than outpatients (mean 1.8 vs 1.4 drugs), with higher daily dose. In addition, inpatients had more other psychotropics prescribed (mean 1.5 vs 1.1 drugs). Overall, more other psychotropic drugs were prescribed among patients with -, than those without - comorbid situations (1.7 vs 1.2 drugs). Median time since admission, at the time of the study, were similar in private and public hospitals (107 vs 99 days) but maximal time since admission was respectively 2.8 and 48.9 years. Visit frequency for outpatients was more than one every two weeks for 43.1% in private and 24.7% in public clinics. Among inpatients only we found a difference between private and public hospitals for polypharmacy of non neuroleptics psychotropics, (mean 1.9 vs 1.5). In outpatients, long acting depot accounted for 26.6% of neuroleptics treatments in public clinics and 15.4% in private clinics. Finally, we found that polypharmacy among outpatients increased with duration of antipsychotic treatment. CONCLUSION: in France, important differences are reported in antipsychotic prescription for schizophrenia between in- and outpatients. Current antipsychotic prescription is more recent in inpatients than in outpatients, with similar duration of overall antipsychotic treatment. Inpatients have more drug prescription, antipsychotics and other psychotropics, than outpatients. Differences are less important between private and public providers. Inpatients in private hospitals receive more non neuroleptic drugs than in public hospitals, and depot antipsychotics are more used among patients of public clinics. Long term inpatients are found in public hospitals only. Outpatients follow up is more intensive in private than in public clinics.

Assessing the impact of a consensus conference on long-term therapy for schizophrenia.

OBJECTIVE: Our aim was to assess the impact of six recommendations regarding drug prescription on the clinical practices of French psychiatrists. The recommendations were part of the conclusions of a consensus conference entitled "Long-term therapy of schizophrenia" (Paris, January 1994). METHODS: The impact of the conference was assessed on the basis of awareness of the existence of the conference, knowledge of its conclusions, and actual changes in clinical practice. We performed: a) a survey of a representative sample of 396 psychiatrists 2 years after the conference; and b) an analysis of changes in drug prescriptions in a cohort of 2,407 patients with schizophrenia under treatment at the time of the conference. RESULTS: Overall, 78% of interviewed psychiatrists were aware of the existence of the conference and 70% of its conclusions. Declared prescription practices conformed with conference conclusions about 60% (10%-95%) of the time. No difference in practices was noted between psychiatrists who were aware of the recommendations and those who were not. Single neuroleptic prescriptions increased in the cohort study in line with the main conference recommendation. The increase was small, but significant from 51.1% to 56.4%, and mainly concerned patients recently put on treatment. Contrary to recommendations, prescriptions of anticholinergics plus neuroleptics inexplicably rose from 48.2% to 54.3%. CONCLUSION: Small changes in prescription habits occurred in the wake of the consensus conference, but we cannot really ascribe them to a direct impact of the conference. Despite the great pains we took in disseminating the conclusions of the conference as widely as possible, it is clear that a more forceful action plan (e.g., including continuous medical education) is required.

[The study of the impact of the consensus conference "Strategies for long-term therapy of patients with schizophrenia"]. / Etude de l'impact de la conférence de consensus "Stratégies thérapeutiques à long terme dans les psychoses schizophréniques".

UNLABELLED: The case management, treatment and psychosocial rehabilitation of schizophrenic patients is an important part of the activity of the psychiatric sector and takes up many human, scientific, organizational and financial resources. The best way to reach satisfactory results for the individual patient is still uncertain and current practice in France shows noticeable variations that have been rarely investigated in terms of outcome. A consensus conference (CC) on "Strategies for long-term therapy of patients with schizophrenia" was therefore held in Paris in 1994 to produce accurate guidelines designed to help both clinicians and patients and to improve practice. It was organized by the French Federation of Psychiatry, the National Union of Friends and Relatives of Mental Patients, and the National Agency for the Development of Health Evaluation. The conclusions of the CC were mailed, in the form of a booklet, to members of these associations (psychiatrists and relatives) and were reported in the medical and general press. METHODS: The impact of the CC was judged by (a) the psychiatrists'awareness of the existence of the CC, (b) their knowledge of its conclusions, and (c) changes in practice. The following were analyzed: press coverage; requests for the booklet; the results of a survey of a representative sample of 396 psychiatrists two years after the CC; prescription changes in the public sector in a cohort of 2,407 schizophrenic patients under treatment at the time of the CC; prescriptions to psychotic patients by a representative sample of psychiatrists in private practice. RESULTS: Awareness: Articles on the CC were published in 27 journals and newspapers, 30,000 booklets were distributed and 8,348 were mailed in response to 1,121 spontaneous requests; 78% of the psychiatrists interviewed said they were aware of the existence of the CC and 70% said they were aware of the conclusions. Knowledge: The psychiatrists' declared practice conformed with CC conclusions 41%-85% of the time depending on the recommendation. No difference in practice was noted between the psychiatrists who said they knew of the recommendations and those who said they did not. Changes in practice: A significant but small improvement in prescription habits was noted for a principal recommendation ("just one neuroleptic is enough"). One-neuroleptic prescriptions increased from 51.1% the year before the CC to 56.4% two years after the CC. The increase mainly concerned the most recently treated patients. However, during the same time-span, prescriptions of anti-cholinergics plus neuroleptics rose from 48.2% to 54.3%. CONCLUSION: It is difficult to attribute changes in practice to a CC. However, the impact of the CC seemed real even if inconstant and not great enough. Clearly, to enhance impact an action plan is needed. It should include corrective measures and focus on additional dissemination efforts, teaching and training programs, and updating of guidelines if necessary.

[Between compliance and freedom: the patient's statement]. / Entre compliance et liberté: le témoignage d'un patient.

According to the patient, obtaining a good compliance is related to a good relationship with his practitioner; this relationship is directly connected to being a good listener for the patient, and not only for their symptoms. If the individual motivation is very important at the beginning, it will be itself greatly influenced by the relationship between the practitioner and the patient. It is one of the rare factors with a positive correlation with compliance, that's what almost all of the researches on medical psychology have observed. Once the problem is sumed up, it's the turn to speak for the patient, who explains how he considers compliance.

[About ethics in psychiatry and psychiatrists facing ethics]. / De l'éthique en psychiatrie au psychiatre face à l'éthique.

The plug in account of the suffering, notably psychological, in a consultation, puts the problem of the relationship between suffering and ethics. However, the originality of the ethical step is justly not to be confined to the social norm conformism, but being specific to the individual dimension. The psychiatric pathology offers in this area of particularities interesting. The neurotic, as the obsessed, suffering inwardly pathological manifestations that he judges absurd, replies to the medical moral in asking a care. The psychotic, which projects his suffering on the other, does not feel sick, requests no therapeutic assistance. As such he contests the medical order in an immoral position by definition, and the patient represents from then on a social and medical scandal. In front of a such clinical diversity, we can easily underline that approaching the theme of ethics in psychiatry isn't a well-off exercise, and necessitates a precise locating registered in the history of the patient.

[Legislative and ethical aspects of drug experimental in children and adolescents]. / Aspects législatifs et éthiques de l'expérimentation des médicaments chez l'enfant et l'adolescent.

Experimentation of drugs in children meets with ethical and legal difficulties. After studying historical development of drug trials regulation, the different ways to define the modalities of clinical trials (law, technical aspect, deontology, ethics) are described. The importance of the informed consent and its particularities when children are concerned are emphasized. Finally, it appears ethical and necessary to practice drug trials in children in order to obtain safe and efficient drugs and prescriptions in pediatrics.

[Consent: between legality and legitimacy or between "formal" and "informed" consent]. / Le consentement: entre légalité et légitimité, ou du consentement "formel" au consentement "informé".

As shown by a recent decree of the supreme court, the legal aspect of information given before consent is more and more important. At beginning, the written consent was reserved to particular cases, as biomedical research for example. It concerns now all the fields of care, since it is considered as a proof of the existence of a prior information. The informed consent changes in a formal consent: the consequence is a modification of the relation between the physician and the patient. We may imagine that this evolution paradoxically results in a worse integration of subjectivity. Then, it seems necessary to stress the clinical aspect so as to give to the consent concept its legitimity back: it consists in an ethical and humanistic acknowledgement of alterity.

Contraception, sterilisation and the mentally ill: beyond Manicheanism, some reference points.

The problem of contraception, sterilisation and the mentally ill is one of the key questions in medical ethics. Even if these two aspects bring into question a person's autonomy in two of the most intimate and fundamental aspects of life - sexuality and motherhood - they should not be confused as they differ greatly in terms of their reversibility. The essential question is rather one of individual freedom and its defence in situations where the subject is unable to defend himself either temporarily or in the long term. The fine line between individual and collective interests poses questions in terms of where to draw this line and the way in which it is defined in care situations. From this viewpoint, carers - that is, doctors and nurses, but also social workers and the patient's entourage - play an important role, not only in theory but also in day-to-day reality.

[A new study of secondary effects in prescribing practices of neuroleptics]. / Une nouvelle lecture des effets secondaires en matière de prescription des neuroleptiques.

Within the context of our knowledge of the neuroleptics, side-effects have not only been considered for a number of years as an unavoidable element of these agents; they in fact practically constitute a defining feature of such drugs. Advances in knowledge and the availability to prescribing practitioners of so-called "atypical" neuroleptics allow some redefinition of the above problem. A multidimensional approach which goes beyond more nosographic considerations, and the addition of a temporal dimension to a question for too long reduced to its spatial aspect are new elements which help put the issue of side-effects in perspective. However, any examination of this subject must also take into account the quality of life and the subjective experience of patients undergoing treatment with neuroleptics, since these considerations represent important pathways for the future. Such analysis must also take into account the current situation, in which excessive prescription of corrective agents, the prevalence of co-prescription of psychotropic agents and wide variations in prescribing of neuroleptics (for too long overlooked, in terms of both analysis and education) have given rise to coercive control strategies. The system of Opposable Medical References (OMR) forms part of a panoply of measures aimed at control rather than education. However, education constitutes a key element in this field if the goal of re-appropriation is to be achieved.

[Processing of nominal data for research purposes: a new text]. / Le traitement des données nominatives à des fins de recherche: un nouveau texte.

The automated processing of nominal data is now governed by the 1st July 1994 law and its application decrees. This new procedure that situates between emphasis of the control and attenuation of the secret professional adds to others already existent. France has now a complete device and it is necessary to articulate this text with the other references concerning biomedical research, notably the 20 December 1988 law told Huriet law. The new social risks of the biomedical research pose the questions of separation of the care and the research in medicine confirmed by this new legislative text and that of the look of the social body on the research. This work aims to favour the comprehension of the context and the knowledge of these judicial references as well as its professionals integration.