[Measuring the emergency psychiatric units activity: An experimental application of the Delphi Method]. / Évaluation de l'activité dans les unités d'urgence psychiatrique : une application de la méthode Delphi.

Psychiatric emergency units (UUP) are nowadays important gateways to healthcare. Whether integrated into general emergency departments or not, these units have very heterogeneous resources and organisations which are not always in line with a populations' needs. The increasing activity of emergency departments in recent years and the recurrent psychiatric bed shortages have shed light upon the weaknesses of this key link in the mental healthcare process. The Seine-Saint-Denis is a department of France located in the Grand Paris metropolis in the Île-de-France region. Ranked third in terms of population size in France, it is marked by social precariousness. With regard to mental health, it has one of the lowest rates of psychiatric beds per capita in France. A great deal of thought has been ongoing for five years on how best to upgrade the offer of unscheduled psychiatric care, particularly the management of emergencies. The growing imbalance between demand and supply depending on living areas urges a rapid equalization of resources. This operation requires an accurate activity characterization, allowing more effective organizations and adequate resource allocation. We sought to characterize the activity of psychiatric emergencies by selecting quantitative and qualitative indicators by means of a consensus method, the Delphi Method, which consists of iterative questioning of an expert group. We first submitted 36 potential criteria to twenty-five experts. Twenty obtained a weak to a strong consensus. Seventeen were then selected as potentially useful for activity characterization. In a second time, we tested the consensus on selected indicators by interviewing a panel of 19 experts. A strong consensus was found on four criteria: "Number of visits for psychiatric advice>2000/year", "Number of emergency room visits>40,000/year", "Density of adult hospital beds<150 per 100,000 inhabitants", "Passage rate for homeless patients and/or outside the sector>10%". Using these criteria in the classification of UUPs would test their validity and provide a potentially helpful tool for improving organizations and resource allocation.

[The intestinal microbiota: A new player in depression?] / Le microbiote intestinal : un nouvel acteur de la dépression ?

Depression is the leading cause of disability in the world according to the World Health Organization. The effectiveness of the available antidepressant therapies is limited. Data from the literature suggest that some subtypes of depression may be associated with chronic low grade inflammation. The uncovering of the role of intestinal microbiota in the development of the immune system and its bidirectional communication with the brain have led to growing interest on reciprocal interactions between inflammation, microbiota and depression. Our purpose is to review the state of knowledge on these interactions. METHODS: We carried out a literature search on Pubmed, Go pubmed, psyC info, Elsevier, Embase until August 13, 2016 using the keywords "depression", "microbiota" and "inflammation". RESULTS: Dysbiosis reported in patients suffering from depression seems to contribute to low grade systemic inflammation which in turn feeds back depression. The hypothetical mechanisms behind these interactions are multiple: leaky gut, hyperreactivity of the corticotropic axis, disturbed neurotransmission. Abnormal microbial exposure during childhood and perinatal stress are reported to influence both the maturation of the immune system and the microbiota hence contributing to the ethiopathogeny of depression. There is no evidence in the literature to support a role for diet. CONCLUSION: The evidence supporting a causal relationship between dysbiosis and depression through low grade inflammation is limited and precludes us from drawing firm conclusions. Further studies are needed to improve our knowledge.

[Follow-up interventions after suicide attempt. What tools, what effects and how to assess them?] / La veille sanitaire dans la prise en charge des suicidants. Quels outils, quels effets, comment les évaluer ?

After attempting suicide, 60 to 70% of patients are discharged from emergency departments and referred to outpatient treatment which entails psychosocial strategies, pharmacological strategies or a combination. The main objective of outpatient care consists in preventing recurrent suicidal behavior. Yet suicide attempters have been found to be very difficult to engage in treatment. Between 11% and 50% of attempters refuse outpatient treatment or drop out of outpatient therapy very quickly. In order to address this extremely serious issue, for the past 20 years monitoring or follow up interventions has been presented as a promising approach. Follow-up intervention is defined as a service that aims at both increased access to and engagement in care as well as to prevent suicide and related behaviors. This approach consists in "stay in contact" or "connectedness" protocols using phone calls or tele-assistance, sending letters, email or mobile phone messages and medical visits or nursing at home. From one study to another these tools have been used separately, associated to one another or reinforced by motivational interviewing or brief psychotherapy. To our knowledge, since 1993 16 controlled and randomized controlled studies assessed the effectiveness of diverse follow-up. Four studies assessing telephone follow up reported a significant decrease in suicide reattempt while one study evaluating a sending letters strategy reported positive results. Among five studies assessing engagement in healthcare, only two (one using phone follow up and the other sending letters reported significantly positive results. The refusal rate of monitoring strategies has not exceeded 11% attesting to the high applicability of these methods. Despite several positive results, we cannot draw firm conclusions on replicability of these results. This is largely due to methodological issues: lack of standardization of interventions, lack of consensus on definition of the main measured variables (recurrent suicidal behavior, engagement in healthcare) but also to the confounding effect of other care approaches frequently associated with follow up intervention services. Further studies and research should be conducted as follow-up intervention services are increasingly used in suicide prevention because of their good acceptability and usefulness.

[The interest of maintenance electroconvulsive therapy in mood disorders]. / Intérêt de l'électroconvulsivothérapie de maintenance dans les troubles de l'humeur.

Maintenance electroconvulsive therapy (M-ECT) is a treatment indicated for the treatment and prevention of recurrent depression in patients who either do not respond or do not tolerate psychotropic medication. We evaluated, retrospectively, clinical response to a 6-month minimum course of M-ECT in 25 patients with a diagnosis of bipolar disorder or schizoaffective disorder according to DSM IV-TR criterion. Our study demonstrated a significant improvement of Global Assessment of functioning (GAF) scores after a six month minimum course of M-ECT (34.8 ± 12.6 vs 65.6 ± 10.8; P<0.05) as well as Brief Psychiatric Rating Scale scores (BPRS): 79.3 ± 12.4 vs 43.4 ± 10.2; P<0.05). We observed a slight increase of Mini Mental State Examination (MMSE) scores after M-ECT; nonetheless, it was not statistically significant (24.2 ± 2.4 vs 26.2 ± 2.4; P=0.2). Regarding the mean duration of hospitalizations, we showed a statistically significant decrease in the median number of days of hospitalization (72 [59-93.50] days before M-ECT vs 43 [25-76] days since the first M-ECT; P=0.017). Maintenance ECT allowed a significant improvement in psychiatric symptoms and global functioning of the patients included in this study, as well as a decrease in the number of days of hospitalization. However, our pattern is limited because of its small size; so, further prospective studies in this field, including larger population is highly recommended.

[Case report: electroconvulsive therapy in a 33-year-old man with hysterical quadriplegia]. / Traitement par électroconvulsivothérapie d'une tétraplégie par conversion hystérique : à propos d'un cas.

UNLABELLED: Conversion disorder refers to the occurrence of neurological-like symptoms or deficits that are neither intentionally produced nor simulated. While it cannot be explained by an organic disease, it is often related to psychological events. CASE REPORT: We report the case of a 33-year-old patient with a fluctuating hysterical tetraplegia, which had started three years earlier. After the failure or the exhaustion of several biological (psychotropic medication, transcranial magnetic stimulation) and psychotherapeutic strategies, treatment with electroconvulsive therapy (ECT) was conducted. A total of thirty-five ECT sessions were performed. Whereas the patient's clinical state was initially characterized by a complete quadriplegia and an uncontrollable muscular hypertonia, we noted that the ECT sessions were associated with a slow, though remarkable, progress. At first, the sessions were followed by moments of altered consciousness during which the patient would be relaxed and could make simple movements. Secondarily, not only was our patient able to consciously move his four limbs, but he was also able to walk. However, those improvements remained partial and fluctuating, sometimes allowing the symptom to return temporarily secondary to frustrations or annoyances. Finally, our patient relapsed. Nevertheless, his clinical state presently remains better than that in which we first knew him. DISCUSSION: The treatment of conversion disorders has been the subject of few studies and predominantly remains symptomatic. Its main goals are: to lessen secondary gains impact by adopting a neutral behaviour towards the symptom and by encouraging physical rehabilitation; to lower the symptom by allowing the patient to understand the normal functioning of the diseased organ, and; to help the patient to deal with stressful situations. There is no evidence that hypnosis is superior to medical and other psychotherapeutic approaches. Pharmacological treatments may be helpful in the case of anxiety, impulsivity or depression, albeit delivered with caution. According to some case reports, transcranial magnetic stimulation has also been associated with clinical remission. Although the use of ECT in motor conversion disorders constitutes an uncommon procedure, and even if no clinical trial has evaluated its impact on such a pathological condition, several case reports suggest that electroconvulsive therapy can be efficient in the treatment of motor conversion disorders. This efficacy may rely on several hypotheses. ECT could induce neural modifications, and participate in the suppression of an active inhibition, which is responsible for hysterical symptoms. Indeed, conversion cerebral disorder correlates can be explored with the help of functional neuro-imaging techniques, which could therefore also identify ECT neural effects. ECT adverse effects on memory could lead to a new relationship with the symptom, and modulate the psychological conflict which has participated in its emergence. Narcoanalysis, ECT sessions could have an impact on consciousness by means of some dissolution and reorganization phenomenon. It could therefore participate in the ending of an emotional block, the psychic integration of traumatic events and the recovery of a voluntary motor control. Finally, ECT could be efficient thanks to its antidepressant properties, especially its ability to stimulate triaminergic, and particularly dopaminergic transmission. This case report reminds us how difficult it can be to deal with severe conversion disorders, and to navigate between two reefs, which are abstention, and therapeutic escalation.

Correlations of cerebello-thalamo-prefrontal structure and neurological soft signs in patients with first-episode psychosis.

OBJECTIVE: This study aimed at determining brain structural imaging correlates of neurological soft signs (NSS) in patients suffering from a first-episode psychosis. METHOD: Fifty-two patients with a DSMIV diagnosis of first-episode psychosis (schizophrenia or schizophrenia spectrum disorder) were consecutively included. Subjects were assessed using a standardized neurological examination for motor coordination, motor integration and sensory integration. Anatomical magnetic resonance images (MRI) were analysed in the whole brain using optimized voxel-based morphometry. RESULTS: Neurological soft signs (NSS) total score (P-corrected = 0.013) and motor integration subscore (P-corrected = 0.035) were found to negatively correlate with grey matter structure of the dorsolateral prefrontal cortices. Motor coordination subscore was positively correlated with grey matter structure of the thalami (P-corrected = 0.002) and negatively with white matter structure of the cerebellum (P-corrected = 0.034). The addition of age and gender as covariate yielded similar results. We did not find any correlation between neither sensory integration subscore and grey matter structure nor NSS total score, motor integration subscore and voxel-based morphometry (VBM) white matter structure. CONCLUSION: Structural alteration in the cerebello-thalamo-prefrontal network is associated with neurological soft signs in schizophrenia, a candidate network for 'cognitive dysmetria'.

Association of Disrupted in Schizophrenia 1 (DISC1) missense variants with ultra-resistant schizophrenia.

Three common missense variants of the Disrupted in Schizophrenia 1 (DISC1) gene, rs3738401 (Q264R), rs6675281 (L607F) and rs821616 (S704C), have been variably associated with the risk of schizophrenia. In a case-control study, we examine whether these gene variants are associated with schizophrenia and ultra-resistant schizophrenia (URS) in a population of French Caucasian patients. The URS phenotype is characterized according to stringent criteria as patients who experience no clinical, social and/or occupational remission in spite of treatment with clozapine and at least two periods of treatment with distinct conventional or atypical antipsychotic drugs. We find a significant association between DISC1 missense variants and URS. The association with rs3738401 remains significant after appropriate correction for multiple testing. These results suggest that the DISC1 rs3738401 missense variant is statistically linked with ultra-resistance to antipsychotic treatment.

[Validation of the French version of the expanded Brief Psychiatric Rating Scale with anchor BPRS-E(A)]. / Validation de la version française de l'échelle abrégée d'appréciation psychiatrique étendue avec ancrage, BPRS-E(A).

INTRODUCTION: The Brief Psychiatric Rating Scale was initially developed as a rapid method to assess symptom change in psychiatric inpatients of various diagnoses. The original version was expanded to an 18-item version and thereafter to a 24-item version to increase sensitivity to a broader range of psychotic and affective symptoms. The latest version of the expanded 24- item BPRS provides probe questions and detailed anchor points for the ratings for each item. LITERATURE FINDINGS: Studies have shown the expanded and anchored 24-item BPRS to be a sensitive and effective measure of psychiatric symptoms with good interrater reliability that can be maintained over time. To our knowledge, there are eight published papers including factor analyses of the BPRS-E(A). While many similarities are evident between these studies, inconsistencies are apparent that may have been due to sample size, characteristics and / or methodological differences in the factor analysis computation. Among these studies, six provided a four-factor solution. There was no French version of this scale available. METHODS: After its translation into French and back translation, we investigated the validity of the French BPRS-E(A) version. We carried out a component analysis on the data of 111 participants of various diagnoses, mostly hospitalised for a first psychotic episode, yielding to a three-factor solution (positive symptoms--disorganisation; depression-anxiety and negative symptoms). RESULTS: A good internal consistency and interrater reliability were found. These results confirm the psychometric value of the BPRS-E(A) in its French version. We compared those findings to earlier reports; similarities and differences are discussed.

[Schizophrenia, a neurodevelopmental illness]. / Les schizophrénies, maladies du neurodéveloppement.

SUMMARY: Developmental anomalies have been identified as risk factors for a future schizophrenic illness: low weight at birth, congenital malformations, delayed motor and social learning. Cognitive deficits and neurological soft signs belong to the indices of the schizophrenic spectrum. Neuroimaging has visualized various structural abnormalities present from the very beginning of schizophrenia. These structural changes may represent an exacerbation of normal neurodevelopmental processes. Moreover, vulnerability genes for schizophrenia are involved at different stages of neurodevelopment: the best studied associations are dysfunctional variants of DISC-1 and neuroregulin-1 genes, the role of other genes (dysbindin, BDNF, reelin...) remaining more widely debated. Lastly, the observation of structural chromosomal anomalies in 15% of patients suffering from schizophrenia (versus 5% of controls), more frequent in early onset schizophrenia (32% of cases) suggests a neurodevelopmental cause. Such a dynamic understanding of schizophrenia is consistent with what we know about cerebral plasticity along the life span. This does not preclude the search for cues of degenerative mechanisms. The issue now is a better characterization of the vulnerable phenotype for screening procedures to be implemented prior to disease onset.

New evidences of gene and environment interactions affecting prenatal neurodevelopment in schizophrenia-spectrum disorders: a family dermatoglyphic study.

BACKGROUND: Several studies have reported an increase of dermatoglyphic anomalies in schizophrenic patients compared to controls. However, the recognition of specific dermatoglyphic variables related to this disorder and their genetic and/or environmental component are still controversial. METHOD: We conducted a dermatoglyphic analysis in a new sample of 617 individuals: 205 patients with schizophrenia-spectrum disorders, 224 healthy first degree relatives and 188 healthy controls. The dermatoglyphic variables studied were: the total a-b ridge count (TABRC) and its fluctuating asymmetry (FAABRC), and the presence of ridge dissociations (RD) and abnormal palmar flexion creases (APFC). RESULTS: Patients, relatives and controls did not differ in TABRC. However, within the patients group those with a low birth weight or absence of psychiatric family history showed lower TABRC than the others. The frequency of ectodermic derivates abnormalities (RD and/or APFC) appeared to be higher in patients and relatives than in controls, while first degree relatives did not differ from patients. Males showed an increased rate of ectodermic derivates abnormalities compared to females in all groups and male patients also presented higher FAABRC than female patients. CONCLUSIONS: Our results suggest a different relative weight of genetic and environmental factors on each dermatoglyphic variable analyzed: i) TABRC may be a sensitive marker to environmental factors in schizophrenia, ii) ectodermal derivates abnormalities appear to be influenced by genetic risk factors, which could be involved both in the disrupted development of ectodermic derivates like dermatoglyphics and central nervous system and in the vulnerability for schizophrenia.