[Homicide, schizophrenia and substance abuse: a complex interaction]. / Homicide, schizophrénie et abus de substances : des liaisons dangereuses ?

BACKGROUND AND AIM: The prevalence of homicide perpetrators with a diagnosis of schizophrenia is 6% in Western countries populations. The relationship between schizophrenia and homicide is complex and cannot be reduced to a simple causal link. The aim of this systematic review was to clarify the role of substance abuse in the commission of murder in people suffering from schizophrenia. METHODS: A systematic English-French Medline and EMBASE literature search of cohort studies, case-control studies and transversal studies published between January 2001 and December 2011 was performed, combining the MeSH terms "schizophrenia", "psychotic disorders", "homicide", "violence", "substance use disorder", and the TIAB term "alcohol". Abstract selection was based on the STROBE and PRISMA checklist for observational studies and systematic and meta-analysis studies, respectively. RESULTS: Of the 471 selected studies, eight prospective studies and six systematic reviews and meta-analysis studies met the selection criteria and were included in the final analysis. Homicide committed by a schizophrenic person is associated with socio-demographic (young age, male gender, low socioeconomic status), historical (history of violence against others), contextual (a stressful event in the year prior to the homicide), and clinical risk factors (severe psychotic symptoms, long duration of untreated psychosis, poor adherence to medication). In comparison to the general population, the risk of homicide is increased 8-fold in schizophrenics with a substance abuse disorder (mainly alcohol abuse) and 2-fold in schizophrenics without any comorbidities. A co-diagnosis of substance abuse allows us to divide the violent schizophrenics into "early-starters" and "late-starters" according to the age of onset of their antisocial and violent behavior. The violence of the "early-starters" is unplanned, usually affects an acquaintance and is not necessarily associated with the schizophrenic symptoms. Substance abuse is frequent and plays an important role in the homicide commission. In addition, the risk of reoffending is high. In the "late-starters", the violence is linked to the psychotic symptoms and is directed to a member of the family. The reoffence risk is low and it depends on the pursuit of care or not. CONCLUSION: Defining subgroups of violent schizophrenic patients would avoid stigmatization and would help to prevent the risk of homicide by offering a multidisciplinary care which would take into account any substance abuse.

[Female intimate partner homicide: clinical and criminological issues]. / Singularités cliniques et criminologiques de l'uxoricide: éléments de compréhension du meurtre conjugal.

BACKGROUND: Female intimate partner homicide (FIPH) is a fatal complication of domestic violence. The aim of this study was to describe the socio-demographic, clinical and criminological characteristics of male perpetrators of FIPH and to compare them to the perpetrators of extrafamilial homicide and the perpetrators of intrafamilial homicide other than FIPH. METHODS: Between 1975 and 2005, 32 FIPH were perpetrated in the region of Angers (France), and these were compared to 26 intrafamilial homicides other than FIPH and to 97 extrafamilial homicides perpetrated in the same period, in the same region. The socio-demographic, clinical and criminological data were collected from psychiatric expert reports and medical files. RESULTS: The mean age of the FIPH perpetrators was 37.8years. They were professionally active, in majority as manual workers. They had a psychiatric record (69%), a previous criminal record (31%), and a history of violence against others (47%). Half of these perpetrators also had experienced a traumatic event before the age of 18. Compared to extrafamilial homicide perpetrators, FIPH perpetrators occupied more frequently a manual job and had prior criminal records less frequently. In the majority of cases of FIPH and intrafamilial homicide, the murder occurred in the evening, at the victim's home, and while the perpetrator was intoxicated. FIPH was mostly premeditated and was accompanied four times less frequently by another criminal behaviour compared to extrafamilial homicide. The FIPH perpetrators had more depressive symptoms and suicidal ideations when committing the crime and remained on the crime scene more often than extrafamilial homicide perpetrators who mostly attempted to flee the crime scene. FIPH perpetrators and extra- and intrafamilial homicide perpetrators were found criminally responsible in half of the cases. The socio-demographic, clinical and criminological characteristics of FIPH perpetrators were not statistically different from those of perpetrators of another intrafamilial homicide except that conflict preceded FIPH more frequently. CONCLUSION: Identification of specific features of FIPH could contribute to the early identification of domestic violence at risk of becoming lethal and to the elaboration of preventive strategies.

[French translation and validation of the Scale to assess Unawareness of Mental Disorder (SUMD) in patients with schizophrenics]. / Traduction et validation française de l'échelle d'évaluation de la conscience des troubles mentaux des patients schizophrènes: the Scale to assess Unawareness of Mental Disorder (SUMD).

BACKGROUND: The Scale to assess Unawareness of Mental Disorder (SUMD) is a semi-structured interview based on a dimensional and quantitative approach of insight. Different forms of insight are assessed: global insight into mental illness, insight into symptoms and insight into symptom aetiology (i.e. attribution). The SUMD divides the recognition of mental disorders into two concepts: awareness of, and attribution for mental disorders. Awareness relates to the subject's ability to recognize that the phenomenon in question is present, whereas attribution refers to explanations as to cause or source of these signs or symptoms. Thus, the scale distinguishes between the recognition of a symptom and its explanation. For example, the scale allows the investigator to distinguish between a patient's ability to recognize visual hallucinations as such (false perceptions), from his/her ability to explain their cause (e.g. due to mental illness or not). OBJECTIVE: The aim of this study was to translate the SUMD (version 3.1 revised) and test its convergent validity among 43 French adult inpatients diagnosed with schizophrenia according to DSM-IV-TR criteria. METHODS: Awareness of mental disorder was assessed using the SUMD and the Hamilton Rating Scale for Depression (HAMD) insight item (item 17) respectively, as done in the original English validation study. The SUMD was translated into French then back-translated into English. The back-translation was performed by both English and French native speakers who had no prior knowledge of the scale (the back translation was reviewed by one of the SUMD's authors, Dr Amador, for accuracy). The SUMD manual (v.2/14/99) was also translated into French. Concerning the SUMD directions followed in this study, the first three SUMD items, which are called general items: G1 "Awareness of mental disorder", G2 "Awareness of the achieved effects of medication" and G3 "Awareness of the social consequences of mental disorder" were systematically rated. However, symptom items (four through 20) are not always relevant for every patient. Indeed, for each symptom-item on the scale, it must first be ascertained that the patient has exhibited the particular symptom during the period under investigation. Therefore, for every patient, the symptom checklist was completed prior to filling out the scale, in order to determine which symptom-items were relevant. In addition, symptom attribution items are rated only if the subject received a score between 1 and 3 on the awareness item. Two periods of time of insight were assessed: "current" insight involved rating the highest level of awareness obtained at the time of the interview for the psychopathology present at anytime during the past 7 days. "Past" insight was defined as the present level of awareness during the period of time preceding the current period of investigation. RESULTS: The French translation of the SUMD achieved good convergent validity with the insight item of the Hamilton rating scale for depression. DISCUSSION: The SUMD has proven to be a reliable and valid instrument to assess insight into schizophrenia. The more psychometrically sound rating tools we have at our disposal, many of which have been published in non French journals, the more we will be able to sharpen our assessment of insight into schizophrenia. We are facing an epistemic paradox in which quantification helps description, i.e. we need to have access to different rating tools to measure insight in order to improve our knowledge of the causes, course and treatment of poor insight into mental disorders.

[Attempted suicide by firearms: a retrospective study of 161 cases]. / Conduites suicidaires au moyen d'une arme à feu : étude clinique à partir de 161 cas.

OBJECTIVES: To determine the specific clinical aspects of patients with suicidal behaviour by firearm and investigate the specificities of the suicide method. BACKGROUND: Suicidal behaviour represents a major public health problem throughout the world. Attempted suicide and completed suicide by firearms rates are very high both in Europe and in the United States. Preventive aspects presently preoccupy the physicians and the politicians. However, methods of suicide are understudied in Europe for the benefit of psychopathological and epidemiological aspects of suicide. Only a minority of studies enquire into the clinical aspects according to the method of suicide. Nevertheless, most of the international studies have already demonstrated the efficacy of reducing the accessibility of weapons. METHODS: A retrospective study including suicide attempters by firearm hospitalized in the general hospital of Poitiers between 1992 and 2005. RESULTS: We included 161 patients with self-inflicted gunshot wounds, among which 88% of patients were males. Most of them did not live alone and had children. Some of them had a past history of attempted suicide, some of them using a violent method. The acting out has mostly been committed at home and the firearm used was frequently a hunting gun. Interpersonal conflicts have been mostly reported by the patient with self-inflicted gunshot wounds. The prevalence of alcoholic behaviour and major depression is very important. Personality disorders are overrepresented in the study, notably paranoiac and borderline disorders. DISCUSSION: Our sample is one of the largest compared to the other studies that often did not exceed 30 patients. Some results are contrary to those of populations of suicide attempters, whereas there are some similarities within the completed suicide population. Finally, paranoiac personality disorder is significantly associated with suicidal behaviour by firearm. CONCLUSIONS: Some clinical characteristics have been reported as far as suicide attempters by firearm are concerned. Actually, there are some significant differences between suicide attempters by firearm and other suicide attempters. These results are very important for the perspective of preventing suicidal behaviour. However, it is essential to continue studies on the clinical aspects according to the method used in attempted and completed suicide.

[Transversal study of the psychosocial rehabilitation and the quality of life of 75 schizophrenics under classical neuroleptics or atypical antipsychotic neuroleptics]. / Comparaison de la réadaptation psychosociale et de la qualité de vie des schizophrènes sous neuroleptique classique ou atypique.

The psychosocial rehabilitation and the quality of life of schizophrenics have constituted the main concern in the taking care of these patients since their return into our society. Thus, the emergence of atypical neuroleptics allows us to imagine very interesting and important perspectives concerning these 2 concepts. The adaptation to social and professional life, and the quality of life have been rarely compared according to the antipsychotic therapeutic used (classical neuroleptics or atypical neuroleptics). As many authors underline it, there are still very few studies undertaken concerning this subject because of the diverse methodological and ethical limitations implied. That is why we established a transversal study of the psychosocial adaptation and of the quality of life of 2 stabilized schizophrenic groups. These 2 different groups are: the NC group under classical neuroleptics on the one hand, and the NA group under atypical neuroleptics on the other hand. The main target of this study is to observe the influence of the atypical neuroleptics independently of the other factors. Three evaluation scales were used: the PANSS, the psychosocial skill scale (EAPS) of G. Darcourt and the French translation by P. Martin of the Functional Statut Questionnaire (FSQ), and a collection of the clinical and therapeutic socio-demographic data. Concerning the psychosocial capacities, the total results revealed one significant difference (p-value<0.01) between the two groups. The NA group showed a better psychosocial adaptation (80 +/- 10.89 versus 72 +/- 13.39). Besides 4 key-domains are statistically different, but are always in favour of the NA group; the domains are family life (p=0.01), social life (p=0.0026), presentation (p=0.003) and housing and food (0.029). These observations incite to modify our cure. The analysis of the total score of the FSQ did not reveal a statistically significant difference between both groups but this total score seems high in both groups, conveying an important feeling of satisfaction about the quality of life of our sample of schizophrenics. Literature data also abound along the same lines. Indeed, authors underline that patients clearly prefer to live outside rather than in the hospital. Besides, this study allows to confirm the literature data while studying some domains (such as sexuality) rarely brought to light in studies. As a conclusion, we can say that our sample is representative of a population of schizophrenics, and in spite of the difficulties of methodology inherent to this type of study, we can make a comparison between our 2 groups thanks to the stu-died data. Data in which differences could be found, did not show any influence on the results of scales, thus, they cannot be considered as a confounding factor. The NA group showed a better psychosocial adaptation. Furthermore the FSQ did not reveal a difference between both groups. It seems important to remind that a prospective study, conducted for several months and with several evaluations, is essential to confirm the results obtained on both types of treatment.

[Anticonvulsants in agitation and behavior disorders in demented subjects. Report of 8 cases]. / Thymorégulateurs dans l'agitation et les troubles du comportement chez le sujet dément. A propos de huit cas.

Aggressive agitation, agitation and insomnia with generalized anxiety are commonly observed in Alzheimer's disease. These symptoms remain a principal problem in the clinical management of elderly patients. Neuroleptics are commonly the selected medication for controlling severe aggression, especially the violent out bursts often seen in demented patients. Their use is frequently complicated by side effects, particularly somnolence and confusion. Valpromide and Carbamazepine have been efficacy alternatives and very well tolerated. We report eight cases of demented patients who presented an agitation and aggressive behaviors and had been treated with Valpromide or Carbamazepine. The patients agitation was well controlled at that point and had no apparent side effects. A combination Valpromide or Carbamazepine with neuroleptics permitted a reduction doses of neuroleptics and their side effects. We think that these behaviors disorders belong to the mood disorders. The symptomatology is modified because an alteration of cognitive faculty.

[Pharmacokinetics of neuroleptics]. / Pharmacocinétique des neuroleptiques.

Clinical pharmacokinetics of antipsychotics has been handicapped by the necessity of accurately measuring nanomolar or even subnanomolar concentrations of the drug and its active metabolites in plasma. The knowledge of fundamental pharmacokinetic properties of antipsychotic drugs has been possible with the discovery of analytical methods measuring plasma concentrations such as Radio-Receptor Assay (R.R.A.), or specific assay methods: Gas Liquid Chromatography (G.L.C.), High Performance Liquid Chromatography (H.P.L.C.) or Radioimmuno-assay. Pharmacokinetic factors of commonly used antipsychotic drugs and Depot Antipsychotics are presented. The clinical utility of plasma monitoring of antipsychotic drugs is discussed: can monitoring help to obtain an optimal therapeutic response and reduce the incidence of side effects and tardive dyskinesia?