[Mental health and public health: an essential bond]. / Santé mentate et sante publique: un lien incontournable.

The Mental Health domain is larger than psychiatry because it implies the establishment of strategies aiming at the promotion of the well-being of the population, the prevention of mental disorders and their treatment and care. Politicians, planners, users and families and society at large have a great expectations and this require health professionals to be able to provide public mental health knowledge. It is necessary to identify those specific public mental health actions to which general practitioners and specialist could contribute. To do so more knowledge in public mental health is needed and more training is necessary.

[Opiate substitution programs: last chance programs or deal for quality of life?]. / Substitution aux oplacés: programme de la dernière chance ou pari sur la qualité de vie?

Substitution treatments have contributed to a successful policy of risk reduction. These treatments should now also include an "existential" dimension. Therefore the development of a life plan for substance abuse patients becomes a main concern. Therapist taking care of substance abuse patients should therefore ask themselves for what purpose prescribe opiate substitution treatments instead of just answering risk reduction issues. This shift requires us to move from a logic of emergency with immediate response to "passive" patients to a logic of crisis asking the patients active participation in their recovery process.

Screening for bipolar disorder among outpatients with substance use disorders.

BACKGROUND: Comorbidity of bipolar disorder and alcohol or substance abuse/dependence is frequent and has marked negative consequences on the course of the illness and treatment compliance. The objective of this study was to compare the validity of two short instruments aimed at screening bipolar disorders among patients treated for substance use disorders. METHODS: The Mood Disorder Questionnaire (MDQ) and the Hypomania Checklist-32 (HCL-32) were tested with reference to the mood section of the Structured Clinical Interview for DSM-IV axis I disorders (SCID) in 152 patients, recruited in two outpatient clinics providing specialized treatment for alcohol and opiate dependence. RESULTS: According to the SCID, 33 patients (21.7%) had a diagnosis within the bipolar spectrum (two bipolar I, 21 bipolar II and 10 bipolar not otherwise specified). The HCL-32 was more sensitive (90.9% vs. 66.7%) and the MDQ more specific (38.7% vs. 77.3%) for the whole sample. The MDQ displayed higher sensitivity and specificity in patients treated for alcohol than for opiate dependence, whereas the HCL-32 was highly sensitive but poorly specific in both samples. Both instruments had a positive predictive value under 50%. CONCLUSIONS: Caution is needed when using the MDQ and HCL-32 in patients treated for substance use disorders.

[Brief-DISCERN, a possible way to improve patient's search on the health-related web]. / Version brève du DISCERN, une voie d'amélioration de la recherche d'information médicale sur le net.

Internet is increasingly used as a source of information on health issues and is probably a major source of patients' empowerment. This process is however limited by the frequently poor quality of web-based health information designed for consumers. A better diffusion of information about criteria defining the quality of the content of websites, and about useful methods designed for searching such needed information, could be particularly useful to patients and their relatives. A brief, six-items DISCERN version, characterized by a high specificity for detecting websites with good or very good content quality was recently developed. This tool could facilitate the identification of high-quality information on the web by patients and may improve the empowerment process initiated by the development of the health-related web.

Hunger and negative alliesthesia to aspartame and sucrose in patients treated with antipsychotic drugs and controls.

The present study explores sweet stimuli effects on hunger and negative alliesthesia in patients treated with antipsychotic drugs and controls. Those phenomena were examined in relation to previous weight gain, eating and weight-related cognitions and type of sweet stimuli: aspartame or sucrose. Alliesthesia is delayed in participants who gained weight regardless of cross group differences. A similar reduction of hunger was observed after the intake of two kinds of sweet stimuli (aspartame or sucrose) whereas alliesthesia measures were not affected. Whereas atypical antipsychotic drug-induced weight gain is linked to delayed satiety, the phenomenon is similar in magnitude in non-psychiatric controls who gained weight.

Prevalence of pathological gambling in Switzerland after the opening of casinos and the introduction of new preventive legislation.

OBJECTIVE: This survey aimed to evaluate the prevalence of pathological gambling (PG) in the Swiss population in 2005 and the link between PG and alcohol abuse. This replication study made it possible to compare the prevalence rates of PG measured before and after the introduction of casinos and new preventive legislation. METHOD: A total of 2803 telephone interviews were completed using standardized assessment instruments for identifying gamblers (South Oaks Gambling Screen) and alcohol abuse (CAGE). RESULTS: The past-year prevalence rates were 0.8% for problem and 0.5% for PG. No relationship was found between alcohol abuse and gambling behaviour. The past-year prevalence of disordered gambling did not change between 1998 and 2005. CONCLUSION: Despite widespread openings of casinos in Switzerland since 2002, the prevalence estimates of past-year disordered gambling have remained stable. The discussion focuses on different factors (social measures, legal obligations and social adaptational capacities) that may account for the stabilization of prevalence estimates.

[Addiction]. / Dépendances.

This year review emphasizes four aspects coming from addiction psychiatry: 1. Initiation and maintenance of cannabis use. 2. Methadone and heart toxicity. 3. Suicidal behaviour in gambling. 4. Treatment of addictive disorders via internet: present and future perspectives.

[Exposure to addictogenic substances, conditioned response and treatment of the exposure with response prevention]. / Exposition aux substances addictogènes, réponses conditionnées et traitements d'exposition avec prévention de la réponse.

AIM OF THE STUDY: Exposure to drugs or related cues is associated with psycho-physiological reactivity. These responses are conditioned during periods of active consumption. Exposure with response prevention (EPR) is a treatment established for anxiety disorder and aims to reduce anxiety by an extinction of previously conditioned responses. The conditioning recognized in additive processes has led to research into EPR's therapeutic potential for treating addiction. This paper is a review of the main studies on reactivity to cues, and EPR, particularly with respect to addiction to alcohol, opiates, cocaine and tobacco. METHODOLOGY: This review is based on information from the Medline database, dealing with cue reactivity, attentional bias during exposure to cues and exposure treatment for addiction in general and, in particular, for each of the aforementioned substances. CONCLUSION: Exposure to drug-related cues is clearly associated with psycho-physiological reactivity and with attentional bias. Those phenomena are associated with craving and more difficulty in maintaining abstinence. The subject's attention is thus held by a large number of drug-related environmental stimuli. These observations are linked with conditioning phenomena and suggest the possibility of treatment by EPR conditioning extinction procedures. EPR has been most widely studied for abuse and alcohol addiction. Case reports give favourable outcomes. Results from controlled studies are less clear. Studies on patients addicted to cocaine or heroine are still limited and not conclusive. Different controlled studies on EPR for nicotine addiction have not produced conclusions in favour of this treatment. Generally, the EPR procedures used vary among studies. Studies focussing particularly on the evolution of physiological responses in a laboratory setting after EPR have demonstrated reduced autonomic nervous system activity. These results do not consistently lead to a reduction in consumption behaviour and in craving when the patient is in his/her natural environment. The difficulties encountered in the development of EPR treatments, despite the appealing reasoning behind them, could be explained by the tendency of conditional stimuli to re-occur spontaneously. However, it is clear from the studies reviewed that by selecting EPR conditions more rigorously, more efficient procedures might be developed at least for some patients. It seems that the place and the conditions of exposure are factors essential to the success of these therapeutic procedures. Exposure in vivo is better than exposure in imagination. Prolonged exposure over an hour is more effective than exposure lasting 10 minutes. Exposures in close succession are also associated with a better extinction of conditioned responses. The moment that the stimulus occurs, how appropriate it is and its proximity with potential reinforcement are also essential elements for the conditioning procedures. Improving the conditions in which EPR is applied could then enhance the therapeutic potential of this approach.

[Addiction]. / Dépendances.

This year review emphasizes three aspects coming from addiction psychiatry: 1. Psychosis and cannabis: a motivational approach. 2. Connection between addiction services and psychiatric wards. 3. Use of antiepileptic agents in addiction medicine.

Dietary underreporting in women with schizophrenia requiring dietary intervention: a case control study.

OBJECTIVE: The purpose of this study was to evaluate diet underreporting of women treated for schizophrenia undergoing dietary treatment and to compare it with nonpsychiatric women. METHODS: The study included 23 women (13 with schizophrenia) who had actively sought treatment for weight loss. All subjects were smokers with low activity level. A 24-hour diet recall using standardized food models was used to collect energy intake (EI) reporting . In order to identify participants who reported low EI, we used the Goldberg cut-off methodology. RESULTS: The percentage of underreporters was higher in patients with schizophrenia [77%, 95% confidence interval (46-95%)] than in controls [50%, 95% confidence interval (19-81%)]. CONCLUSIONS: Diet underreporting is a frequent phenomenon in women with schizophrenia requiring dietary intervention.

Persistence of anorectic cognitions following a moderate calorie restricted diet.

Cognitive attitudes and beliefs towards food and body shape are repeatedly reported as a maintaining factor of obesity. In order to assess evolution of those cognitions following a dietary treatment 18 overweight and obese females undergoing a dietary treatment were assessed using the Mizes Anorectic Cognitions questionnaire (revised form) before and after a 3-month moderate calorie restricted diet. Binge eating status was also assessed in pre-treatment. The main finding of the present study is persistence of anorectic cognitions following a moderate calorie restricted diet treatment, and furthermore a more pejorative evolution of those cognitions in patients with binge symptomatology.

[Confounding effects of medical illness in the treatment of anxiety]. / Angststörungen im Rahmen körperlicher Erkrankungen.

Cognitive-behavior therapy combined with medication has proven to be an effective treatment combination for individuals suffering from anxiety disorders. Certain cases may prove difficult however, particularly when an individual is recovering in the wake of a serious medical illness in which many of the symptoms of the illness overlap with the symptoms of anxiety. This article reviews some of the complicating factors that may occur with such cases as well as techniques for helping individuals differentiate between symptoms that denote a recurrence of the medical illness and those that involve anxiety, especially panic disorder. Two case vignettes are included which portray the manner in which cognitive-behavioral techniques can be used to help individuals reduce their anxiety and panic and also effectively differentiate symptoms of a reoccurring medical illness.

Opioid antagonist detoxification under anaesthesia versus traditional clonidine detoxification combined with an additional week of psychosocial support: a randomised clinical trial.

BACKGROUND: While detoxification under anaesthesia accelerates the detoxification procedure, there is a lack of randomised clinical trials evaluating its effectiveness compared to traditional detoxification procedures, and a lack of data on long-term abstinence. METHODS: Prospective randomised clinical trial. Analysis by intention to treat and per protocol. SETTING: Specialised substance abuse unit in a psychiatric teaching hospital and an intensive care unit of a general hospital. PARTICIPANTS: Seventy patients with opiate mono-dependence requesting detoxification: 36 randomised to RODA (treatment as allocated received by 26) and 34 randomised to classical clonidine detoxification (treatment as allocated received by 21). MAIN OUTCOME MEASURES: Successful detoxification, safety and self-reported abstinence at 3, 6 and 12 months after detoxification. RESULTS: Socio-demographics were similar in both groups at baseline. No complications were reported during or after anaesthesia. According to the intention to treat analysis, 28/36 (78%) RODA patients and 21/34 (62%) of the clonidine group successfully completed the detoxification process (p=0.14). In the intention to treat analysis, 30% of RODA patients were abstinent after 3 months compared to 14% in the clonidine group (p=0.11). No difference was found at 6 and 12 months (both groups showed less than 5% abstinence after 12 months). The per-protocol analysis showed similar results with no statistical differences either for ASI mean scores or for the SF36 questionnaire. CONCLUSION: Although the detoxification success rate and abstinence after 3 months were slightly better for the RODA procedure compared to clonidine treatment, these differences were not statistically significant and disappeared completely after 6 and 12 months.

Prescribing practices in German and Swiss psychiatric university and in non-university hospitals: national differences.

OBJECTIVE: There are great variations between hospitals in the way drugs are prescribed, and these variations may be due to multiple factors such as local prescribing traditions, pharmacoeconomic considerations, drug availability, regional differences of population, disease prevalence etc. Available studies on prescribing habits, apart from studies performed in a unique center, have until now been mainly restricted to single countries or regions and the comparisons across countries or regions have often been limited by the use of diverse methodologies and definitions. The aim of the present study was to compare drug prescriptions between German and Swiss psychiatric services with regard to their preference of newer psychotropics. MATERIAL AND METHODS: Five psychiatric hospitals, associated to the AMSP project, were chosen to represent Swiss and German clinics, university and non-university settings. Data were available from one index day on 572 patients and 1,745 prescriptions. The comparisons were adjusted for age and gender. RESULTS: There was a significant difference (p < 0.001) with regard to the prescription of newer antidepressants (NAD), Swiss clinicians giving proportionally more (65.2%) than the German psychiatrists (48.3%). No significant difference was, on the other hand, found as to the proportion of atypical antipsychotics, the lack of difference being due to the higher proportion of clozapine among the atypical antipsychotics in Germany. CONCLUSION: There seems, therefore, to be a higher propensity for Swiss hospital psychiatrists to prescribe newer antidepressants. This seems to be due to national or regional prescribing traditions. Further studies are needed to investigate the economical influences on antidepressant prescribing in Swiss and German clinics.

[St. John's Wort, corticosteroids, cocaine, alcohol ... and a first manic episode]. / Millepertuis, corticoïdes, cocaïne, alcool ... et un premier épisode maniaque. Femme, 36 ans, artiste.

We describe an alcohol and cocaine abusing female patient who developed a first manic episode in the context of a corticosteroid prescription. The differential diagnoses are discussed on the basis of the available literature on secondary manias.

[Pharmacotherapy of generalized anxiety disorder: state of the art]. / Pharmacothérapie de l'anxiété généralisée: etat actuel.

A large percentage of patients in primary care suffer from Generalized Anxiety Disorder (GAD). A task force of the Swiss GAD Society has reviewed the scientific literature and has developed treatment recommendations. Basic treatment, adjunctive treatment and therapy of specific problems like insomnia and comorbidities are differentiated. Newer antidepressants are recommended as basic treatment, especially venlafaxine and paroxetine, which are licensed for that indication.

[The place of SSRIs in the treatment of schizophrenia]. / La place des SSRIs dans le traitement de la schizophrénie.

One of the major clinical challenges in the treatment of schizophrenia is the treatment of negative symptoms, which are particularly associated with poor long-term outcome. Clozapine is often effective in the treatment of a great proportion of previously neuroleptic refractory patients. Its utility is, however, limited by the high risk of agranulocytosis. Depressive and negative symptoms such as anhedonia, lack of interest, motor retardation and social withdrawal show some overlap. Because of the similarities between negative and depressive symptoms in schizophrenic patients and the success of antidepressants in the treatment of depressive symptoms in schizophrenic disorders, the augmentation of antipsychotics by SSRI antidepressants has repeatedly been suggested as a promising strategy in schizophrenic patients with negative symptoms. Besides several open studies, five controlled trials of the effect of SSRI addition to current treatment with classic neuroleptic agents, have been published. They reveal some evidence for increased efficacy of conventional antipsychotics after addition of SSRIs. Neither placebo-controlled studies nor open trials have revealed additional efficacy of antipsychotic/SSRI combination on the positive symptoms or depressive symptoms in comparison with antipsychotic treatment alone, but the patients in the reviewed studies had been generally selected for their prominent negative symptoms, their neuroleptic resistance or their chronicity. There seems to be, however, clear evidence supporting the efficacy of SSRI augmentation of conventional antipsychotics in the treatment of negative schizophrenic symptoms. The data on clozapine reveal no additional therapeutic potential if pharmacokinetic interactions are controlled for. Path analysis allows an estimate whether, and to which degree, the effect of a treatment on a symptom is mediated by effects on other symptoms. Path analysis has, though, not been reported for antipsychotic/SSRI combinations until now. Nevertheless, SSRI augmentation in the treatment of schizophrenia seems to act directly, has only limited efficacy in treating depressive symptoms, and does not seem to have an effect on positive symptoms or EPS. Furthermore, there is no evidence for an increased efficacy due to increased plasma levels of typical neuroleptics. A paradox exists, as both the serotonin-agonists and antagonists produce similar effects in combination with dopamine-blocking drugs. As reasons for this paradox have been proposed: the complexity of multiple 5HT receptor types, their differing distribution, their different serotonin-affinity and their partly divergent postsynaptic effects. In conclusion, some inferences can be made despite the limitations of the data. There is some evidence for increased efficacy of conventional antipsychotics in negative symptoms after addition of SSRIs, and, whereas path analyses are still lacking, this seems to be a direct effect. SSRIs may be an alternative to clozapine, especially in patients for whom there are contraindications for a clozapine treatment. As yet, there is no convincing rationalization for the paradox that both serotonergic and antiserotonergic substances, e.g. atypical antipsychotics, may improve negative symptoms.