[A guide to psychiatric prescribing in pregnancy, postpartum and breastfeeding]. / Guide de prescription psychiatrique pendant la grossesse, le postpartum et l'allaitement.

Perinatal psychopharmacology is an emerging specialty that is gradually developing alongside perinatal psychiatry. The management of psychiatric disorders during the perinatal period is a challenge for perinatal practitioners due to the multiple changes occurring during this crucial period. This little-known specialty still suffers from inappropriate considerations on the impact of psychotropic treatments on the mother and the infant during pregnancy and postpartum, which can promote a deficiency in perinatal psychic care. However, the risks associated with insufficient management of mental health are major, impacting both the mental and physical health of the mother and the infant. In this paper, we propose a perinatal psychopharmacology prescription guide based on available scientific evidence and international and national recommendations. We thus propose a decision-making process formalized on simple heuristics in order to help the clinician to prescribe psychotropic drugs during the perinatal period.

Clomipramine in Combination with Fluvoxamine: A Potent Medication Combination for Severe or Refractory Pediatric OCD.

Clomipramine (CMI) and fluvoxamine (FLV) combination therapy has been shown in adults to be a potent medication strategy for obsessive compulsive disorder (OCD). Fung et al. (2021) is the first to show similar benefit in pediatric OCD. The addition of FLV to CMI inhibits the metabolism of clomipramine to desmethylclomipramine (DCMI) and enhances the serotonergic potency of CMI by shifting the routine ratio of CMIDCMI via inhibition of the CYP450 system. The approach to CMI+FLV combination therapy outlined by Fung et al. requires close monitoring. This commentary reviews the benefits and challenges of the approach of Fung et al. (2021) and provides other strategies to take advantage of this combination. Clinicians may consider starting with CMI and adding FLV for patients with refractory OCD to offer a faster pathway to potentially more effective treatment. If a clinician prefers starting with SSRI monotherapy, choosing FLV initially allows for a simpler transition to CMI+FLV in the event that SSRI monotherapy fails.

La thérapie de combinaison de la clomipramine (CMI) et de la fluvoxamine (FLV) s'est révélée chez les adultes une stratégie médicamenteuse puissante pour le trouble obsessionnel-compulsif (TOC). Fung et coll. est le premier à montrer un bénéfice semblable dans le TOC pédiatrique. L'ajout de FLV à la CMI inhibe le métabolisme de la clomipramine pour la desméthylclomipramine (DCMI) et augmente la puissance sérotoninergique de la CMI en changeant le rapport régulier de CMI>DCMI au moyen de l'inhibition du système CYP450. L'approche de la thérapie de combinaison CMI+FLV présentée par Fung et coll. nécessite une surveillance étroite. Le présent commentaire révise les avantages et les difficultés de l'approche de Fung et coll. et offre d'autres stratégies pour profiter de cette combinaison. Les cliniciens peuvent songer à commencer avec la CMI puis à ajouter la FLV pour les patients souffrant d'un TOC réfractaire afin de leur offrir une trajectoire plus rapide vers un traitement possiblement plus efficace. Si un clinicien préfère commencer par une monothérapie d'ISRS, choisir la FLV au départ permet une transition plus simple à CMI+FLV au cas où la monothérapie d'ISRS ne fonctionne pas.

[Vortioxetine: a new antidepressant to treat depressive episodes]. / La vortioxétine : un nouvel antidépresseur pour traiter les épisodes dépressifs caractérisés.

Vortioxetine is a new antidepressant, which mechanism of action is multimodal, targeting the 5-HT1A, 5-HT1B, 5-HT1D, 5-HT3, 5-HT7 receptors and the serotonin transporter (5-HTT). Its efficacy and safety were assessed in fourteen studies including more than 3700 patients with a major depressive episode and treated with vortioxetine. In short-term studies (8 weeks), vortioxetine is more efficacious than placebo in decreasing depressive symptoms as measured by the MADRS total score, response rate (vortioxetine: 53.2% vs placebo: 35.2%) and remission rate (vortioxetine: 29.2% vs placebo: 19.3%). In a long-term study (52 weeks), vortioxetine is also superior to placebo in preventing relapses and recurrences. Moreover, in second line treatment, after failure of a first line selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrin reuptake inhibitor (SNRI), vortioxetine is superior to agomelatine in improving depressive symptoms and achieving response and remission. Furthermore, the positive effects of vortioxetine on improvement of cognitive symptoms of major depressive episodes are particularly well established in several clinical trials. The tolerability profile of vortioxetine is favourable. The recommended daily posology of vortioxetine is 10mg/d. Vortioxetine is a new antidepressant drug with a multimodal mechanism of action, well-documented efficacy and safety profiles.

[Clinical forms of post-traumatic depression]. / Formes cliniques des dépressions post-traumatiques.

INTRODUCTION: As a result of determinants specific to the psychopathological structure of the psychological trauma, psycho-traumatised patients very rarely solicit the health care system directly with a request for treatment centred on their trauma. The medical profession is consulted for non-specific symptoms and complications, which are mainly somatoform, addictions and depressive disorders. After a few epidemiological reminders followed by a discussion concerning contemporary depressive and post-traumatic nosographic features, we define, through our clinical experience collated with the data in the literature, different clinical and etiopathogenic contexts of post-traumatic depression in order to control their therapeutic treatment. CLINICAL FINDINGS: Burnout post-traumatic depression in response to re-experiencing is the most common: it is a reactive psycho-physiological burnout in response to the emotional distress re-experienced during flashbacks, insomnia, a constant feeling of insecurity and the deleterious consequences of this symptomatology in terms of social adaptation. A common genetic predisposition affecting serotoninergic regulation seems to be a vulnerability marker of both depressive and psychotraumatic symptoms. In this case, SSRI will be effective on sadness. In addition, these antidepressants have been widely prescribed for the first-line treatment of depressive and psychotraumatic symptoms. However, this pharmacological class is often insufficient in relieving autonomic hyperactivity such as re-experiencing which are mediated more by noradrenergic hyperactivity. SNRI such as venlafaxine can be used as a first-line treatment. Post-traumatic depression with psychotic features congruent with mood is dominated by a feeling of incurability; the subject blames himself and feels guilty about the traumatic event and its consequences. Symptoms of denial of identity are sometimes observed: confined by an intense depersonalization, the psycho-traumatised subject evokes that he is "no longer himself" and that his mind "is disconnected". Confronted with the psychological emptiness of the traumatic scene, the psycho-traumatised subject remains devoid of thought as if their mind has left him. In addition to antidepressant therapy, an atypical antipsychotic drug must be prescribed to relieve the melancholic symptoms as well as the concomitant psychotraumatic symptoms. Post-traumatic depression masked by peripheral physical injuries is the result of accidents combining psychological and physical impairment. The physical pain resulting from the accident regularly recalls the drama in the same way as traumatic re-experiencing. Depression masked by this somatic suffering is difficult to diagnose, but the repeated somatic complaints at the forefront of the request for treatment, the breakdown of self-esteem as well as the level of subjective strain due to pain and dysesthesia are all indications. The psychotherapy will focus on the symbolic reconstruction of the organs that have been damaged or destroyed, with the aim of healing the extensive narcissistic impairment. Post-concussive depression is diagnosed following a head trauma, however severe. It is sometimes assigned to neurological lesions and at other times recognised as the expression of a purely psychological reaction. Antidepressant therapy, or possibly trial therapy, is often indicated. The terms traumatic grief and post-traumatic grief are often used synonymously in publications: a conceptual opposition must however been recalled. If the traumatic grief is the result of the loss of an object that holds much psychological importance for the individual, the subject has not however been traumatised by this event and is not suffering and will not suffer from re-experiencing. The therapy will include methods used in the psychotherapeutic treatment of grief; antidepressants are often insufficient. Differently, post-traumatic grief takes shape when the loss of another is concomitant with the confrontation with the reality of the death witnessed in a moment of peri-traumatic dissociation. This grief is often observed following the discovery of the body of a close friend or family member who has committed suicide, or when part of a family has been decimated by an accident whilst the survivors watch their close relations die pending the arrival of the emergency services, or when a military comrade is wounded in combat in front of his partner. The mourning process cannot really begin until the flashbacks cease. CONCLUSIONS: Clinical depression or even melancholia, possibly masked by somatic or post-concussive complaints, is often the initial mode of contact with the health care system for the psycho-traumatised subject. The different clinical and etiopathogenic contexts of post-traumatic depression that we have developed in this work use specific therapies which need to be clarified by further research based on this nosography.

[French Society for Biological Psychiatry and Neuropsychopharmacology task force. Formal consensus for the treatment of bipolar disorder: an update (2014)]. / Recommandations Formalisées d'Experts de l'Association Française de Psychiatrie Biologique et Neuropsychopharmacologie sur le dépistage et prise en charge du trouble bipolaire : mise à jour 2014.

As part of a process to improve the quality of care, the French Society for Biological Psychiatry and Neuropsychopharmacology developed in 2010 formal consensus guidelines for the treatment of bipolar disorder. The evolution of therapeutic options available in France for the treatment of bipolar disorder has justified the update of this guideline. The purpose of this work was to provide an updated and ergonomic document to promote its use by clinicians. This update focuses on two of the six thematic previously published (acute treatment and long-term treatment). Aspects of the treatment of bipolar patients sparking debate and questions of clinicians (use of antidepressant, place of the bitherapy, interest of long-acting antipsychotics…) were also covered. Finally, we proposed graded recommendations taking into account specifically the risk-benefit balance of each molecule.

Medicina moderna: rumo à prevenção, à cura, ao bem-estar e à longevidade / Modern medicine: towards prevention, cure, well-being and longevity / La médecine moderne: vers la prévention, la guérison, le bien-être et la longévité / Medicina moderna: en direción a la prevención, a la cura, al bienestar y a la longevidad

A medicina moderna tem realizado muitas coisas nos campos de doenças infecciosas e de emergências para assistir a cura. Na maior parte dos outros campos, ela visa, sobretudo, ao controle, que é outro nome para o tratamento paliativo. A farmacologia, na qual se inclui a psicofarmacologia, é igualmente dirigida ao controle e ao alívio. Está na hora de profissionais da área e pesquisadores voltarem-se decisivamente para a prevenção e para a cura. Ademais, o outro grande desafio da medicina moderna é a longevidade aliada ao bem-estar. Avanços em vacinas contra hipertensão, diabetes, câncer etc. merecem atenção, bem como o papel da meditação, yoga, espiritualidade etc. na prevenção de doenças em vários níveis. Pesquisas sobre longevidade, mudanças no estilo de vida e centenários saudáveis merecem um exame especialmente minucioso na busca dos fatores que contribuem para a longevidade com bem-estar. Um olhar de perto para a medicina complementar e alternativa é necessário para encontrar modelos apropriados que esta possa vir a ter, à parte seus grandes discursos ou sua hostilidade para com o cuidado médico tradicional. A medicina é uma manifestação do Eros humano, e não deve tornar-se instrumento de seu Tanatos. Ela deve realizar seu verdadeiro potencial, de forma que Eros prevaleça, e Tanatos prevaleça apenas finalmente, não prematuramente.

Modern medicine has done much in the fields of infectious diseases and emergencies to aid cure. In most other fields, it is mostly control that it aims for, which is another name for palliation. Pharmacology, psychopharmacology included, is mostly directed towards such control and palliation too. The thrust, both of clinicians and research, must now turn decisively towards prevention and cure. Also, longevity with well-being is modern medicine's other big challenge. Advances in vaccines for hypertension, diabetes, cancers etc, deserve attention; as also, the role of meditation, yoga, spirituality etc in preventing disease at various levels. Studies on longevity, life style changes and healthy centenarians deserve special scrutiny to find what aids longevity with wellbeing. A close look at complementary and alternative medicine is needed to find any suitable models they may have, cutting aside their big talk and/or hostility towards mainstream medical care. Medicine is a manifestation of the human eros, and should not become a means of its thanatos. It must realise its true potential, so that eros prevails, and thanatos prevails only ultimately, not prematurely.

La médecine moderne a fait de grands progrès dans les domaines des maladies infectieuses et des secours médicaux. Par contre, dans la plupart des autres domaines, y compris la pharmacologie et la psychopharmacologie, elle vise surtout les soins palliatifs. Dorénavant, les cliniciens et chercheurs devront se concentrer sur la prévention et la guérison, ainsi que sur le vieillissement en bonne santé. Les progrès dans les domaines des vaccins contre l'hypertension, le diabète, le cancer, etc. méritent une attention particulière ainsi que le rôle de la méditation, due yoga et de la spiritualité dans la prévention des maladies à différents niveaux. Les études sur la longévité, les changements de style de vie et les centenaires en bonne santé sont essentielles pour découvrir les facteurs qui influencent le vieillissement en bonne santé. Les médecines complémentaires et alternatives doivent être examinées en détail pour trouver des modèles appropriés. La médecine est une manifestation de l'éros humain et ne doit pas passer au service du thanatos. Elle doit réaliser son véritable potentiel, de sorte que éros puisse prévaloir et que thanatos ne l'emporte qu'en dernière instance, et non pas de façon prématurée.

La medicina moderna ha dado mucho para ayudar a curar en el campo de las enfermedades infecciosas y de emergencias. En la mayor parte de los otros campos, ella visa, sobretodo, el control, que é otro nombre para el tratamiento paliativo. La farmacología, dentro de la cual se incluye la psicofarmacología, es igualmente dirigida al controle y al alivio. Es tiempo de profesionales del área e investigadores volcarse decisivamente para la prevención y la cura. Además, el otro grande desafío de la medicina moderna es la longevidad aliada al bienestar. Adelantos en vacunas contra la hipertensión, diabetes, cáncer etc. merecen atención, tanto como el papel de la meditación, yoga, espiritualidad etc., en la prevención de enfermedades en varios niveles. Investigaciones sobre longevidad, mudanzas en el estilo de vida y la existencia de centenarios saludables merecen un examen especialmente minucioso en la búsqueda de los factores que contribuyen para la longevidad con bienestar. Una mirada más próxima para la medicina complementaria y alternativa es necesaria para encontrar modelos apropiados que esta pueda llegar a tener, dejando de lado los grandes discursos y/o su hostilidad para con el cuidado médico tradicional. La medicina es una manifestación del Eros humano, y no debe tornar-se instrumento de su Tánatos. Ella debe realizar su verdadero potencial, de forma a que Eros prevalezca y Tánatos prevalezca apenas finalmente, no prematuramente.