[A preliminary validation of a new French instrument to assess quality of life for caregivers of patients suffering from schizophrenia]. / Validation française d'un questionnaire de qualité de vie des aidants naturels de patients schizophrènes.

INTRODUCTION: Since psychiatric institutions began discharging mentally ill patients into the community, family of patients suffering from schizophrenia are more and more involved in the therapeutic process. The adverse consequences of having a patient suffering from schizophrenia at home are called "burden of care" and have been studied by numerous authors. We were interested in the quality of life of caregivers and its evaluation. This concept represents a more complex, multidimensional approach in which many variables are taken into account. We propose the development of a French self-administered instrument of quality of life for caregivers of individuals with schizophrenia, the caregiver schizophrenia quality of life questionnaire (S-CGQoL). METHODS: Data were collected through the departments of six psychiatric hospitals in France (n=246). The item reduction and validation processes were based on both item response theory and classical test theory. The study of external validity used the generic Short Form 36 questionnaire. Scores of isolated dimensions were also confronted with caregivers' and patients' demographic data and with patients' clinical data. RESULTS: The S-CGQoL contains 25 items describing seven dimensions (psychological and physical well-being; burden and daily routine; relationships with spouse; relationships with psychiatric team; relationships with family; relationships with friends; and material burden). The seven-factor structure accounted for 74.4% of the total variance. Internal consistency was satisfactory; Cronbach's alpha coefficients ranged from 0.79 to 0.92 in the whole sample. The scalability was satisfactory, with INFIT statistics within an acceptable range. In addition, the results confirmed the absence of DIF and supported the invariance of the item calibrations. Acceptability was good. The study of external validity found significant correlation between S-CGQoL index and all SF-36 dimension scores. Certain dimensions of the S-CGQoL are associated with caregivers' characteristics (age, sex, number of children, living situation, and employment status). Moreover, some domains of caregiver's quality of life are dependant on subtype of schizophrenia (paranoid) and symptomatology (positive factor and general psychopathology). We did not find any correlation with negative factor. DISCUSSION: The content of the S-CGQoL encompasses experiences of great importance to patients and is substantially different from other generic quality of life or burden instruments. In our questionnaire, the focus on the different aspect of the social life permits a precise analytical description of the social dimension that is not assessed as much in other questionnaires. LIMITATIONS: The psychometric properties need to be studied in a wider population. Some parameters of internal validity are missing, such as reproductibility (test-retest reliability) and sensibility to change. The external validity needs to study relationships between S-CGQoL and burden. CONCLUSION: The S-CGQoL is the first self-administered quality of life questionnaire for caregivers of patients suffering from schizophrenia. It presents satisfactory psychometric properties, which can be completed in five minutes and, therefore, fulfils the goal of brevity sought in research and clinical practice.

The Schizophrenia Caregiver Quality of Life questionnaire (S-CGQoL): development and validation of an instrument to measure quality of life of caregivers of individuals with schizophrenia.

OBJECTIVE: This study aims to validate a self-administered, multidimensional QoL instrument based on the point of view of caregivers of individuals with schizophrenia. METHODS: Data were collected through the departments of six psychiatric hospitals in France (n=246). The item reduction and validation processes were based on both item response theory and classical test theory. RESULTS: The S-CGQoL contains 25 items describing seven dimensions (Psychological and Physical Well-Being; Psychological Burden and Daily Life; Relationships with Spouse; Relationships with Psychiatric Team; Relationships with Family; Relationships with Friends; and Material Burden). The seven-factor structure accounted for 74.4% of the total variance. Internal consistency was satisfactory; Cronbach's alpha coefficients ranged from 0.79 to 0.92 in the whole sample. The scalability was satisfactory, with INFIT statistics falling within an acceptable range. In addition, the results confirmed the absence of DIF and supported the invariance of the item calibrations. CONCLUSION: The S-CGQoL is a self-administered QoL instrument that presents satisfactory psychometric properties and can be completed in 5 min, thereby fulfilling the goal of brevity sought in research and clinical practice.

[Development and validation of a self rating quality of life scale: the S-QoL]. / Développement et validation d'un instrument d'auto-évaluation de la qualité de vie des patients souffrant de schizophrénie: la S-QoL.

INTRODUCTION: Evaluation of subjective quality of life in schizophrenia is a recent phenomenon. Few subjective quality of life questionnaires are available and validated, especially in French. Most of the available scales are hetero questionnaires based on experts' opinion. We describe the development and the validation of a new self-rating questionnaire of quality of life for schizophrenic patients, the S-QoL. The S-QoL was based on Calman's approach to the subject's point of view. The S-QoL is a multidimensional instrument. Generation of the items was based on three series of semi-directive interviews with patients' various types (hospitalized, ambulatory, acute phase, stabilized...). Synthesis of the interviews permitted the elaboration of a pre-questionnaire of 97 items. SETTING: A first version of the questionnaire (V0) was used in a sub-group of 141 schizophrenic patients. After a preliminary study of the psychometric properties a first questionnaire (V1) of 53 items was elaborated. A second experimental study was performed in a group of 207 patients. A shorter version (41 items) was developed and a validation study was conducted. Eight dimensions were isolated. METHODS: Nomological validity was studied with clinical parameters (clinical severity, psychotic symptomatology, global functioning) correlated with the S-QoL. The trait validity was estimated by measuring the correlation of the S-QoL with two other instruments: the QoLi and the SF 36. The test-retest reliability was estimated on a subgroup of 53 patients stabilized in a 30-day period. RESULTS: The coefficients of correlation were from 0.64 to 0.79. The acceptability of the S-QoL was good (missing rate of data lower than 10% for all the scores and the rate of spontaneous refusal between 8 and 12%). The average time of completion was 13.6 +/- 10.8 minutes. Sensitivity to change was studied in a population of 46 patients between day 0 and day 30. The S-QoL was also sensitive to the change. The S-QoL measures the impact of schizophrenia on quality of life of the individuals suffering from the disease. CONCLUSION: The S-Qol is a new self-administered questionnaire able to follow the evolution of the disease. S-Qol covers domains that differ from areas tapped in other measures of quality of life. The use of the S-QoL in the assessment of the efficacy of the clinical programme will be evaluated.

[The influence of memory disorders on self-evaluation of subjective quality of life among schizophrenic patients]. / Inluence des troubles mnéstique sur l'auto-évaluation de la qualité de vie subjective des patients schizophrènes.

INTRODUCTION: For the past few years, in the field of psychiatric disorders, measurements of subjective quality of life are integrated as an important criterion of judgment. The use of standardized questionnaires, based on the patients point of view has become widespread. However, in schizophrenic patients, cognitive impairement, and notably memory, is often advanced as a limit to the use of the self-reported questionnaires. METHODS: In this preliminary study, we investigated in 53 schizophrenic patients, the impact of memory impairment, specifically the episodic memory, on quality of life, taking into account confounding socio-demographic and clinical factors. The memory was assessed using the BEM 84. The patient's subjective quality of life was assessed by the self-reported questionnaire S-QoL. RESULTS: No correlation was found between memory efficiency and quality of life level: patients with severe and non-severe impairment scored all the S-QoL domains similarly. DISCUSSION: However, the majority of schizophrenic patients could be considered as deficient on a wide assortment of neuropsychological evaluations, in particular in the attention and executive functions. The influence of the whole cognitive impairment of life must be confirmed.

[Caregiver burden in relatives of persons with schizophrenia: an overview of measure instruments]. / La charge des aidants naturels de patients schizophrènes: revue critique des instruments d'évaluation.

The high prevalence and chronic evolution of schizophrenia are responsible for a major social cost. The adverse consequences of such psychiatric disorders for relatives have been studied since the early 1950s, when psychiatric institutions began discharging patients into the community. According to Treudley (1946) "burden on the family" refers to the consequences for those in close contact with a severely disturbed psychiatric patient. Grad and Sainsbury (1963) and Hoenig and Hamilton (1966) developed the first burden scales for caregivers of severely mentally ill patients, and a number of authors further developed instruments trying to distinguish between "objective" and "subjective" burden. Objective burden concerns the patient's symptoms, behaviour and socio-demographic characteristics, but also the changes in household routine, family or social relations, work, leisure time, physical health.... Subjective burden is the mental health and subjective distress among family members. While the first authors referred to those problems which are deemed to be related to, or caused by the patient, Platt et al. (1983) tried to distinguish between the occurrence of a problem, its alleged aetiology, and the perceived distress, when developing the SBAS questionnaire. These authors also proposed separate evaluations of behavioral disturbance and social performance by relatives, and a report of extra-disease stressors in family life. The SBAS is actually the most complete, but also complex instrument for evaluating burden in caregivers. Since 1967 Pasamanick and others proposed questionnaires for burden evaluation in relatives of schizophrenic patients. Relatives may be included in specific psychoeducational programs, but few of these programs have been evaluated in terms of caregiver burden. The theoretical approach in schizophrenia was not different from that one adopted in mentally ill population. Some instruments were validated first in a mentally ill group and then adapated for schizophrenic population. This paper describes the available data about intruments measuring caregiver burden in relatives of schizophrenic patients. Measures are summarized according to purpose, content and psychometric properties. Sixteen instruments have been collected from the litterature (1955-2001), and 2 instruments developed for relatives of mentally ill have also been taken into account. A group of 5 instruments focuses on the measurement of behavioural disturbance in persons with schizophrenia as perceived by their family members. Eleven scales include behavioural disturbance in a more complete decription of objective burden. Thirteen questionnaires also report the subjective distress in caregivers. One instrument has been developed in french language. Few of these instruments have been developed from a verbatim and really describe the caregiver's point of view. Most of them rely on experts point of view or on previously published studies. The content and domains explored by these instruments are variable. The psychometric properties are poorly documented for a number of them and no information is published about responsiveness. Some validated instruments are the Perceived Family Burden Scale (PFBS) the Involvement Evaluation Questionnaire (IEQ) and the Experience of Caregiving Inventory (ECI). In past studies, researchers more or less agreed about the dimensions that comprise the family burden. There was less agreement with regard to the definition of objective and subjective burden, and quite no agreement about the theoretical approach to the concept of burden. The evaluation of behavioural disturbance should now be excluded from the objective burden dimension. It is a specific domain, both objective and subjective, which can be described as a stressor in the stress-appraisal-coping model. A good approach of this domain can be found in the PFBS. It comprises 24 items and the principal components analysis produces 2 factors ("active" and "passive"), explaining 35% of the variance, with good consitency and acceptable test-retest reliability. The evaluation is both objective (presence or absence) and subjective (induced distress). The Behavior Disturbance Scale (BDS) may also be taken into account, although it is less validated. This scale derives from the SBAS, modified as a self-questionnaire, with both objective and subjective evaluations of all items. The concept of burden was recently modified in a new theoretical approach by Schene, when developing the IEQ. According to this author, the burden scale is supposed to exclude stressors (patient's behaviors), as well as outcome variables (distress or psychological impairment in caregiver). The "caregiving consequences" section comprises 36 items, which focus on the subjective aspects of the caregiver's experience. Principal component factor analysis generates 4 factors which explain 45% of the variance: tension, supervision, worrying, urging. The overall caregiving score substantially explains the connection between patient, caregiver, relationship variables and the caregiver's distress. This scale is a valid and simple instrument for caregiving eveluation The ECI also introduces a new approach of caregiving and rejects the notion of burden. The 66 item version is composed of 10 factors (8 "negative" and 2 "positive") with good internal consistency. The introduction of two positive factors (rewarding personal experiences, good aspects of the relationship with the patient) might be the basis of a useful outcome measure for intervention aimed at promoting caregiver well-being. Nevertheless, the authors fail to develop an overall score that includes these factors, and focus on the negative dimensions as predictors of morbidity and well-being. None of the variables included in the regression model explain a significant percent of the variance of the ECI positive score. None of these instruments was employed for evaluating programs or treatments, even psychoeducational programs for caregivers. This may be partly due to the lack of data about sensitivity to change. No instrument is now available for evaluating therapeutics from the caregiver's point of view. Developing such an instrument is necessary, in view of the increasing role of families in care for schizophrenic patients. These data and the review of the literature leeds us to propose the development of a self-administered questionnaire for evaluating subjective health-related quality of life in caregivers of schizophrenic patients. The instrument should be developed from the caregiver's point of view and be derived from qualitative interviews with relatives of patients suffering from schizophrenia. It's responsiveness should be documented before inclusion in clinical trials or evaluation of psychoeducational programs. We are now working with the National Union of Friends and Families of Patients to validate an instrument in french language.

Depression and subjective quality of life in chronic phase schizophrenic patients.

OBJECTIVE: To evaluate the influence of depression on subjective quality of life in schizophrenic patients. METHOD: Sixty-seven schizophrenic patients in a stabilized phase were included. Schizophrenic symptoms were evaluated using the Positive and Negative Symptoms Scale (PANSS). The subjective quality of life was evaluated using the short version of the Lehman quality of life scale (QoLI). Depression was evaluated using the Calgary Depression Scale for Schizophrenia (CDSS) and extrapyramidal effects with the Extrapyramidal Symptoms Rating Scale (ESRS). RESULTS: The PANSS total score, PANSS general psychopathology subscore, PANSS depression factor, the total CDSS and some ESRS scores were negatively correlated with the overall life satisfaction score. The CDSS score was negatively correlated with all except one QoLI score. QoLI scores were significantly lower in depressed patients, and this result remained consistent for four QoLi dimensions when adjusted on ESRS and PANSS scores. When analysing the association between high depression scores and high parkinsonism scores with reduced quality of life, multivariate analysis showed that depression was the main explanatory factor: the CDSS total score explained 22% of the variance of the overall subjective quality of life score. The patient questionnaire at the ESRS explained 10.5% of the variance of the 'mental and physical health' QoLI score. CONCLUSION: In schizophrenic patients, depressive symptoms should be focused because of their strong association to overall subjective quality of life.

Development and validation of a patient-based health-related quality of life questionnaire in schizophrenia: the S-QoL.

We developed a self-administered instrument to assess health-related quality of life (HRQL) among people with schizophrenia. The S-QoL, based on Calman's approach to the subject's point of view, is a multidimensional instrument that is sensitive to change. The scale is a 41-item questionnaire with eight subscales (psychological well-being, self-esteem, family relationships, relationships with friends, resilience, physical well-being, autonomy and sentimental life) and a total score. In-depth interviews with patients determined the pertinent issues for item development. The validation study, performed with 207 patients, showed high internal consistency reliability, reproducibility and responsiveness. Construct validity was confirmed using established clinical and HRQL measures. S-QoL covers domains that differ from areas tapped in other measures, with greater responsiveness. The S-QoL is an efficient instrument for the measurement of the impact of schizophrenia on individuals' lives.

Relationships between depression and psychotic symptoms of schizophrenia during an acute episode and stable period.

The aim of the present study is to explore the relationship between depression and psychotic symptoms of schizophrenia over the course of illness. Sixty-eight patients meeting DSM-IV criteria for schizophrenia were enrolled, 27 in an acute episode, 41 when stable. Assessments were performed using the Calgary Depression Scale for Schizophrenia (CDSS) for depression and the Positive and Negative Syndrome Scale (PANSS) for psychotic symptoms. When considering patients in an acute episode (52% depressed), the CDSS score was correlated only with the PANSS positive sub-scale score. For patients in the stable period (38% depressed), the CDSS score was correlated with positive as well as negative and general psychopathology sub-scale scores. Hence, the relationship between depression and other symptoms of schizophrenia appear to differ during different stages of illness.

[Psychometric properties of French version of the Calgary depression scale for schizophrenics (CDSS)]. / Propriétés psychométriques de la version française de l'échelle de dépression de Calgary pour schizophrènes (CDSS).

The Calgary Depression scale for schizophrenia (CDSS) is a 9 items scale, simple, quick and easy to use. It allows a quantitative approach of the subjective (or cognitive) dimension of the depression, and was developed by Addington et al. (1-5). In this work, we studied the psychometric properties of the CDSS in a population of 95 schizophrenic patients, and 41 non schizophrenic depressed patients. The CDSS was compared with commonly used hetero-questionnaires as the Hamilton Depression Scale (HDRS), the Montgomery-Asberg Depression Scale (MADRS), the Widlöcher depressive slowness scale (ERD), and auto-questionnaires as the Beck Depression Inventory (BDI), and the Beck Hopelessness scale (H). In the schizophrenic group, psychotic symptoms were evaluated with the Positive and Negative Symptoms Scale (PANSS), and the extrapyramidal symptoms with the Extrapyramidal symptoms scale (EPRS). In the two populations, the CDSS has similar psychometric properties. The principal component analyses accounts for a unifactorial structure in both groups. In schizophrenics the total score of the CDSS is strongly correlated with the total scores of the HDRS, the MADRS, the ERD, and the G6 item of the PANSS. In non schizophrenic depressed patients, the total score of the CDSS is highly correlated to the total scores of the HDRS, the MADRS and the BDI, with a weaker correlation with the ERD and the H total scores. In these patients, a cut-point strictly superior to 13 may be proposed as a severity criterion for depression in these patients. The internal consistency is satisfactory in both groups, with a Cronbach's alpha of 0.82 in schizophrenics and 0.59 in non schizophrenic depressed subjects. In schizophrenics, items C4 (guilty ideas of reference) and C7 (early awakening) are not necessary to the constitution of the scale. In depressed patients, the deletion of item C6 (morning depression) might increase the internal consistency. Inte-raters agreement is high, with weighted kappas all superior to 0.75 in schizophrenics and to 0.61 in depressed patients. Stability over time is good, and the 72 hours test-retest total score of the CDSS is independent from negative and extrapyramidal symptoms. On the other hand, the positive sub-score and the positive factor of the PANSS are correlated to the CDSS total score. The validation of the CDSS is still not complete: sensitivity to change and stability of the factorial structure remain to be explored. Nevertheless, the CDSS is an interesting tool for a quantitative approach of the subjective dimension of depression in both schizophrenic and non schizophrenic patients.

Stability of the five-factor structure of the Positive and Negative Syndrome Scale (PANSS).

The main objective of the study was to verify the stability of the five-factor (negative. positive, excitation, depression and cognitive) structure of the Positive and Negative Syndrome Scale (PANSS). The psychometric properties (validity and reliability) of the forced five-factor structure of the PANSS were explored in two different populations of schizophrenic patients: one in relapse and the other in the chronic phase of the disease. Three hundred and forty-two schizophrenic patients according to DSM-III-R criteria were involved. One hundred and eighteen (34.5%) patients were in relapse, and 224 (65.5%) were in the chronic phase. The forced five-factor principal-component analysis explained 64.3% of the total variance in the relapse patients and 62.1% in the chronic patients. The order of the factors was reversed for the depression and excitation factors in chronic patients compared with patients in relapse. The internal consistency of this five-factor structure was good (Cronbach's alpha >0.70) in the relapse and chronic patients, except for the cognitive factor. In conclusion. five dimensions (negative, positive, excitation, depression and cognition) are necessary to account for the various clinical aspects of schizophrenia described by PANSS in relapse and chronic schizophrenic patients.

Study of the concurrent validity of the Calgary Depression Scale for Schizophrenics (CDSS).

The aim of this study was to investigate the concurrent validity of the French language version of the Calgary Depression Scale for Schizophrenics (CDSS). Ninety-five schizophrenic patients meeting the DSM-III-R criteria were enrolled in the study. The depressive symptoms were evaluated using the Calgary Depression Scale for Schizophrenics (CDSS), Hamilton Depression Rating Scale (HDRS), Montgomery and Asberg Rating Scale (MADRS), and Widlocher Psychomotor Retardation Scale (ERD). The psychotic symptoms were evaluated with the Positive and Negative Syndrome Scale (PANSS) and the extrapyramidal symptoms with the Extrapyramidal Syndrome Rating Scale (ESRS). The CDDS was significantly correlated with all the conventional depression-rating scales. We only found significant positive correlations between the CDSS and the PANSS-positive sub-scale. The CDSS total score was significantly correlated with some PANSS-positive items (delusions and hallucinatory behaviour). No significant correlation between the depression-rating scales and the PANSS-negative sub-scale was observed. For all the depression-rating scales, no correlation with the extrapyramidal symptom was evidenced. The results confirmed the validity of the CDSS in the evaluation of depression in schizophrenia. The relationship between depression and the positive symptoms of schizophrenia is discussed.

Validity and reliability of the French-language version of the Positive and Negative Syndrome Scale (PANSS).

OBJECTIVE: The main objective of this study was to evaluate the psychometric properties of the French-language version of the Positive and Negative Syndrome Scale (PANSS). METHOD: The validity and reliability of the PANSS were studied in a population of 342 patients diagnosed as schizophrenic according to DSM-III-R criteria. RESULTS: The study of the internal consistency and principal-component analysis of the initial structure with three subscales (positive, negative and general psychopathology) led us to investigate other factorial structures. We isolated a 5-factor structure (negative, positive, hostility, disorganization and anxiety/depression) explaining 57.5% of the total variance. The internal consistency of the 5 factors isolated was good (0.87 for the negative factor, 0.82 for the positive factor, 0.78 for the hostility factor, 0.71 for the disorganization factor and 0.68 for the anxiety/depression factor, respectively). The validity study on the external criteria confirmed the relationship between the negative and anxiety/depression factors and the extrapyramidal symptoms. CONCLUSION: The stability of the PANSS factorial warrants discussion.

Evaluation of depression in schizophrenia: psychometric properties of a French version of the Calgary Depression Scale.

The aim of this study was to determine the psychometric properties (especially validity and reliability) of the French language version of the Calgary Depression Scale for Schizophrenia (CDSS) in schizophrenic patients. Ninety-five subjects who met DSM-IV criteria for schizophrenia were enrolled. The studies of the internal structural validity and of the reliability (internal consistency) showed that some items from the CDSS (early awakening and guilty ideas of reference) must be discussed in the constitution of this scale. The total score of the CDSS was significantly correlated with the MADRS total score, the HDRS total score, and the depression item (G6) on the PANSS, which suggests that the CDSS is a valid instrument for the assessment of depression in schizophrenia. The existence of a significant correlation between the CDSS total score and the PANSS positive sub-scale suggests a possible relationship between positive and depressive symptoms in schizophrenia.

Calgary Depression Scale for Schizophrenia: a study of the validity of a French-language version in a population of schizophrenic patients.

The Calgary Depression Scale for Schizophrenia (CDSS) is a nine-item structured interview scale developed by Addington et al. to assess depression in schizophrenics. This paper describes the testing of the reliability and validity of the French version of the CDSS in a population of 70 schizophrenic patients. The validity of the CDSS as a measure of depression was confirmed; a single factor accounted for 41% of the variance of the nine items. The total score on the CDSS was strongly correlated with those on the Montgomery-Asberg Depression Rating Scale (MADRS), the Hamilton Depression Rating Scale (HDRS) and also the G6 item (depression) of the Positive and Negative Syndrome Scale (PANSS). The correlation with the Psychomotor Retardation Scale (ERD) total score was much less significant and was better with the 'subjective' subscore. The internal consistency was good, with a Cronbach's alpha of 0.79. A high level of inter-rater reliability was observed (weighted kappa values were >0.75 in all cases). The CDSS has a lower stability over time than other depression scales. It is a simple, quick and reliable scale for assessing depression in schizophrenic populations.

[Depression scales in schizophrenia: a critical review]. / Echelles d'évaluation de la dépression dans la schizophrénie: revue critique.

Depressive syndromes frequently occur during the evolution of schizophrenia. The evaluation of depression in schizophrenic patients is difficult because of an overlap between depressive, negative and extrapyramidal symptoms. The scales usually employed to evaluate depression have not been validated in schizophrenic populations, therefore, some authors developed specific depression scales for schizophrenics. In this work, we present the available data about the metrologic and psychometric properties of the Hamilton (HDRS), Montgomery Asberg (MADRS) and Widlöcher (ERD) depression scales in schizophrenic populations. We further present the validation works of the Psychotic Depression Scale (PDS) and the Calgary Depression Scale (CDSS). Non specific depression scales are unsatisfactory, since negative and extrapyramidal symptoms overlap with depressive symptoms. The ERD allows a distinction of the three symptom groups, when motor, ideic and subjective subscores are used. The two specific scales actually distinguish depression with a minimal level of contamination. Nevertheless, the factorial structure of the PDS comprises several non depressive factors that are of questionable interest. The CDSS is a well documented and validated tool, with an unidimensional structure, a good internal consistency, a high inter-rater reliability, and good external validity and specificity.

[Psychoses, mood, suicidal tendencies and clozapine]. / Psychoses, humeur, suicidalité et clozapine.

Depression and mood disorders are frequently associated. They can be described as a part of schizophrenic symptomatology, observed as post-psychotic depression, be a part of a schizoaffective disorder or be a consequence of neuroleptic treatment. Suicide is the main risk of evolution in young schizophrenics and is often associated to depression. Despite methodological difficulties, a few studies demonstrate the efficacy of clozapine, one of the first atypical antipsychotic, in the treatment of depressive symptomatology in schizophrenics and schizoaffectives. This action remains controversial in the treatment of post-psychotic depression. This drug also contribute to reduce suicidality in a sample of chronic schizophrenics in an open study. This action has to be considered when we evaluate the risk-benefit of the prescription of clozapine.

Influence of school enrollment on adolescent emergency department visits.

PURPOSE: This study examined the influence of school enrollment on the spectrum of adolescent problems seen in emergency department. METHODS: Medical charts of all adolescent patients presenting to an urban general emergency department for 2 years (1991-1993) were retrospectively reviewed. Data obtained included date, time, and means of arrival, triage acuity score, primary diagnosis with disposition, and whether enrolled in school. RESULTS: Of 3,269 charts reviewed, 36% of visits were the result of injuries and 64% owing to acute medical complaints. Of all visits, 7% were for sexually related complaints. A total of 86% of adolescent patients had no medical insurance or federal assistance. Based on emergency department triage criteria, 40% of all visits were judged nonemergency. Ambulance arrivals accounted for 4%, admissions 4%, and those not currently enrolled in school 40%. Adolescents not enrolled in school had a similar spectrum of medical illnesses and significantly more injuries (45% vs. 30%), and were triaged as emergency (8% vs. 4%) or nonemergency (48% vs. 34%) significantly more often than adolescents enrolled in school. There were no significant differences by sex or race. CONCLUSIONS: Adolescents use the emergency department as a source of primary care and injury treatment. Adolescents presenting to the emergency department who are not enrolled in school have significant differences in diagnosis and severity of illness compared with adolescents enrolled in school. General emergency departments must be prepared to deal with the unique needs of all adolescents, especially those not enrolled in school, including nonemergency primary care and injury management.

[Mechanism of action of antidepressants]. / Mécanisme d'action des antidépresseurs.

Modifications in noradrenergic and serotonergic systems are involved in the central mechanism of action of antidepressants. Most antidepressants (electroconvulsive therapy included) induce a desensitization of the beta-noradrenergic receptor, as shown by a decrease in noradrenaline-stimulated cAMP production. Down-regulation of the beta receptor is often associated with desensitization, as well as modifications in the activity of the serotonergic system, among which alternations in 5-HT2 receptors are frequent. Finally, complex interactions between noradrenergic and serotonergic receptors may also contribute to the pharmacological effect of long term antidepressive treatment.

Effects of lesion of the cholinergic basal forebrain nuclei on the activity of glutamatergic and GABAergic systems in the rat frontal cortex and hippocampus.

The effects of cholinergic basal forebrain lesions on the activity of the glutamatergic and GABAergic systems were investigated in the rat frontal cortex and hippocampus. Bilateral quisqualic acid injections in the nucleus basalis magnocellularis (NBM) at the origin of the main cholinergic innervation to the neocortex induced a cholinergic deficit in the cerebral cortex 15 days later, as shown by the marked selective decrease in cortical choline acetyltransferase (CAT) activity observed. Concurrent alterations in the kinetic parameters of high affinity glutamate uptake consisting mainly of a decrease in the Vmax were observed in the cerebral cortex. These changes presumably reflect a decreased glutamatergic transmission and provide support for the hypothesis that cortical glutamatergic neurons may undergo the influence of cholinergic projections from the NBM. Surprisingly, similar alterations in the glutamate uptake process were found to occur at hippocampal level in the absence of any significant change in the hippocampal cholinergic activity. These data indicate that the NBM may contribute to regulating hippocampal glutamatergic function without interfering with the hippocampal cholinergic innervation that mainly originates in the medial septal area-diagonal band (MSA-DB) complex. No change in parameters of GABAergic activity, namely the glutamic acid decarboxylase (GAD) activity and high affinity GABA uptake, were observed in any of the structures examined. In a second series of experiments involving bilateral intraventricular injections of AF64A, marked survival time-dependent decreases in CAT and high affinity choline uptake activities but no significant change in the high affinity glutamate uptake rate were observed in the hippocampus. No significant change in either parameters of cholinergic activity or in the glutamate uptake was concurrently observed in the cerebral cortex. The GABAergic activity was again unaffected whatever the survival time and the structure considered. Taken as a whole, these data suggest that basal forebrain projections originating in the NBM may play a major role in regulating glutamatergic but not GABAergic function in both the cerebral cortex and the hippocampus; whereas the glutamatergic and GABAergic activities in these two structures may not be primarily under the influence of the cholinergic projections from the MSA-DB complex.