Mobile app measuring sleep and behaviors: A trial in adolescents with addiction.

INTRODUCTION: The smartphones generalisation allows the development of attractive "real-life" monitoring tools for care and research enabling the measurement of addictive behaviours and comorbidities such as sleep disorders. The study objective was to assess the interest of a mobile app collecting such information among adolescents with addictive behaviours in order to enhance the availability of behavioural data in consultation. METHODS: An open label randomised pilot study was held along two parallel arms. The patients randomised to the intervention group (n=18) used a mobile app to provide daily data for 15 days relating to their sleep and their behaviour (addictive behaviours with or without substances). The patients in the control group (n=18) used a paper diary allowing the collection of the same data, only the medium differed. RESULTS: The patients' median age was 16 years [15.0-16.5]. A median of 67% and 10% of the expected information was completed respectively in the intervention and control groups during the 15 days of follow-up and could be used in consultation (P=0.08). The patient's knowledge, attitudes, intentions to change, behaviour change and seeking help related to the use of the diaries appeared higher in the intervention group (20.5/30) than in the control group (11/20). CONCLUSION: This study described the high patient compliance with the data collection by means of the app. The diary app seems to have been more impactful for patients than the paper diary. This app could represent an important tool to improve the therapeutic alliance and care due to a better knowledge of the behaviours on the part of the clinician but also a better awareness of the patients themselves.

Digital Phenotyping: Data-Driven Psychiatry to Redefine Mental Health.

The term "digital phenotype" refers to the digital footprint left by patient-environment interactions. It has potential for both research and clinical applications but challenges our conception of health care by opposing 2 distinct approaches to medicine: one centered on illness with the aim of classifying and curing disease, and the other centered on patients, their personal distress, and their lived experiences. In the context of mental health and psychiatry, the potential benefits of digital phenotyping include creating new avenues for treatment and enabling patients to take control of their own well-being. However, this comes at the cost of sacrificing the fundamental human element of psychotherapy, which is crucial to addressing patients' distress. In this viewpoint paper, we discuss the advances rendered possible by digital phenotyping and highlight the risk that this technology may pose by partially excluding health care professionals from the diagnosis and therapeutic process, thereby foregoing an essential dimension of care. We conclude by setting out concrete recommendations on how to improve current digital phenotyping technology so that it can be harnessed to redefine mental health by empowering patients without alienating them.

Transcranial Magnetic Stimulation (rTMS) on the Precuneus in Alzheimer's Disease: A Literature Review.

The current literature review aimed to evaluate the effectiveness of rTMS on the precuneus as a potential treatment for Alzheimer's disease (AD). Although the number of studies specifically targeting the precuneus is limited, the results from this review suggest the potential benefits of this approach. Future studies should focus on exploring the long-term effects of rTMS on the precuneus in Alzheimer's disease patients, as well as determining the optimal stimulation parameters and protocols for this population. Additionally, investigating the effects of rTMS on the precuneus in combination with other brain regions implicated in AD may provide valuable insights into the development of effective treatment for this debilitating neurodegenerative disorder.

Digital phenotype of mood disorders: A conceptual and critical review.

Background: Mood disorders are commonly diagnosed and staged using clinical features that rely merely on subjective data. The concept of digital phenotyping is based on the idea that collecting real-time markers of human behavior allows us to determine the digital signature of a pathology. This strategy assumes that behaviors are quantifiable from data extracted and analyzed through digital sensors, wearable devices, or smartphones. That concept could bring a shift in the diagnosis of mood disorders, introducing for the first time additional examinations on psychiatric routine care. Objective: The main objective of this review was to propose a conceptual and critical review of the literature regarding the theoretical and technical principles of the digital phenotypes applied to mood disorders. Methods: We conducted a review of the literature by updating a previous article and querying the PubMed database between February 2017 and November 2021 on titles with relevant keywords regarding digital phenotyping, mood disorders and artificial intelligence. Results: Out of 884 articles included for evaluation, 45 articles were taken into account and classified by data source (multimodal, actigraphy, ECG, smartphone use, voice analysis, or body temperature). For depressive episodes, the main finding is a decrease in terms of functional and biological parameters [decrease in activities and walking, decrease in the number of calls and SMS messages, decrease in temperature and heart rate variability (HRV)], while the manic phase produces the reverse phenomenon (increase in activities, number of calls and HRV). Conclusion: The various studies presented support the potential interest in digital phenotyping to computerize the clinical characteristics of mood disorders.

Memory reconsolidation impairment using the ß-adrenergic receptor blocker propranolol reduces nightmare severity in patients with posttraumatic stress disorder: a preliminary study.

STUDY OBJECTIVES: Posttraumatic nightmares may exacerbate and perpetuate the daytime symptoms of posttraumatic stress disorder and might represent a therapeutic target. The therapeutic strategy of memory reconsolidation using the ß-adrenergic receptor blocker propranolol associated with re-exposure psychotherapy is a promising treatment in patients with posttraumatic stress disorder. Previous studies have established this therapy is effective in reducing overall clinician-assessed posttraumatic stress disorder symptoms, but to date no previous study has specifically focused on posttraumatic nightmares in this therapy. This study provides a preliminary assessment of the evolution of nightmare severity during this therapy protocol compared with the decrease of the other posttraumatic stress disorder symptoms. It evaluates the incidence of side effects and examines the relative effects on posttraumatic nightmares. METHODS: Patients were recruited as part of the Paris Mémoire Vive Study. Data were collected using a prospective longitudinal design including 1 baseline visit, 6 therapeutic visits, and 2 follow-up visits. During the 6 therapeutic visits, propranolol was administered orally 60 to 75 minutes prior to the psychotherapeutic session. RESULTS: On average, nightmare severity decreased from "severe" to "mild" during the protocol and remained stable 2 months after the last session. Whereas 85% of patients reported nightmares at baseline, only 50% still had them after the protocol. The protocol was generally well tolerated and did not increase nightmare severity for any patient in the study. CONCLUSIONS: Memory reconsolidation therapy with propranolol seems promising in reducing nightmare severity, up to and including remission. However, research using a randomized controlled design and assessing maintenance of nightmare extinction is warranted. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Using Reconsolidation Blockade to Treat Trauma Related Disorders After Paris Attacks: An Effectiveness Study (PARIS-MEM); Identifier: NCT02789982; URL: https://www.clinicaltrials.gov/ct2/show/NCT02789982. CITATION: Mallet C, Chick CF, Maatoug R, Fossati P, Brunet A, Millet B. Memory reconsolidation impairment using the ß-adrenergic receptor blocker propranolol reduces nightmare severity in patients with posttraumatic stress disorder: a preliminary study. J Clin Sleep Med. 2022;18(7):1847-1855.

In Search of Digital Dopamine: How Apps Can Motivate Depressed Patients, a Review and Conceptual Analysis.

INTRODUCTION: Depression is highly prevalent and causes considerable suffering and disease burden despite the existence of wide-ranging treatment options. Momentary assessment is a promising tool in the management of psychiatric disorders, and particularly depression. It allows for a real-time evaluation of symptoms and an earlier detection of relapse or treatment efficacy. Treating the motivational and hedonic aspects of depression is a key target reported in the literature, but it is time-consuming in terms of human resources. Digital Applications offer a major opportunity to indirectly regulate impaired motivational circuits through dopaminergic pathways. OBJECTIVE: The main objective of this review was twofold: (1) propose a conceptual and critical review of the literature regarding the theoretical and technical principles of digital applications focused on motivation in depression, activating dopamine, and (2) suggest recommendations on the relevance of using these tools and their potential place in the treatment of depression. MATERIAL AND METHODS: A search for words related to "dopamine", "depression", "smartphone apps", "digital phenotype" has been conducted on PubMed. RESULTS: Ecological momentary interventions (EMIs) differ from traditional treatments by providing relevant, useful intervention strategies in the context of people's daily lives. EMIs triggered by ecological momentary assessment (EMA) are called "Smart-EMI". Smart-EMIs can mimic the "dopamine reward system" if the intervention is tailored for motivation or hedonic enhancement, and it has been shown that a simple reward (such as a digital badge) can increase motivation. DISCUSSION: The various studies presented support the potential interest of digital health in effectively motivating depressed patients to adopt therapeutic activation behaviors. Finding effective ways to integrate EMIs with human-provided therapeutic support may ultimately yield the most efficient and effective intervention method. This approach could be a helpful tool to increase adherence and motivation. CONCLUSION: Smartphone apps can motivate depressed patients by enhancing dopamine, offering the opportunity to enhance motivation and behavioral changes, although longer term studies are still needed.

The wide spectrum of COVID-19 neuropsychiatric complications within a multidisciplinary centre.

A variety of neuropsychiatric complications has been described in association with COVID-19 infection. Large scale studies presenting a wider picture of these complications and their relative frequency are lacking. The objective of our study was to describe the spectrum of neurological and psychiatric complications in patients with COVID-19 seen in a multidisciplinary hospital centre over 6 months. We conducted a retrospective, observational study of all patients showing neurological or psychiatric symptoms in the context of COVID-19 seen in the medical and university neuroscience department of Assistance Publique Hopitaux de Paris-Sorbonne University. We collected demographic data, comorbidities, symptoms and severity of COVID-19 infection, neurological and psychiatric symptoms, neurological and psychiatric examination data and, when available, results from CSF analysis, MRI, EEG and EMG. A total of 249 COVID-19 patients with a de novo neurological or psychiatric manifestation were included in the database and 245 were included in the final analyses. One-hundred fourteen patients (47%) were admitted to the intensive care unit and 10 (4%) died. The most frequent neuropsychiatric complications diagnosed were encephalopathy (43%), critical illness polyneuropathy and myopathy (26%), isolated psychiatric disturbance (18%) and cerebrovascular disorders (16%). No patients showed CSF evidence of SARS-CoV-2. Encephalopathy was associated with older age and higher risk of death. Critical illness neuromyopathy was associated with an extended stay in the intensive care unit. The majority of these neuropsychiatric complications could be imputed to critical illness, intensive care and systemic inflammation, which contrasts with the paucity of more direct SARS-CoV-2-related complications or post-infection disorders.

Ecological Momentary Assessment Using Smartphones in Patients With Depression: Feasibility Study.

BACKGROUND: Ecological momentary assessment (EMA) is a promising tool in the management of psychiatric disorders and particularly depression. It allows for a real-time evaluation of symptoms and an earlier detection of relapse or treatment efficacy. The generalization of the smartphone in the modern world offers a new, large-scale support for EMA. OBJECTIVE: The main objective of this study was twofold: (1) to assess patients' compliance with an EMA smartphone app defined by the number of EMAs completed, and (2) to estimate the external validity of the EMA using a correlation between self-esteem/guilt/mood variables and Hamilton Depression Rating Scale (HDRS) score. METHODS: Eleven patients at the Pitié-Salpêtrière Hospital, Paris, France, were monitored for 28 days by means of a smartphone app. Every patient enrolled in the study had two types of assessment: (1) three outpatient consultations with a psychiatrist at three different time points (days 1, 15, and 28), and (2) real-time data collection using an EMA smartphone app with a single, fixed notification per day at 3 pm for 28 days. The results of the real-time data collected were reviewed during the three outpatient consultations by a psychiatrist using a dashboard that aggregated all of the patients' data into a user-friendly format. RESULTS: Of the 11 patients in the study, 6 patients attended the 3 outpatient consultations with the psychiatrist and completed the HDRS at each consultation. We found a positive correlation between the HDRS score and the variables of self-esteem, guilt, and mood (Spearman correlation coefficient 0.57). Seven patients completed the daily EMAs for 28 days or longer, with an average response rate to the EMAs of 62.5% (175/280). Furthermore, we observed a positive correlation between the number of responses to EMAs and the duration of follow-up (Spearman correlation coefficient 0.63). CONCLUSIONS: This preliminary study with a prolonged follow-up demonstrates significant patient compliance with the smartphone app. In addition, the self-assessments performed by patients seemed faithful to the standardized measurements performed by the psychiatrist. The results also suggest that for some patients it is more convenient to use the smartphone app than to attend outpatient consultations.

Improving clinical decision-making in psychiatry: implementation of digital phenotyping could mitigate the influence of patient's and practitioner's individual cognitive biases.

High stake clinical choices in psychiatry can be impacted by external irrelevant factors. A strong understanding of the cognitive and behavioural mechanisms involved in clinical reasoning and decision-making is fundamental in improving healthcare quality. Indeed, the decision in clinical practice can be influenced by errors or approximations which can affect the diagnosis and, by extension, the prognosis: human factors are responsible for a significant proportion of medical errors, often of cognitive origin. Both patient's and clinician's cognitive biases can affect decision-making procedures at different time points. From the patient's point of view, the quality of explicit symptoms and data reported to the psychiatrist might be affected by cognitive biases affecting attention, perception or memory. From the clinician's point of view, a variety of reasoning and decision-making pitfalls might affect the interpretation of information provided by the patient. As personal technology becomes increasingly embedded in human lives, a new concept called digital phenotyping is based on the idea of collecting real-time markers of human behaviour in order to determine the 'digital signature of a pathology'. Indeed, this strategy relies on the assumption that behaviours are 'quantifiable' from data extracted and analysed through connected tools (smartphone, digital sensors and wearable devices) to deduce an 'e-semiology'. In this article, we postulate that implementing digital phenotyping could improve clinical reasoning and decision-making outcomes by mitigating the influence of patient's and practitioner's individual cognitive biases.

Sustained Recovery in a Treatment-Refractory Obsessive-Compulsive Disorder Patient After Deep Brain Stimulation Battery Failure.

Obsessive-compulsive disorder (OCD) is a widespread chronic neuropsychiatric disorder characterized by recurrent intrusive thoughts, images, or urges (obsessions) that typically cause anxiety or distress. Even when optimal treatment is provided, 10% of patients remain severely affected chronically. In some countries, deep brain stimulation (DBS) is an approved and effective therapy for patients suffering from treatment-resistant OCD. Hereafter, we report the case of a middle-aged man with a long history of treatment-resistant OCD spanning nearly a decade with Yale-Brown Obsessive Compulsive Scale (Y-BOCS) scores oscillating between 21 and 28. The patient underwent bilateral implantation of ventral striatum/ventral capsule DBS leads attached to a battery-operated implanted pulse generator. After a 3-month postimplantation period, the DBS protocol started. Three months after the onset of DBS treatment, the patient's Y-BOCS score had dropped to 3, and he became steadily asymptomatic. However, inadvertently, at this time, it was found out that the implanted pulse generator battery had discharged completely, interrupting brain stimulation. The medical team carried on with the original therapeutic and evaluation plan in the absence of active DBS current. After 12 additional months under off-DBS, the patient remained at a Y-BOCS score of 7 and asymptomatic. To our knowledge, this is the first report that provides an opportunity to discuss four different hypotheses of long-term recovery induced by DBS in a treatment-refractory OCD patient, notably: (1) A placebo effect; (2) Paradoxical improvements induced by micro-lesions generated by DBS probe implantation procedures; (3) Unexpected late spontaneous improvements; (4) Recovery driven by a combination of active DBS-induction, the effects of medication, and DBS-placebo effects.

Brain Stimulation in Eating Disorders: State of the Art and Future Perspectives.

The management of eating disorders (EDs) is still difficult and few treatments are effective. Recently, several studies have described the important contribution of non-invasive brain stimulation (repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and electroconvulsive therapy) and invasive brain stimulation (deep brain stimulation and vagal nerve stimulation) for ED management. This review summarizes the available evidence supporting the use of brain stimulation in ED. All published studies on brain stimulation in ED as well as ongoing trials registered at clinicaltrials.gov were examined. Articles on neuromodulation research and perspective articles were also included. This analysis indicates that brain stimulation in EDs is still in its infancy. Literature data consist mainly of case reports, cases series, open studies, and only a few randomized controlled trials. Consequently, the evidence supporting the use of brain stimulation in EDs remains weak. Finally, this review discusses future directions in this research domain (e.g., sites of modulation, how to enhance neuromodulation efficacy, personalized protocols).

Correction: Performance in delayed non-matching to sample task predicts the diagnosis of obsessive-compulsive disorder.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Psychiatric Advance Directives and Artificial Intelligence: A Conceptual Framework for Theoretical and Ethical Principles.

The patient's decision-making abilities are often altered in psychiatric disorders. The legal framework of psychiatric advance directives (PADs) has been made to provide care to patients in these situations while respecting their free and informed consent. The implementation of artificial intelligence (AI) within Clinical Decision Support Systems (CDSS) may result in improvements for complex decisions that are often made in situations covered by PADs. Still, it raises theoretical and ethical issues this paper aims to address. First, it goes through every level of possible intervention of AI in the PAD drafting process, beginning with what data sources it could access and if its data processing competencies should be limited, then treating of the opportune moments it should be used and its place in the contractual relationship between each party (patient, caregivers, and trusted person). Second, it focuses on ethical principles and how these principles, whether they are medical principles (autonomy, beneficence, non-maleficence, justice) applied to AI or AI principles (loyalty and vigilance) applied to medicine, should be taken into account in the future of the PAD drafting process. Some general guidelines are proposed in conclusion: AI must remain a decision support system as a partner of each party of the PAD contract; patients should be able to choose a personalized type of AI intervention or no AI intervention at all; they should stay informed, i.e., understand the functioning and relevance of AI thanks to educational programs; finally, a committee should be created for ensuring the principle of vigilance by auditing these new tools in terms of successes, failures, security, and relevance.

Multivisceral Failure in a Context of Serotonin Syndrome Induced by MDMA: The Investigation of a Unique and Nationwide Network.

: The occasional ingestion of 3,4-methylenedioxy-N-methylamphetamine (MDMA) presents serious risks of side effects including death through multivisceral failure in a context of serotonin syndrome. The significant increasing evolution of illicit MDMA street dosages over the past 2 decades and the difficulty for physicians to know what quantity the patients may have consumed, make MDMA a drug with unpredictable effects. Through this case report of a 16-year-old Caucasian, we made use of a unique and nationwide French health monitoring system called TREND (Recent Trends and New Drugs)-SINTES (National Identification System for Drugs and Substances), which, combined with the hair follicle test, can assist medical practitioners in rapidly establishing a precise diagnosis and consequently provide the most appropriate treatment for each individual case in a timely manner.

Revisiting 'brain modes' in a new computational era: approaches for the characterization of brain-behavioural associations.

The study of brain-function relationships is undergoing a conceptual and methodological transformation due to the emergence of network neuroscience and the development of multivariate methods for lesion-deficit inferences. Anticipating this process, in 1998 Godefroy and co-workers conceptualized the potential of four elementary typologies of brain-behaviour relationships named 'brain modes' (unicity, equivalence, association, summation) as building blocks able to describe the association between intact or lesioned brain regions and cognitive processes or neurological deficits. In the light of new multivariate lesion inference and network approaches, we critically revisit and update the original theoretical notion of brain modes, and provide real-life clinical examples that support their existence. To improve the characterization of elementary units of brain-behavioural relationships further, we extend such conceptualization with a fifth brain mode (mutual inhibition/masking summation). We critically assess the ability of these five brain modes to account for any type of brain-function relationship, and discuss past versus future contributions in redefining the anatomical basis of human cognition. We also address the potential of brain modes for predicting the behavioural consequences of lesions and their future role in the design of cognitive neurorehabilitation therapies.

Performance in delayed non-matching to sample task predicts the diagnosis of obsessive-compulsive disorder.

Electrical stimulation studies have recently evidenced the involvement of orbitofrontal cortex (OFC) in obsessive-compulsive disorder (OCD). In addition, lateral OFC is activated in healthy subjects during delayed non-matching-to-sample task (DNMS). In the present study, we hypothesized that OCD results from a specific defect of lateral OFC processing that can be evidenced via a DNMS task. To this end, we compared the DNMS performances of 20 OCD patients vs 20 demographically matched healthy controls. As predicted, our results showed that OCD patients performed worse than healthy controls at DNMS task. To test for the specificity of this behavioral impairment, we furthermore compared OCD patients and healthy subjects on a different task not involving directly the lateral OFC: the delayed match-to-sample task (DMS). As expected, OCD patients are more impaired for both the DNMS and the DMS task, compared with healthy subjects. Moreover, OCD patients tend statistically to perform worse for the DNMS task than for DMS task. Our results suggest the DNMS task specifically target the malfunctioning areas in OCD, such as the lateral OFC. In light of these results, lateral OFC should therefore be the focus of future therapeutic interventions.

The French Society of Internal Medicine's Top-5 List of Recommendations: a National Web-Based Survey.

BACKGROUND: The international project "Choosing Wisely" aims to target unnecessary and potentially harmful examinations and treatments. OBJECTIVE: To define the French Internal Medicine Top-5 list. DESIGN: Based on a review of existing Top-5 lists and personal experience, a working group of the French National Society of Internal Medicine selected 27 diagnostic and therapeutic procedures. They were submitted through a national web-based survey to French internists who rated from 1 to 5 the perceived frequency, uselessness, and risk of each procedure. A composite score was calculated as the unweighted addition of the three scores. PARTICIPANTS: Four hundred thirty internists answered the web-based survey (14% of all French internists including residents). All the French regions and status of the profession were represented. KEY RESULTS: For the 27 submitted procedures, the mean score (± SD) was 3.25 (± 0.48) for frequency, 3.10 (± 0.43) for uselessness, and 2.63 (± 0.84) for risk. The Top-5 list obtained with the composite score was as follows: 1. Do not prescribe long-term treatment with proton pump inhibitors without regular reevaluation of the indication 2. Do not administer preventive treatments (e.g., for dyslipidemia, hypertension…) in elderly people with dementia when potential risks outweigh the benefits 3. Do not administer hypnotic medications as first-line treatment for insomnia 4. Do not treat with an anticoagulant for more than 3 months a patient with a first venous thromboembolism occurring in the setting of a major transient risk factor 5. Do not screen for Lyme disease without an exposure history or related clinical examination findings We found that the composite score was strongly correlated to the risk score (rs = 0.88, p < 10-5) and not to the frequency (rs = 0.06, p = 0.75) or uselessness score (rs = 0.17, p = 0.38). CONCLUSIONS: This Top-5 list provides an opportunity to discuss appropriate use of health care practices in internal medicine.

[Sex addiction: losing its taboo]. / Un tabou qui ne l'est plus : l'addiction sexuelle.

Sex addiction or dependency is a complex and debilitating pathology characterised by a disproportionate preoccupation with sex or sexual activity. The aim of scientific research carried out into this disorder is both nosographic, to establish which subtype of mental disorder it belongs to, and physiopathological, to explain its origin and develop potential therapies. A state of the science on sexual dependency is charted, in the world of psychiatry, based on its very first mention to the present day.