[Psychiatry: what's new in 2023]. / Psychiatrie : ce qui a changé en 2023.

Resistance to treatment in psychiatry can arise from a variety of causes, and here we look at two strategies that can improve this problem. First, we discuss the role of patients' relatives; in addition to family therapy interventions, setting up groups of relatives makes it possible to increase their skills in helping their sick relative and to help each other in this process. And finally, we look at the option of interventional psychiatry. These methods, which have been greatly enriched in recent years, are now available in the interventional psychiatry unit recently opened in the new Cery psychiatric hospital in Lausanne.

La résistance au traitement en psychiatrie peut découler de multiples causes ; deux stratégies pouvant améliorer ce problème sont abordées dans cet article. En premier lieu, le rôle des proches des patients ; au-delà d'interventions de thérapie de famille, la mise en place de groupes de proches permet d'augmenter leurs compétences à aider leur proche malade et de s'entraider dans cette démarche. Et enfin, l'option que peuvent constituer les approches de psychiatrie interventionnelle. Ces méthodes se sont grandement enrichies au cours des dernières années et sont maintenant accessibles dans l'Unité de psychiatrie interventionnelle récemment ouverte dans le nouvel hôpital psychiatrique de Cery, récemment inauguré à Lausanne.

Psychiatric symptoms and mortality in older adults with major psychiatric disorders: results from a multicenter study.

Prior research suggests that certain psychiatric symptoms could be associated with increased risk of death. However, it remains unclear whether this association could rely on all or specific symptoms. In this report, we used data from a multicenter 5-year prospective study (N = 641) of older adults with an ICD-10 diagnosis of schizophrenia, bipolar disorder or major depressive disorder, recruited from French community psychiatric departments. We used a latent variable approach to disentangle the effects shared by all psychiatric symptoms (i.e., general psychopathology factor) and those specific to individual psychiatric symptoms, while adjusting for sociodemographic and clinical factors. Psychiatric symptoms were assessed face-to-face by psychiatrists trained to semi-structured interviews using the Brief Psychiatric Rating Scale (BPRS). Among older adults with major psychiatric disorders, we found that all psychiatric symptoms were associated with increased mortality, and that their effect on the 5-year mortality were exerted mostly through a general psychopathology dimension (ß = 0.13, SE = 0.05, p < 0.05). No BPRS item or lower order factor had a significant effect on mortality beyond and above the effect of the general psychopathology factor. Greater number of medical conditions, older age, male sex, and being hospitalized or institutionalized at baseline were significantly associated with this risk beyond the effect of the general psychopathology factor. Since psychiatric symptoms may affect mortality mainly through a general psychopathology dimension, biological and psychological mechanisms underlying this dimension should be considered as promising targets for interventions to decrease excess mortality of older individuals with psychiatric disorders.

Do Individuals with Internet Gaming Disorder Share Personality Traits with Substance-Dependent Individuals?

(1) Background: Internet gaming disorder (IGD) shares many similarities with substance use disorder (SUD), contributing to its recognition as an addictive disorder. Nevertheless, no study has compared IGD to other addictive disorders in terms of personality traits established as highly co-occurring with SUDs. (2) Methods: We recruited a sample of gamers (massively multiplayer online role-playing games) (MMORPGs) via online in-game forums. We compared 83 individuals with IGD (MMORPG-IGD group) to 47 former heroin addicts under methadone maintenance treatment (MMT; MMT group) with regard to alexithymia, impulsivity, sensation seeking and aggressiveness assessed through self-administered scales, being TAS-20, BIS-10, Z-SSS and BDHI, respectively. (3) Results: Our results draw a relatively similar personality profile between groups but indicate that the subject traits are generally more pronounced in the MMT cohort. The overall lesser intensity of these traits in the MMORPG-IGD group might reflect the greater variability in the severity of the IGD. (4) Conclusions: IGD shares personality traits with MMT, and intensity may be influenced by the severity of the addiction or by certain direct environmental factors, and might also influence the propensity towards one behavior rather than another.

Plasma amyloid beta predicts conversion to dementia in subjects with mild cognitive impairment: The BALTAZAR study.

INTRODUCTION: Blood-based biomarkers are the next challenge for Alzheimer's disease (AD) diagnosis and prognosis. METHODS: Mild cognitive impairment (MCI) participants (N = 485) of the BALTAZAR study, a large-scale longitudinal multicenter cohort, were followed-up for 3 years. A total of 165 of them converted to dementia (95% AD). Associations of conversion and plasma amyloid beta (Aß)1-42 , Aß1-40 , Aß1-42 /Aß1-40 ratio were analyzed with logistic and Cox models. RESULTS: Converters to dementia had lower level of plasma Aß1-42 (37.1 pg/mL [12.5] vs. 39.2 [11.1] , P value = .03) and lower Aß1-42 /Aß1-40 ratio than non-converters (0.148 [0.125] vs. 0.154 [0.076], P value = .02). MCI participants in the highest quartile of Aß1-42 /Aß1-40 ratio (>0.169) had a significant lower risk of conversion (hazard ratio adjusted for age, sex, education, apolipoprotein E ε4, hippocampus atrophy = 0.52 (95% confidence interval [0.31-0.86], P value = .01). DISCUSSION: In this large cohort of MCI subjects we identified a threshold for plasma Aß1-42 /Aß1-40 ratio that may detect patients with a low risk of conversion to dementia within 3 years.

Cognitive functions in late-life depression.

Cognitive disorders are frequently found during late-life depression (LLD). Many cognitive functions may be concerned and can be explained by frontostriatal brain circuits and hippocampus dysfunctions partly through abnormalities related to cerebrovascular diseases. It seems important to distinguish between early and late onset depression, the cognitive characterisation and aetiopathogenesis of which differ in some respects. Cognitive impairment may represent markers of depression, but it is still unclear whether potential biomarkers of disease should be considered as markers of condition, trait or risk factors. These disorders may precede depression and persist despite symptomatic remission. Moreover, the interest of specifying these disorders is multiple because they can have pejorative consequences, such as by modifying emotional content, encouraging suicidal acts, limiting the effectiveness of psychotherapy, being a risk factor for a poor response to antidepressants, or being a potential risk factor for progression to a minor or major neurocognitive disorder, especially Alzheimer disease.

Saccadic Eye Movements in Elderly Depressed Patients With Suicidal Behaviors: An Exploratory Eye-Tracking Study.

Suicidal behaviors (SBs) are often associated with impaired performance on neuropsychological executive functioning (EF) measures that encourage the development of more specific and reliable tools. Recent evidence could suggest that saccadic movement using eye tracking can provide reliable information on EF in depressive elderly. The aim of this study was to describe oculomotor performances in elderly depressed patients with SB. To achieve this aim, we compared saccadic eye movement (SEM) performances in elderly depressed patients (N = 24) with SB and with no SB in prosaccade (PS) and antisaccade (AS) tasks under the gap, step, and overlap conditions. All participants also underwent a complete neuropsychological battery. Performances were impaired in patients with SB who exhibited less corrected AS errors and longer time to correct them than patients with no SB. Moreover, both groups had a similar performance for PS latencies and correct AS. These preliminary results suggested higher cognitive inflexibility in suicidal patients compared to non-suicidal. This inflexibility may explain the difficulty of the depressed elderly in generating solutions to the resurgence of suicidal ideation (SI) to respond adequately to stressful environments. The assessment of eye movement parameters in depressed elderly patients may be a first step in identifying high-risk patients for suicide.

Cognitive Impairment in Late-Life Depression: A Comparative Study of Healthy Older People, Late-Life Depression, and Mild Alzheimer's Disease Using Multivariate Base Rates of Low Scores.

Late-Life Depression (LLD) is often associated with cognitive impairment. However, distinction between cognitive impairment due to LLD and those due to normal aging or mild Alzheimer's Disease (AD) remain difficult. The aim of this study was to present and compare the multivariate base rates of low scores in LLD, mild AD, and healthy control groups on a battery of neuropsychological tests. Participants (ages 60-89) were 352 older healthy adults, 390 patients with LLD, and 234 patients with mild AD (i.e., MMSE ≥ 20). Multivariate base rates of low scores (i.e., ≤ 5th percentile) were calculated for each participant group within different cognitive domains (verbal episodic memory, executive skills, mental processing speed, constructional praxis, and language/semantic memory). Obtaining at least one low score was relatively common in healthy older people controls (from 9.4 to 17.6%), and may thus result in a large number of false positives. By contrast, having at least two low scores was unusual (from 0.3 to 4.6%) and seems to be a more reliable criterion for identifying cognitive impairment in LLD. Having at least three low memory scores was poorly associated with LLD (5.9%) compared to mild AD (76.1%) and may provide a useful way to differentiate between these two conditions [ χ ( 1 ) 2 = 329.8, p < 0.001; Odds Ratio = 50.7, 95% CI = 38.2-77.5]. The multivariate base rate information about low scores in healthy older people and mild AD may help clinicians to identify cognitive impairments in LLD patients, improve the clinical decision-making, and target those who require regular cognitive and clinical follow-up.

Dosing antipsychotics in special populations of patients with schizophrenia: severe psychotic agitation, first psychotic episode and elderly patients.

Antipsychotic (AP) dosing is well established in nonelderly patients with acute exacerbations of schizophrenia, but not in special populations.This review describes the AP dosing procedures that have been used in clinical studies for acute psychotic agitation, a first episode of psychosis (FEP), and elderly patients. AP dosing data was extracted from the databases of drug regulatory authorities, and from clinical studies available in the medical literature. In acute psychotic agitation, intramuscular and oral APs are frequently prescribed in higher doses than those that saturate D2 receptors. Supersaturating doses of APs should be avoided due to an increased risk of adverse effects. In FEP, many studies showed efficacy of low doses of APs. Studies with risperidone and haloperidol suggested a dose reduction of approximately one third. Titration with a lower starting dose is recommended in elderly patients, due to possible decreases in pharmacokinetic clearance, and due to the risk of concomitant diseases and drug interactions. Exposure to some APs has been associated with QTc prolongation and arrhythmias, and a small but significant increase in the risk of stroke and mortality with APs has been seen, particularly in older people with dementia-related psychosis.

Repetitive Transcranial Magnetic Stimulation as an Add-On Treatment for Cognitive Impairment in Alzheimer's Disease and Its Impact on Self-Rated Quality of Life and Caregiver's Burden.

Alzheimer's disease (AD) is associated with progressive memory loss and decline in executive functions, as well as neuropsychiatric symptoms. Patients usually consider quality of life (QoL) and mood as more important for their health status than disease-specific physical and mental symptoms. In this open-label uncontrolled trial, 12 subjects diagnosed with AD underwent 10 sessions of repetitive transcranial magnetic stimulation (rTMS) over the left dorsolateral prefrontal cortex (10 Hz, 20 min, 2000 pulses/day, 110% MT). Outcomes were measured before and 30 days after treatment. Our primary objective was to test the efficacy of rTMS as an add-on treatment for AD on the global cognitive function, assessed through the Mini-Mental State Examination (MMSE) and the Mattis Dementia Rating Scale (MDRS). As secondary objectives, the detailed effect on cognitive functions, depression and anxiety symptoms, QoL, and functionality in daily life activities were evaluated, as well as correlations between QoL and cognition, depression and anxiety scores. The treatment significantly enhanced semantic memory and reduced anxiety. Improvement of these features in AD could become an important target for treatment strategies. Although limited by its design, this trial may contribute with another perspective on the analysis and the impact of rTMS on AD.

[Cognitive functions in late life depression]. / Troubles cognitifs au cours de la dépression du sujet âgé.

Cognitive disorders are frequently found during late-life depression. Many cognitive functions may be concerned and can be explained by fronto-striatal brain circuits and hippocampus dysfunctions partly through abnormalities related to cerebrovascular diseases. It seems important to distinguish between early and late onset depression whose cognitive characterisation and etiopathogenia differ in some aspects. Cognitive impairment may represent markers of depression but it is still unclear whether one should consider potential biomarkers of disease state or trait or risk factor. These disorders may precede depression and persist despite symptomatic remission. Moreover, the interest of specifying these disorders is multiple because they can have pejorative consequences such as the modification of emotional content, promote suicidal act, limit the effectiveness of psychotherapy, be a risk factor for poor response to antidepressants. or be a potential risk factor for progression to a minor or major neurocognitive disorder, especially Alzheimer's disease.

Late-onset and nonlate-onset schizophrenia: A comparison of clinical characteristics in a multicenter study.

OBJECTIVES: Data are scarce regarding the potential clinical differences between non-late onset schizophrenia (NLOS, i.e., disorder occurring before 40 years of age), late-onset schizophrenia (LOS, occurring between ages 40 and 60 years) and very-late-onset schizophrenia-like psychosis (VLOSLP, occurring after 60 years of age). Furthermore, previous research compared LOS patients with non-age matched NLOS patients. In this study, we sought to examine potential clinical differences between patients of similar age with LOS and NLOS. METHODS/DESIGN: This is a cross-sectional multicentre study that recruited in- and outpatients older adults (aged ≥55 years) with an ICD-10 diagnosis of schizophrenia or schizoaffective disorder with NLOS and LOS. Sociodemographic and clinical characteristics, comorbidity, psychotropic medications, quality of life, functioning, and mental health care utilization were drawn for comparison. RESULTS: Two hundred seventy-two participants (79.8%) had NLOS, 61 (17.9%) LOS, and 8 (2.3%) VLOSLP. LOS was significantly and independently associated with greater severity of emotional withdrawal and lower severity of depression (all p < 0.05). However, the magnitude of these associations was modest, with significant adjusted odds ratios ranging from 0.71 to 1.24, and there were no significant between-group differences in other characteristics. CONCLUSION: In an age-matched multicenter sample of elderly patients with schizophrenia, older adults with LOS were largely similar to older adults with NLOS in terms of clinical characteristics. The few differences observed may be at least partially related to symptom fluctuation with time. Implications of these findings for pharmacological and nonpharmacological management is yet to be determined.

A comprehensive model of predictors of quality of life in older adults with schizophrenia: results from the CSA study.

BACKGROUND: Numerous factors are known to influence quality of life of adults with schizophrenia. However, little is known regarding the potential predictors of quality of life in the increasing population of older adults with schizophrenia. The main objective of the present study was to propose a comprehensive model of quality of life in this specific population. METHODS: Data were derived from the Cohort of individuals with Schizophrenia Aged 55 years or more (CSA) study, a large (N = 353) multicenter sample of older adults with schizophrenia or schizoaffective disorder recruited from French community mental-health teams. We used structural equation modeling to simultaneously examine the effects of six broad groups of clinical factors previously identified as potential predictors of quality of life in this population, including (1) severity of general psychopathology, (2) severity of depression, (3) severity of cognitive impairment, (4) psychotropic medications, (5) general medical conditions and (6) sociodemographic characteristics. RESULTS: General psychopathology symptoms, and in particular negative and depressive symptoms, cognitive impairment, reduced overall functioning and low education were significantly and independently associated with diminished quality of life (all p < 0.05). Greater number of medical conditions and greater number of antipsychotics were also independently and negatively associated with quality of life, although these associations did not reach statistical significance in sensitivity analyses, possibly due to limited statistical power. CONCLUSION: Several domains are implicated in quality of life among older adults with schizophrenia. Interventions targeting these factors may help improve importantly quality of life of this vulnerable population.

Behavioral and Neural Arguments of Motivational Influence on Decision Making During Uncertainty.

The scientific world is increasingly interested in motivation, primarily due to the suspected impact on decision-making abilities, particularly in uncertain conditions. To explore this plausible relationship, 28 healthy participants were included in the study and performed decision-making and motivational tasks while their neural activity was recorded. All participants performed the Iowa Gambling Task (IGT) and were split into two groups based on their score, one favorable group with 14 participants who performed advantageously and one undecided group with 14 participants who failed to develop the correct strategy on the IGT. In addition, all participants performed the Effort Expenditure for Reward Task (EEfRT), which defines the motivational level of each participant by the effort that participants agree to do in function of reward magnitudes and probabilities to receive these reward (10, 50, and 90%). The completion of both tasks allowed for the exploration of the relationship between the motivational level and decision-making abilities. The EEfRT was adapted to electroencephalography (EEG) recordings to explore how motivation could influence reward experience. Behavioral results showed no difference in EEfRT performances on the whole task between the two groups' performances on the IGT. However, there was a negative correlation between the difficulty to develop an optimal strategy on the IGT and the percentage of difficult choices at the 90% condition on the EEfRT. Each probability condition has been previously associated to different motivational and emotional states, with the 90% condition associated to the reward sensitivity. This behavioral result leads to the hypothesis that reward sensitivity may induce an inability to develop an optimal strategy on the IGT. Group analysis demonstrated that only the undecided group showed a P300 during the processing of the outcome, whereas the favorable group showed a blunted P300. Similarly, there was a negative correlation between the P300 amplitude and the ability to develop an optimal strategy on the IGT. In conclusion, behavioral and neuronal data provides evidence that the propensity to focus only on the immediate outcomes is related to the development of an inefficient strategy on the IGT, without influence of motivation.

Event-Related Potentials (ERP) Indices of Motivation during the Effort Expenditure for Reward Task.

Dynamic and temporal facets of the various constructs that comprise motivation remain to be explored. Here, we adapted the Effort Expenditure for Reward Task, a well-known laboratory task used to evaluate motivation, to study the event-related potentials associated with reward processing. The Stimulus Preceding Negativity (SPN) and the P300 were utilized as motivation indicators with high density electroencephalography. The SPN was found to be more negative for difficult choices compared to easy choices, suggesting a greater level of motivation, at a neurophysiological level. The insula, a structure previously associated with both effort discounting and prediction error, was concomitantly activated during the generation of the SPN. Processing a gain significantly altered the amplitude of the P300 compared to an absence of gain, particularly on centroparietal electrodes. One of the generators of the P300 was located on the vmPFC, a cerebral structure involved in the choice between two positive results and their predictions, during loss processing. Both the SPN and the P300 appear to be reliable neural markers of motivation. We postulate that the SPN represents the strength of the motivational level, while the P300 represents the impact of motivation on updating memories of the feedback.

Can transcranial direct current stimulation (tDCS) improve impulsivity in healthy and psychiatric adult populations? A systematic review.

Impulsivity is a multidimensional phenomenon that remains hard to define. It compounds the core pathological construct of many neuropsychiatric illnesses, and despite its close relation to suicide risk, it currently has no specific treatment. Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique whose application results in cognitive function improvement, both in healthy and psychiatric populations. Following PRISMA recommendations, a systematic review of the literature concerning tDCS's effects on impulsive behaviour was performed using the PubMed database. The research was based on the combination of the keyword 'tDCS' with 'impulsivity', 'response inhibition', 'risk-taking', 'planning', 'delay discounting' or 'craving'. The initial search yielded 309 articles, 92 of which were included. Seventy-four papers demonstrated improvement in task performance related to impulsivity in both healthy and clinical adult populations. However, results were often inconsistent. The conditions associated with improvement, such as tDCS parameters and other aspects that may influence tDCS's outcomes, are discussed. The overall effects of tDCS on impulsivity are promising. Yet further research is required to develop a more comprehensive understanding of impulsivity, allowing for a more accurate assessment of its behavioural outcomes as well as a definition of tDCS therapeutic protocols for impulsive disorders.

Behavioral and Electrophysiological Arguments in Favor of a Relationship between Impulsivity, Risk-Taking, and Success on the Iowa Gambling Task.

The aim of the present study was to investigate the relationship between trait impulsivity, risk-taking, and decision-making performance. We recruited 20 healthy participants who performed the Iowa Gambling Task (IGT) and the Balloon Analog Risk Task (BART) to measure decision-making and risk-taking. The impulsivity was measured by the Barratt Impulsiveness Scale. Resting-state neural activity was recorded to explore whether brain oscillatory rhythms provide important information about the dispositional trait of impulsivity. We found a significant correlation between the ability to develop a successful strategy and the propensity to take more risks in the first trials of the BART. Risk-taking was negatively correlated with cognitive impulsivity in participants who were unable to develop a successful strategy. Neither risk-taking nor decision-making was correlated with cortical asymmetry. In a more exploratory approach, the group was sub-divided in function of participants' performances at the IGT. We found that the group who developed a successful strategy at the IGT was more prone to risk, whereas the group who failed showed a greater cognitive impulsivity. These results emphasize the need for individuals to explore their environment to develop a successful strategy in uncertain situations, which may not be possible without taking risks.

Efficacy of transcranial direct current stimulation in reducing impulsivity in borderline personality disorder (TIMBER): study protocol of a randomized controlled clinical trial.

BACKGROUND: Impulsivity is a core feature of borderline personality disorder (BPD) and is closely related to suicide risk and destructive and aggressive behaviors. Although transcranial direct current stimulation (tDCS) has shown its promising effects as an intervention to modulate impulsivity, no study has explored its potential regarding BPD. METHODS/DESIGN: This is a multicenter, crossover, double-blind study comparing active versus sham tDCS (2 mA, 30 min), applied over the dorsolateral prefrontal cortex for five consecutive days in 50 BPD patients. Participants will be assessed for impulsivity, depressive symptoms, and suicide risk. The main efficacy criteria on reduction of impulsivity will be the amplitude variation of one specific evoked potential detected by electroencephalography (EEG) during the balloon analogue risk task. Baseline measures will be compared to scores obtained immediately after sessions, then 12 and 30 days later. DISCUSSION: This study investigates the safety and effects of tDCS, which may have a significant impact on impulsivity in patients with BPD and may be useful to reduce risky behaviors. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03498937 . Registered on 17 April 2018.

[Potential interest of ocular saccades for detection of suicidal behavior in depressed elderly]. / Intérêt potentiel des saccades oculaires pour la détection des conduites suicidaires chez la personne dépressive âgée.

Elderly people, especially those with depression, represent the population most at risk for suicide. In addition to commonly used neuropsychological, psychiatric and biological tests, ocular saccadic analysis can be an interesting tool for identifying suicidal behaviors (SB). These SBs could be associated with an alteration of the cortical structures involved in the executive functions. This alteration is particularly manifested by a decrease in the ability to control eye movements (EM). Thus, depressed elderly people with SB may have a greater impairment of oculomotor performance than those without SB. The purpose of this article is to summarize the literature allowing us to support this hypothesis.

France Will No More Reimburse Available Symptomatic Drugs Against Alzheimer's Disease.

The French Minister of Health published a decree on May 29th of 2018 removing the drugs used to fight against symptoms due to Alzheimer's disease (donepezil, rivastigmine, galantamine, memantine) from the list of available reimbursed drugs. This follows the advice delivered by the High Authority for Health in 2016 and 2018 stating an "insufficient medical benefit and dangerousness because of significant side effects". The main French scientific and medical societies and professional associations want to state here their deep disagreement regarding this unfair decision. The evidence-based medicine related to these drugs reaches a high level in literature, whereas the clinical relevance of these treatments must be considered with co-prescription of psychosocial interventions and related approaches. As no serious pharmacovigilance signal has been provided by health authorities, the ratio of benefits/risks favors these drugs.

Predictors of remission to antidepressants in late-life depression: a systematic review.

Late-life depression is a heterogeneous mood disorder frequently associated with many adverse conditions, including decreased cognitive function and an elevated risk for comorbid medical disorders, as well as with an elevated mortality rate. Late-life depression encompasses both late-onset as well as early-onset depression that occurs or continues into later years of life. Conventional treatment often required several trials of antidepressants before an effective regimen can be found for an individual. This is associated with persistent depressive symptoms, a disability in activities of daily living and an increased risk of suicide and worsening of medical comorbidities. Thus, in the elderly, it is particularly important to identify predictors of treatment remission to reduce these risks. The purpose of this paper was to review the current status of knowledge regarding predictors of remission to antidepressants among older depressed patients. Patients with high number of cardiovascular risk factors, poor performance in working memory, verbal fluency tests and executive functioning, reduced volumes of cerebral structures (hippocampus, anterior cingular cortex, orbitofrontal cortex) were more likely to reach remission. Reduction of depression score during the first weeks of treatment was correlated with remission. However, more studies are needed to confirm these results.