Clinical correlates of anxiety disorders : Tunisian study about 436 subjects

Introduction

Anxiety disorders are very common and burdensome mental illnesses worldwide, characterized by exagerated feelings of worry and fear. These disorders are highly comorbid with other conditions.

Objectives

The aim of our study is to explore the physical and psychiatric comorbidities and their clinical correlates. The second objective is to identify the predictors of recurrence of anxiety disorders.

Methods

Our study concerned 436 outpatients who met DSM-V diagnostic criteria for anxiety disorders and were followed in the Department of Psychiatry of Monastir (Tunisia) between 1998 and 2017. Selective mutism and seperation anxiety were excluded for lack of cases.

Results

Our results demonstrated that Generalized Anxiety Disorder (GAD) was significantly associated with cardiovascular comorbidity (OR=3.208). Social Anxiety Disorder (SAD) was significantly correlated to avoidant personality disorder (OR=17). Patients with suicide attempts are more likely to have a comorbid personality disorder (OR=11.606). Being married and having a later age of onset are predictors of having comorbid depressive disorder. Furthermore, being married, having an anxiety-anxiety comorbidity and a longer duration of untreated illness (DUI) are predictors of recurrence.

Conclusions

Our study highlights the fact that comorbidities (physical and psychopathological) call for a closer follow up due to the higher risk of recurrence, the higher risk of suicide attempts and the poorer treatment response.

Disclosure

No significant relationships.

Factors Associated with Mental Health Outcomes and the Level of Work Engagement Among Health Care Workers Exposed to Coronavirus Disease 2019 in Tunisia

Introduction

Heath workers especiallyin the emergency rooms and emergency medical services are exposed to sustained stress which had increased due to the Pandemic situation

Objectives

To search for factors associated with mental disorders among health workers during the Covid 19 pandemic

Methods

Data were collected through a questionnaire,with demographic variables anddifferentscales to evaluate the degree of symptoms of depression, anxiety, insomnia, distress, and the level of work engagement(PHQ-9,GAD-7,ISI,IES-R,UWES-9).

Results

Of the 217 participants, 46% were physicians, 42% were nurses and 12% were emergency medical technicians. We also found a femalepredominance of 66%, 55% were single and a total of 155 participants of whom 71% were frontline health workers. In our study, 54.8% of the HCWs had symptoms of depression, 68.2% had symptoms of anxiety and insomnia and 71.4% had symptoms of distress. Binarylogisticregressionanalysisshowedthat being married was associated with depression, anxiety, and insomnia, and being a frontlineworkerappeared to be a risk factor for depression and insomnia. Psychiatric support was an independentrisk factor for all psychiatric symptoms.In addition, living in a rural area was associated with depression, and age 31 or older was associated with anxiety. In addition, having a history of psychiatric illness was a risk factor for insomnia. Being a nurse was identified as a risk factor for psychiatric distress. We also found a moderatelevel of professional commitment to be a protective factor.

Conclusions

Protecting healthcare workers is a crucial part of the public health response to the COVID-19 outbreak.

Disclosure

No significant relationships.

Tobacco dependence and schizophrenia: Tunisian cross-sectional study of 50 cases

Introduction

Tobacco-use is currently one of the major public health problems and is more common among patients with schizophrenia.

Objectives

We aimed in this study to estimate the prevalence of smoking in a population of patients with schizophrenia, to assess tobacco dependence and to identify its correlated factors.

Methods

This is a descriptive and analytical cross-sectional study carried out on 50 outpatients at the Department of Psychiatry (Tunisia) over a period of two months. For the data collection, we used: a general questionnaire on sociodemographic characteristics and tobacco consumption and the Fagerström test for nicotine dependence.

Results

All the patients were male with a mean age of 32.7±7.02 years and 84% of them were tobacco consumers. More than half of the sample were single (68%) and had a primary school level (52%). A professional irregularity and low socio-economic level were found successively in 84% and 78% of cases. Half of the patients (52%) were diagnosed with paranoid schizophrenia and 46% of them were treated by atypical antipsychotics. Cigarette dependence was strong or very strong in 82% according to the Fagerstrom test. A positive correlation was found between strong tobacco dependence on the one hand and low socio-economic level, professional irregularity, smoking in a first-degree relative and treatment with a typical neuroleptic on the other hand.

Conclusions

Our study and data from the literature show that subjects with schizophrenia constitute a population of highly dependent smokers. A smoking cessation assistance program for this vulnerable population is a priority to improve their quality of life.

Disclosure

No significant relationships.

Mandatory containment of COVID-19 patients in Monastir: Legislative framework and impact on freedoms

Introduction

Tunisia found itself in an exceptional situation during the covid 19 pandemic requiring a legal regime of exceptionality and sanitary necessity with a double challenge: the fight against the sanitary crisis, and the preservation of democratic gains

Objectives

To describe the legislative framework put in place concerning patients with COVID-19 who stayed at the compulsory containment and to discuss the legality of these emergency decisions

Methods

The authors conducted a descriptive cross-sectional study of patients with COVID-19 staying in the compulsory containment centre of Monastir, with a review of the literature The data were collected through telephone calls. A review of the literature as well as a consultation of the different legislative

Results

The average age was 41.39 ± 1.26 and the sex ratio was 1.17.Imported cases represented 45.3% of the sample and 23% of them expressed a desire to consult a specialist. The duration of mandatory confinement was on average 35.86±1.31 days with extremes ranging from 7 to 86 days. Concerning the legislative framework of the emergency decisions taken during the first wave, the President of the Republic and the Head of Government used Articles 80 and 70 of the Tunisian Constitution, respectively, to issue legislative texts announcing the state of emergency and accompanying. Thus, these legislative measures were restrictive of rights and freedoms and seriously threatened the fragile gains of our democracy

Conclusions

COVID-19 redefined not only the health system but also the economic conditions, as well as the normative and legislative system 2014

Disclosure

No significant relationships.

Trainees between theoreticalknowledge and the initiative takingat the hospital

Introduction

The internshipis a period in which the studentimplements what they have learned from their training to obtain or certification and to promote their professionalintegration, the difficulty of taking initiative and the lack of self-esteemrepresenting an obstacle to their training

Objectives

This is a quantitative descriptive study conducted at the different placement departments among all 2nd-year students in all sections. Our data collection was done using two questionnaires administered, one for the supervisors and the other for the students.

Methods

Theoretical Framework: Theorist Patricia Benner

Results

According to the results found, in oursample, thereis a predominance of females 89.17%, with a sex ratio of 0.121. 88.34% are aged between 20 - 21 years and an averageage of 22.4 years. According to the interpretation of the Rosenberg Self-Esteem Scale scores, 17.5% of the trainees have a “Very Low Self-Esteem”, 47.5% have a “Low Self-Esteem”, 25.83% have an “Average Self-Esteem”, and only 9.17% have a “High Self-Esteem”. In addition, more than half of the respondents, 53.33%, state thatthey “often” have difficultytaking the initiative in the traineeshipenvironment, while 30.83% do not have such difficulty but “rarely”. Indeed, 53.33% of confirmedsupervisorssaythatthey “often” have difficultytaking the initiative in the placement environment

Conclusions

It isnecessary to take into account these obstacles to the trainee’s training through better psychological supervision, which could be the first steptowardssolving the problem

Disclosure

No significant relationships.

Prevalence and clinical features of anxiety disorders: Tunisian study about 436 subjects

Introduction

Anxiety disorders represent one of the most common mental disorders following a chronic course.

Objectives

The aim of our study is to determine the prevalence, incidence and clinical characteristics of these disorders.

Methods

We conducted a retrospective and descriptive study about 436 outpatients fulfilling the DSM-V diagnostic criteria for anxiety disorder and followed in the department of psychiatry of Monastir (Tunisia) between 1998 and 2017. Selective mutism and separation anxiety were excluded for lack of cases.

Results

The overall prevalence was 5.51%. Panic Disorder was the most prevalent anxiety disorder subtype (3.2%). The incidence of anxiety disorders in the last years has increased from 3.31% in 1998 to 7.5% in 2017. The mean age at diagnosis was 37.76±12.87 years [16-77]. Female gender was the most prevalent in overall anxiety disorders with a sex ratio of 0.78, however, a significant male predominance was recorded in Social Anxiety Disorder (SAD) with a sex ratio of 1.85. Generalized Anxiety Disorder patients were more likely to have low educational level (OR= 1.879), to be laborers (OR=2.55), to be married (OR=2.418) and to have children (OR=2.564) whereas SAD patients were more likely to have higher education (OR=9.118), to be students (OR=5.565), to be single (OR=11.325) and have no children (OR=7.464).

Conclusions

This study highlignts the frequency of anxiety disorders and the fact that being a middle-age married woman with kids make oneself more prone to have an anxiety disorder. Specific attention should be paid to these anxiety disorders with early preventive programs.

Disclosure

No significant relationships.

The role of academic factors on the development of mental illness stigma

Introduction

Stigma and discrimination can disrupt the lives of individuals with a mental illness, preventing their opportunities to become productive citizens. These Individuals must also face either an avoidant attitude by healthcare professionals or prejudices about their adherence to medications and the psychological nature of their physical symptoms.

Objectives

Assess stigma in terms of explicit and implicit attitudes among medical school students and junior doctors. Evaluate academic factors and interfering with these attitudes.

Methods

A cross-sectional study was conducted among students from medical schools in Tunisia.

All participants were invited to complete a brief anonymous electronic survey administered on the google forms online platform.

Data were collected using self-administered questionnaires, Stigma Measurement, Mental Illness: Clinicians’ Attitudes (MICA).

Results

The sample consisted of 1028 respondents. The respondents’ mean age was 24.54 years (SD=3.7). Post-clinical students scored higher than pre-clinical students in questions 2, 6, and 12 on the rating scale. A positive significant relationship was identified with specialization in psychiatry. Residents who were specialized in family medicine, emergency, and intensive care had a higher stigma level compared to other residents (Mean score>0.51). The completion of a psychiatry clerkship did not significantly reduce the level of stigma toward people with a mental illness ( p=0.8).

Conclusions

A combination of medical school experiences of psychiatry’s theoretical learning and clerkship are important factors that shape students. Awareness of this will enable educators to develop locally relevant anti-stigma teaching resources throughout the psychiatry curriculum to improve students’ attitudes towards psychiatry as a discipline and mental illness in general.

Disclosure

No significant relationships.

First episode-psychosis: Short- and long-term outcomes and related features predicting the transition to schizophrenia

Introduction

The occurrence of a first episode-psychosis in adolescents or young adults represents a difficult struggle with an uncertain and divergent outcome, since the clinician does not have at his disposal the clinical elements sufficient to predict these different disease trajectories.

Objectives

Our aims are to describe the socio-demographic, clinical characteristics and the short and long-term outcomes of a first episode-psychosis and to identify the predictive factors of the transition to schizophrenia.

Methods

We conducted a retrospective study about 117 patients hospitalized for a first episode-psychosis in the Psychiatric Department of Monastir (Tunisia). Sociodemographic and clinical features were collected using a pre-established form.

Results

First-episode psychosis affected young male subjects with low educational level. Stressors were present in 54.7%. An 8-week prodromal phase preceded the onset of the disorder in 59%. The disorder course included diagnosis of: Brief psychotic disorder (32.5%), schizophrenia (31.6%) and bipolar disorder (18.8%). The short-term outcome was characterized by a complete remission rate of 58.1% at 3 months and 37.6% at 6 months. The long-term outcome was marked by a high rate of lost to follow-up: 70.8% after 5 years. The transition to schizophrenia was linked to the presence of delirium of influence and the absence of favorable course at 3 months.

Conclusions

Our results led to the identification of the profile of patients with a first episode-psychosis and the factors correlated with a diagnosis of schizophrenia. Indeed, the determination of risk factors would make it possible to adapt earlier the care.

Disclosure

No significant relationships.

Impact of temperament on mental illness stigma among medical students

Introduction

Mental illness stigma is the most significant obstacle impeding the wellbeing of individuals with such conditions. Thus, research on determinants of mental illness stigma may be of crucial importance in avoiding these attitudes. Affective temperaments are thought to be present in up to 20% of the healthy general population. However, there are very few studies addressing the relationship between temperament and mental health-related stigma.

Objectives

Evaluate attitudes and behavioral responses of medical students towards individuals with a mental illness. Explore factors associated with stigma including temperament.

Methods

A cross-sectional study was conducted among students in medical universities.

All participants were invited to complete a brief anonymous electronic survey administered on the google forms online platform.

Data were collected using self-administered questionnaires, Stigma Measurement, Mental Illness: Clinicians’ Attitudes (MICA). Students were also asked to complete the TEMPS-A Scale.

Results

The sample consisted of 1028 respondents (9.3% of the total population). Females represented 78,3% of the study sample. A dominant affective temperament was found in 17% of the cases under study, represented mainly by depressive and irritable temperaments. Bivariate correlations performed to assess the association between temperament and mental illness stigma revealed that a positive relationship was identified between the MICA scale and hyperthymic temperament( p=0,04). There were no significant associations between the other type of temperaments and The MICA scale.

Conclusions

Students’ temperament should be considered in developing anti-stigma programs in undergraduate education. Further researches should be undertaken to disentangle the complex relationship among demographic features, personality traits, and attitudes toward people with a mental illness.

Disclosure

No significant relationships.

Depression and quality of life in Tunisian institutionalized elderly subjects

Introduction

Depression in the elderly is common and closely interrelated with the deterioration of the quality of life, especially in the institutionalized elderly.

Objectives

In this work, we propose to determine the prevalence of depression in the elderly in institution, to assess their quality of life and to evaluate the correlations between depression and the quality of life.

Methods

Our study concerned 30 elderly subjects institutionalized at the retirement home(Sousse, Tunisia). Three validated Arabic version scales were used: The 30-item GDS (Geriatric Depression Scale), the MMSE (Mini Mental State Examination) and the SF36 (assessing the quality of life).

Results

The mean age of our population was 75±7.3 years, the sex ratio was 1.73. The prevalence of depression was 37%. The elderly had a cognitive impairment in 16.7%. The mean global SF36 score were 11.2, attesting an altered quality of life in all our subjects: the mental component (9.43) were more altered than the physical one (13.03). No correlation between depression and quality of life was found. Depression was significantly correlated with the presence of a medical history (p=0.05). Depression had a negative and statistically significant correlation with the physical score of SF36 (r=-0.41, p=0.02) and tended towards significance for the “general health” dimension of SF36 (r=-0.32, p=0.08).

Conclusions

Our study shows a high frequency of depression in the institutionalized elderly as well as a deterioration in their quality of life. Depression is strongly linked to deterioration in physical condition.Our results underline the influence of somatic diseases as a major risk factor for depression in the elderly.

Disclosure

No significant relationships.

prevalence of addictions among students at the High School of The Health Sciences and Techniques of Sousse

Introduction

Addiction isfrequent in youngsubjects, particularly in students, who are in contact with psychoactive substances such as drugs, tobacco, alcohol, and cannabis

Objectives

The objectives of our study were to investigate the prevalence of addictions among ESSTSS students and to determine the factors associated with addictions.

Methods

A descriptive correlational cross-sectional study was conducted at ESSTSS among 122 students for 2 months (March and April 2021). The data was collectedusing a questionnaire administered to the students.

Results

There were 102 women and 20 men with an averageage of 20.96 years. theprevalence of drug use was 56.6% according to DAST-10, with addiction notedin 5.7% of cases. The prevalence of tobacco use was 35.3% according to the Fagerstörm test, with 23.3% of the students being highlyaddicted to tobacco. The prevalence of alcohol use was 29.5%, 35% for men, and 28.43% for womenaccording to the AUDIT, alcoholdependence was notedin 14.3% of men and 6.9% of women. The prevalence of cannabis use was 16.4% according to the CAST test, a high risk of dependence was observedin 20% of cases. The analytical study showedthat the factors associated with addiction were age, gender, year of study, and specialty

Conclusions

The prevalence of substance use among health science students is significant and since the use of these substances has a detrimental effect on health itisbetter to understand the associated factors and this obliges us to establish appropriate preventive interventions

Disclosure

No significant relationships.

Value of psychological counseling for trainees exposed to the death of a patient in emergency and resuscitation departments

Introduction

Trainee emergency and resuscitation technicians are not prepared during their academic training to deal with their psychological reactions to the death of a patient, we wanted to describe their feelings and understand the aggravating factors and highlight the need for intervention.

Objectives

Our study aims to describe the psychological reactions of traineesexposed to the death of a patient on the internship grounds and to demonstrate the usefulness of specific psychological counseling

Methods

It is a prospective interventional study carried out with 2nd and 3rd-year students of the emergency and resuscitation section, our collection was done using a self-administered questionnaire with a validated PDI scale before the training, and a satisfaction questionnaire with the same scale after the training.

Results

Our population isyoung, with an averageage of 20.05 years, and ispredominantlyfemale, with a sex ratio of 0.12. Eighty-seven percent of the population statedthatthey were not prepared to deal with their feelings about the death of a patient, and thiseventharmed the quality of care for 68% of the students. According to the scores of the PDI scale in pre-training 77.33% of the students are at risk of developing PTSD, this percentage decreases to 30.67% according to the same scale in post-training.

Conclusions

it is important to take into consideration the suffering of traineesexposed to traumaticevents such as the death of patients and to prepare them psychologically to deal with these situations

Disclosure

No significant relationships.

Child psychiatry expertise in the context of parental separation

Introduction

Marriages’ dissolution phenomenon had increased in recent years in Tunisia. The impact of divorce on children depends on the interweaving of several factors and is not inevitably pathological. We have noticed in our daily practice a concomitant increase in the number of request for expert opinions concerning children.

Objectives

Determine the clinical children’s profile of separated parents carried out within the framework of legal expertise.

Methods

We carried out a retrospective study in the outpatient child psychiatry ward at Fattouma Bourguiba general hospital in Monastir, Tunisia. Including all the expert reports of children affected by parental separations during a period of two years (2017 to 2019).

Results

56 children were included in our study. The average age were (6.7 years) with a majority of males (58.2%). School failure concerned (24%). In most cases, the request for expertise was made in the context of mistreatment’s suspicion (60.7%), than following the parents’ separation (16.1%). Concerning the clinical picture: a normal psychiatric examination was found in the majority of cases (55.4%), anxiety symptoms concerned (32.1%). Cases of depression, global developmental delay and autism were also found.

Conclusions

According to our study, the vast majority of children presented a normal psychiatric examination. Moreover, a preponderant part of the symptoms seemed to result from educational errors. While parental separation poses risks for children, research shows that these negative effects are not the same for everyone. Several factors can reduce these risks and promote children’s resilience. Thus, first-line psychosocial care should be offered for families and children in seprations’ context.

Disclosure

No significant relationships.

The importance of psychological support for end-stage renal disease dialyzed patients

Introduction

End-Stage Renal Disease (ESRD) patients have difficult and challenging lifestyle due to the burden of the disease that, leads to numerous psychological issues. Regardless, healthcare providers usually focus on the somatic side and don’t take care of the psychological dimension.

Objectives

Determine the effect of psychological support on the wellbeing of patients with ESRD.

Methods

A survey sheet including sociodemographic and clinical data were distributed to two different groups. Psychological counseling was given to one of the groups, and wasn’t given to the other one.

Results

Patients not receiving psychological support had higher levels of anxious and depressive symptoms and suicidal ideations compared to the group receiving psychological support that had lower levels of anxious, depressive symptoms and suicidal ideation.

Conclusions

ESRD patients are at risk of developing all sorts of psychological issues. Which underlines the importance of the psychological support associated to the appropriate somatic care.

Disclosure

No significant relationships.

Cancer and the threat of death

Introduction

Fear of death is somehow a normal sensation. Though for those having a cancer, it could increase the burden of the disease and have negative psychological impacts. This death anxiety isn’t easily verbalized by patients, thus it’s important for caregivers to manage it to improve those patients’ quality of life.

Objectives

Assess death anxiety in cancer patients and to identify factors that may influence it

Methods

Our study was a cross-sectional descriptive study with an analytical focus on quantitative specifications. It targeted patients hospitalized at the oncology department or consultant at the day hospital of the regional hospital of Gabes, Tunisia. Participants completed a questionnaire including sociodemographic and clinical data, using HADS scale for anxious and depressive symptoms and DAS scale for death anxiety.

Results

One hundred and twenty patients were enrolled in the study. The average age of participants were 54, 9 ±11, 8 years. The majority of patients were married (68.3%) and had an average socioeconomic level (74, 2%). Our results showed that 43, 3% of patients had a high death anxiety score. Higher level of threat of death, were found in older patients(p=0.028), females (p=0.018) and for those having children (p=0,01). Death anxiety were also higher in patients having anxiety (p=0.007) and those having depression (p=0.033).

Conclusions

The degree of death anxiety among cancer patients seems important. Its assessment and resolution by the caregivers remains paramount. The identification of this death anxiety should optimize the overall care of the patient.

Disclosure

No significant relationships.

The psychological impact of the COVID-19 pandemic and confinement period on a tunisian sample

Introduction

Coronavirus disease 2019, is now a global pandemic that has spread rapidly causing many deaths. Most countries have opted for compulsory confinement which had repercussions on mental health and well-being.

Objectives

The purpose of this study is to assess mental health consequences during the confinement period.

Methods

This is a cross-sectional descriptive study of 360 Tunisians in April and May 2020. We used an anonymous E-questionnaire that included a socio-demographic fact sheet, The HAD questionnaire, and a Q-EDD questionnaire to explore eating disorders.

Results

The subjects of our sample were mostly males with a mean age of 31. The body mass index was 25.5 (range 16.10 -46.24), 15% suffered from obesity. Half of the subjects were single and 6.7% spent the confinement time alone. 11.1% were smokers while 4.4% were alcohol users. The HAD-A and the HAD-D scores had an average of 9.1 and 8.48 respectively.A pathological threshold of anxiety and depression was found in 20% and 30% of the sample respectively.15% had an eating disorder: 76% had binge eating, 20% had bulimia and 17% had anorexia. In our study, we found an association between eating disorder and obesity, single marital status (p=0.007), living alone (p=0.001), history of depression (p=0.046), anxiety (p=0.049) and depression (p=0.038).

Conclusions

Reduced social interactions, decreased physical activity and increased stress are potentially harmful causes for our brain. Confining the population for several weeks has a negative impact on our physical and mental health. A crisis unit has been formed in Tunisia to help subjects overcome these psychological difficulties.

Pain perception in schizophrenia: A neglected phenomenon with a great impact

Introduction

A decrease in pain sensitivity has been observed in patients with schizophrenia since the beginning of the twentieth century. This hypothesis further emerged during the last decades due to many clinical findings.

Objectives

To study pain responsiveness in patients with schizophrenia and explore its physiopathological mechanism through a review of the literature.

Methods

We searched the Medline database with no time restrictions, and we hand searched the references of all retrieved reviews. After removing duplicates, we selected Full-text articles in both French and English languages. Keywords: “schizophrenia”, “pain”, “pain threshold”, “nociceptors”, “opioid receptors”, “opioid peptides”

Results

We have collected 399 references, we finally included 50 Articles only. Many case reports with heterogeneous types of pain concluded that despite the high prevalence of somatic comorbidities in patients with schizophrenia, there was no significant difference in pain complaints between patients with schizophrenia and controls. There was a positive correlation between the decrease in pain sensitivity and schizophrenia. Experimental studies supported a decrease in pain perception and a high pain threshold in those patients. The neurobiological hypothesis suggested the lack of pain transmission by the dysfunctional glutamatergic system and the involvement of the opioid system. these findings have been reported in patients even before starting treatment. The psychopathology theory pointed to the impact of psychotic defenses such as denial and cleavage in the phenomenon of pain insensitivity.

Conclusions

The meticulous research of pain symptoms should be systematic in patients with schizophrenia and the hypoalgesia should be considered when dealing with somatic conditions in this specific population.

Internet addiction in times of COVID-19: Review of the situation

Introduction

Covid-19 pandemic represents a sanitary crisis with social, economic and political negative impacts. Studies had well established the link between stress and the display or maintenance of addictive behaviour. Measures like social distancing and confinement imposed by governments during this pandemic, could explain an outbreak of internet addiction cases.

Objectives

Assess the prevalence of internet addiction in times of the covid-19 pandemic and to study its relationship with personal and family factors but also with the psychiatric comorbidities.

Methods

We conducted a cross sectional analytical study during the period of the covid-19 pandemic, using an internet survey exploring socio-demographic and clinical data: through Hamilton depression and anxiety rating scale and the Rosenberg self esteem scale. The assessment of internet addiction was carried out using Young’s Internet Addiction test.

Results

Our study included 150 users, the average age was 36 years, mainly made up of women, married, having children, with a good socioeconomic level and of university education. The prevalence of depressive and anxious symptoms were respectively 7.3% and 18.7%. The prevalence of internet addiction in our study was 9.4% including 0.7% having severe repercussions. Being married (p<10-3) and having children (p=0.006) were considered as protective factors against internet addiction. People having an internet addiction were at bigger risk of having low self esteem (p=0.023), depressive (p=0.04) and anxious symptoms (p<10-3).

Conclusions

Internet addiction is a new concept, though it’s impact on the well being is well established and it’s likely to worsen in times of pandemic. Therefore, it’s necessary to take preventive measures to deal with it.

Disclosure

No significant relationships.

When healing becomes a burden: The feedback of tunisian psychiatrists

Introduction

Psychiatry is a fascinating medical specialty. Many reasons may motivate early career doctors to choose this field. However, this experience could have a different impact on their quality of life and social functioning.

Objectives

we aimed to assess the impact of psychiatry as a medical career, on the psychiatrist’s quality of life, and to evaluate their feedback on their experience and how it effects their life.

Methods

This is a cross-sectional descriptive study of 68 psychiatrists. An E-questionnaire has been sent via a psychiatrist’s closed groups on social media. We collected sociodemographic data, we also used the stress perceived scale, and we explored the quality of life using the SF-12 questionnaire.

Results

The participants were mostly females with a mean age of 32 years (range25-65). Only 10% of psychiatrists had psychiatric history mostly depression. Concerning substance use, 15% were smokers, 17% used alcohol, 10% smoked occasionally cannabis and 23 % used different psychotropic drugs. 73% our sample were interested in psychiatry during their studies. 60% of our population considered the role of psychiatrists ambiguous among other colleagues. A very high perceived stress was noted in 90 % of our sample. Physical health status was in the average of standard deviation wether mental health status was below average among psychiatrists. The most frustrating situation mentioned was the absence of intermediate structures to receive psychotic patients.

Conclusions

Tunisians psychiatrists are facing many obstacles during the practice of their job, that would transform their passion into demotivation and a desire to leave the country.

Tunisian revolution and the demand of healthcare in psychiatry outward department

Introduction

Tunisian revolution has been a major upheavel in the tunisian history and has brought many political, social and economic changes. Little were found about the revolution’s potential impact on the psychiatric demand.

Objectives

Compare the clinical profile of all the new consultants in the out ward psychiatry department before and after the revolution.

Methods

The study had a retrospective descriptive design including all the new consultants in the outpatient psychiatry department in the general hospital Fattouma Bourguiba in Monastir, Tunisia before (during 2007) and after (during 2016) the revolution. We used a pre-established questionnaire including sociodemographic and clinical data.

Results

After the revolution, an increase in the number of new patients (p<10^-3) 438 to 451 were found. In 2016, there were more unemployed consultants(p=0.004), having criminal record (p=0.01) and having a problematic substance use (p<10^-3). An increase also concerned patients consulting for anxiety(p=0.002) and suicidal ideation (p=0.022). Considering the clinical diagnosis, there were also a significant increase regarding anxiety disorders (p=0.001) and mood disorders (p=0.011) essentially major depressive disorder (p=0.002). Although a significant decrease concerned somatoform disorder (p<10^-3).

Conclusions

Our study showed a change in the profile of consultants after the Tunisian revolution. A study in the general population could find specific etiological factors. Thus highlight the importance of implementing preventive measures in general population in crisis’ times.

Disclosure

No significant relationships.

Aspects culturels de la psychiatrie en Tunisie

L’approche socioculturelle en psychiatrie constitue un champ précieux d’investigation des pathologies mentales. Elle représente, au-delà d’un héritage important, un domaine en constant développement dont l’évolution est tributaire de son inscription dans un contexte intégrant plusieurs intervenants, médecins mais aussi anthropologues, ethnopsychiatres, et sociologues. En effet, l’abord transculturel se multiplie dans l’ensemble des recherches épidémiologiques et cliniques en psychiatrie et maintenant on lui assigne une place essentielle dans les classifications officielles.

Nous nous proposons dans ce présent travail, d’étudier à travers une revue de la littérature et des travaux réalisés dans le service de psychiatrie de Monastir l’implication des aspects culturels en Tunisie dans la survenue des troubles psychiatriques.

Au fil des échanges professionnels entre psychiatres tunisiens, il est apparu que la dimension culturelle infiltrait la pratique de la psychiatrie. Parmi les facteurs liés au patient et à son environnement, on trouve la migration (isolement, défaut de communication, problèmes linguistiques), le chômage, l’inaccessibilité aux soins, la tolérance des familles, le recours à la tradi-thérapie et la pensée magique dans l’explication des manifestations psychiatriques.

Bien que la maladie mentale soit universelle, de nombreuses études transculturelles nationales et mêmes internationales ont montré des aspects différentiels et comparatifs des troubles mentaux suivant les différentes cultures. Cette divergence clinique a fait l’unanimité de la littérature quant à l’influence significative de la culture dans la survenue des troubles psychiatriques, mais n’ont pas encore, bien sûr, d’établir une relation de causalité.

L’histoire, la littérature et notre pratique clinique quotidienne attestent que notre culture maghrébine peut influencer largement la forme, le contenu, l’ampleur des manifestations cliniques et le pronostic des troubles mentaux. L’ensemble de ces aspects culturels requiert une évaluation fine et systématisée par les thérapeutes psychiatres afin d’offrir une prise en charge globale, ciblée et s’intégrant dans un projet de soins personnalisé.

[Dyslipidemia and suicidal risk in patients with psychiatric disorders]

The aim of this work is to study the association between dyslipidemia and suicidal risk in patients with psychiatric pathology. Our study has involved 155 patients suffering from major depressive disorder and 124 schizophrenic patients aged 40.58±12.16 and 43.43±10.60 years, respectively. Total cholesterol (TC), triglycerides (TG) and HDL-c were determined by enzymatic methods, LDL-c was calculated by the Friedewald formula. Plasma cholesterol level was significantly lower among suicidal schizophrenic or depressive patients. There were no significant differences in the others lipid levels. The results of our study suggest that total cholesterol values less than 3.59mmol/L could be an indicator of suicide vulnerability in patients with schizophrenia or major depressive disorder.

Is low total cholesterol levels associated with suicide attempt in depressive patients?

BACKGROUND

Patients with major depressive disorder (MDD) have a high risk of suicide. Many pathophysiological factors involved in MDD and suicide such us a low cholesterol levels have been associated with MDD and increased vulnerability to suicide. In this study, we investigate the relation between lipid parameters and suicide risk in patients with MDD.

METHODS

Plasma levels of total cholesterol, triglycerides, and high-density lipoprotein cholesterol (HDL-c) and low-density lipoprotein cholesterol (LDL-c) were determined in 160 patients meeting the DSM-IV-TR criteria for MDD (110 patients without suicidal behavior and 52 suicidal attempters) and 151 healthy controls.

RESULTS

A significant decrease in plasma cholesterol levels was observed in the group of suicidal depressive patients compared to those without suicidal behavior (p < 0.001). For the other lipid levels (triglycerides, HDL cholesterol, and LDL cholesterol), there were no significant differences between suicidal and non-suicidal patients.

CONCLUSIONS

Our study showed a significant decrease in plasma cholesterol levels in suicidal patients. This result support the hypothesis of the association of low plasma cholesterol level and suicidal behavior in patients with major depressive disorder.

Is lithium implicated in tobacco addiction?

Introduction

Tobacco is a source of mineral elements that can affect human health in various ways, such as lithium, which is used as a psychiatric medication. Lithium salts are used as mood-stabilizing drugs and indicated in the treatment of manic-depressive psychosis.

Objective

Studying the lithium content in tobacco over the smokers’plasma content and evaluate the potential role of lithium in tobacco addiction.

Methods

A total of 18 different tobacco products (cigarettes, smokeless and water pipe tobacco) and 125 plasma samples (45 from smokers, 10 from ex-smokers and 70 from non-smokers) were collected to determinate the lithium content. Tobacco samples were digested with nitric acid and lithium concentration was measured by inductively coupled plasma-optical emission. The collected plasma samples were diluted 1/10 with a nitric acid solution and the lithium level was measured by inductively coupled plasma-mass spectrometry.

Results

The average concentration of lithium in the cigarettes (16.59 ± 0.59 μg/g) was higher compared to those in the smokeless tobacco (8.39 ± 4.44 μg/g) and in the water pipe tobacco (6.13 ± 6.32 μg/g) but with no significant difference (P = 0.182). For plasma lithium levels, there was no significant difference (P = 0.186) between smokers and non-smokers (6.20 ± 6.24 vs. 4.98 ± 6.20 μg/g). However, a significant negative correlation was noted between plasma and the lithium content in tobacco products (r = –0.435; P = 0.04). The lithium plasma level was significantly and negatively correlated with the dependence score (r = –0.316; P = 0.031).

Conclusion

The correlation between plasmatic lithium and dependence score in smokers suggests that lithium would be involved in tobacco addiction probably through his regulating action of mood.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Effect of cigarette smoking on insulin resistance risk

OBJECTIVES

Smoking is one of the main risk factors for cardiovascular disease (CVD). The mechanism(s) of the effects of smoking on CVD are not clearly understood; however, a number of atherogenic characteristics, such as insulin resistance have been reported. We aim to investigate the effects of cigarette smoking on insulin resistance and to determine the correlation between this parameter with smoking status characteristics.

STUDY DESIGN

This study was conducted on 138 non-smokers and 162 smokers aged respectively 35.6±16.0 and 38.5±21.9 years. All subjects are not diabetic.

METHODS

Fasting glucose was determined by enzymatic methods and insulin by chemiluminescence method. Insulin resistance (IR) was estimated using the Homeostasis Model of Assessment equation: HOMA-IR=[fasting insulin (mU/L)×fasting glucose (mmol/L)]/22.5. IR was defined as the upper quartile of HOMA-IR. Values above 2.5 were taken as abnormal and reflect insulin resistance.

RESULTS

Compared to non-smokers, smokers had significantly higher levels of fasting glucose, fasting insulin and HOMA-IR index. These associations remained significant after adjustment for confounding factors (age, gender, BMI and alcohol consumption). A statistically significant association was noted between the smoking status parameters, including both the number of cigarettes smoked/day and the duration of smoking, and fasting insulin levels as well for HOMA-IR index. Among smokers, we noted a positive correlation between HOMA-IR index and both plasma thiocyanates and urinary cotinine.

CONCLUSION

Our results show that smokers have a high risk to developing an insulin resistance and hyperinsulinemia, compared with a matched group of non-smokers, and may help to explain the high risk of cardiovascular diseases in smokers.

[Minor neurological and physical anomalies in patients with first-episode psychosis]

INTRODUCTION

Over the last several decades, there has been an increasing number of neuroanatomical, neuroimaging, neurophysiological, and neuropsychological studies in search of structural, functional, and cognitive correlates of brain insult(s) that could ultimately lead to unravelling the pathophysiology of schizophrenia. A direct, easily administered, and inexpensive way of investigating brain dysfunction in schizophrenia is the study of neurological soft signs and minor physical anomalies, two putative indices of developmental abnormality. The study of these neurodevelopmental markers in the first-episode psychosis allows the detection of the neurodevelopmental abnormalities at the onset of psychosis.

AIMS OF THE STUDY

The objectives of our study were to determinate the prevalence, the scores, and the nature of neurological soft signs (NSS) and minor physical anomalies (MPA) in patients with first-episode psychosis and to explore the correlations between these neurodevelopmental markers and the demographic, clinical and therapeutic features.

METHOD

A cross-sectional study was carried-out on 61 patients (mean age: 28.9±9.4years; 86.9% were males), hospitalized for first-episode psychosis (DSM-IV-TR diagnosis of schizophrenia, schizophreniform disorder, brief psychotic disorder, delusional disorder, and psychotic disorder not otherwise specified). The evaluation procedure consisted of a retrospective assessment of the premorbid functioning by the Premorbid Functioning Scale (PAS) and the following clinical scales: Positive and Negative Symptoms Scale (PANSS), Clinical Global Impression (CGI) and Global Assessment of Functioning (GAF), the NSS scale of Krebs et al. (23 items exploring motor coordination, motor integrative function, sensory integration, involuntary movements or posture, quality of lateralization) and the MPA scale of Gourion et al. (41 items, exploring anomalies of face, eyes, ears, mouth, hands and feet).

RESULTS

The prevalence of NSS was 83.6% (cut-off point=9.5), with a mean total score of 15.3±6.7. The highest score was for the motor coordination. The prevalence of MPA was 62.7% (cut-off point=5), with a mean total score of 5.8±3.2. The most common MPA were the fine hair (50.8%), adherent earlobes (49.2%) and clinodactyly (31.1%). Correlations were found between the NSS total score and the Poor Premorbid Functioning (r=0.32, P=0.04), the PANSS total score (r=0.36, P=0.005), and the negative (r=0.45, P<0.001) and disorganization sub-scores (r=0.41, P=0.001), the CGI-severity of (r=0.30, P=0.02), the impairment functioning in the GAF (r=-0.26, P=0.04) and with extrapyramidal symptoms (r=0.52, P<0.001). However, no correlation was found between the NSS total scores, age, gender, the PANSS positive sub-score, the daily dosage of antipsychotics, the CGI-improvement score and the MPA total score. There was no correlation between MPA total score and demographic, clinical and therapeutic features of patients. Moreover, there was no correlation between the NSS or MPA scores and the short-term evolution (6months to 1year) towards schizophrenia.

CONCLUSION

These results confirm the data in the literature relating high NSS and MPA scores in patients with a first-episode psychosis. The NSS appear to characterize severe psychotic disorders with more negative and disorganization symptoms and poor social functioning and may be a prognostic indicator.

[Screening for depression in an elderly population living at home. Interest of the Mini-Geriatric Depression Scale]

BACKGROUND

Depression is the most usual mental disorder in the elderly, but underdiagnosed and undertreated. Its prevalence is variable. Symptoms of depression present in the elderly can be masked and difficult to recognize. The purpose of this study was to examine prevalence and risk factors for depression in elderly living in their home.

METHODS

A cross-sectional study of randomly selected homes in randomly selected geographical islets was carried out Monastir City (Tunisia). Questionnaire-based interviews were conducted among the elderly aged more than 65 years living in their home. Depression symptoms were assessed using a Mini-Geriatric Depression Scale. The relationship between the risk of depression and sociodemographic and health-related variables was studied using logistic regression.

RESULTS

Out of 598 (female 66 %, mean (SD) age 72.3 (7.4) years) elderly persons interviewed, 136 (22.7 %) were screened to have a Mini-Geriatric Depression Scale more than or equal to 1. Multiple logistic regression analysis revealed that the following were significant (P<0.01) independent predictors of risk of depression: female sex (OR=2.36 [95 % CI=1.43-3.94]), having a low level of education (OR=4.02 [95 % CI=1.38-11.65]), disability (OR=3.50 [95 % CI=1.94-6.46]), a history of stroke (OR=2.90 [95 % CI=1.20-7.72]) and the use of hypnotic medications (OR=2.47 [95 % CI=1.38-4.42]).

CONCLUSION

This study suggests that the risk of depression is a common psychiatric disorder in elderly living in their home, and underlines the usefulness of the Mini-Geriatric Depression Scale to detect the risk of depression in the elderly. This clinical approach should be encouraged in all medical practices to improve the prognosis of depression in the elderly.

Le syndrome prémenstruel: revue générale

Premenstrual syndrome (PMS) is a recurrent disorder that occurs in the luteal phase of the menstrual cycle. It is characterized by intense physical, psychological, and behavioral changes that interrupt interpersonal relationships and disrupt the lives of affected women. Premenstrual syndrome is believed to affect 75% of women of childbearing age. Because no tests can confirm PMS, the diagnosis should be made on the basis of a patient-completed daily symptom calendar and the exclusion of other medical disorders. PMS symptoms occur during the luteal phase of the menstrual cycle and remit with the onset of menstruation or shortly afterward. The aetiology of PMS is still unknown uncertain, but are likely associated with aberrant responses to normal hormonal fluctuations during the menstrual cycle. A wide range of therapeutic interventions has been tested in the treatment of premenstrual symptoms. Most non-pharmacological interventions that have been proven efficacious require a series of interventions. If non-medical approaches are ineffective, drug therapy may be appropriate. Several pharmaceutics agents have been shown to relieve symptoms. Calcium carbonate and selective serotonin reuptake inhibitors have demonstrated excellent efficacy.

Vitiligo et qualité de vie : étude cas-témoins

BACKGROUND

Vitiligo is a common and visible form of leukoderma that can adversely affect the quality of life of patients. The aim of this study was to assess the impact of vitiligo on the quality of life of patients.

PATIENTS AND METHODS

This was a cross-sectional case-control study performed between 1 September 2000 and 31 December 2001. Sixty patients with vitiligo and 60 controls paired for age and gender were collated. Quality of life was assessed using the Dermatology Life Quality Index (DLQI).

RESULTS

Mean patient age was 38.9 years. The sex-ratio M/F was 1.1. Vitiligo was generalized in 80% of cases. Quality of life was significantly impaired in patients and to a greater extent in women and in cases affecting more than 10% of the body surface. All aspects of quality of life were affected.

CONCLUSION

Because of its visible nature, vitiligo can impair patients' quality of life and have marked psychological impact.

Implication du stress oxydant dans la physiopathologie de la schizophrénie : revue de la literature

BACKGROUND

Schizophrenia is a devastating psychiatric disorder with a broad range of behavioural and biologic manifestations. There are several clinical characteristics of the illness that have been consistently associated with poor premorbid adjustment, long duration of psychosis prior to treatment and prominent negative symptoms. The etiopathogenic mechanisms of lack of insight in patients with schizophrenia are to date unknown, although several hypotheses have been suggested. A point of convergence for the theoretical models occurs with regard to the neuronal membrane. Neuronal membrane contains a high proportion of polyunsaturated fatty acid and is the site for oxidative stress. Oxidative stress is a state when there is unbalance between the generation of reactive oxygen species and antioxidant defence capacity of the body. It is closely associated with a number of diseases including Parkinson's disease, Alzheimer-type dementia and Huntington's chorea. Accumulating evidence points to many interrelated mechanisms that increase production of reactive oxygen or decrease antioxidant protection in schizophrenic patients.

OBJECTIVES

This review aims to summarize the perturbations in antioxidant protection systems during schizophrenia, their interrelationships with the characteristic clinics and therapeutics and the implications of these observations in the pathophysiology of schizophrenia are discussed.

LITERATURE FINDINGS

In schizophrenia there is evidence for deregulation of free radical metabolism, as detected by abnormal activity of critical antioxidant enzymes (superoxide dismutase, glutathione peroxidase and catalase). Many studies conclude in the decrease in the activity of key antioxidant enzymes in schizophrenia. A few studies have examined levels of non enzymatic antioxidants such as plasma antioxidant proteins (albumin, bilirubine, uric acid) and trace elements. How showed decreased levels in schizophrenic patients. Others studies have provided evidence of oxidative membrane damage by examining levels of lipid peroxidation products. Such abnormalities have been associated with certain clinical symptoms and therapeutic features. Negative symptoms have been associated with low levels of GSH-Px. Positive symptoms have been positively correlated with SOD activity. Plasma TAS was significantly lower in drug-free and haloperidol treated patients with schizophrenia. A low erythrocyte SOD activity has been found in never-treated patients, but with haloperidol treatment, SOD activity increased.

DISCUSSION

These results demonstrate altered membrane dynamics and antioxidant enzyme activity in schizophrenia. Membrane dysfunction can be secondary to free a radical-mediated pathology, and may contribute to specific aspects of the schizophrenia symptomatology. Membrane defects can significantly alter a broad range of membrane functions and presumably modify behavior through multiple downstream biological effects. Phospholipid metabolism in the brain may be perturbed in schizophrenia, with reduced amounts of phosphatidylcholins and phosphatidylethanolamine in post-mortem brain tissue from schizophrenic patients, and large amounts of lipofuscin-like materiel in the oligodendrocytes. The existence of these products within cell membranes results in an unstable membrane structure, altered membrane fluidity and permeability and impaired signal transduction. Recent findings suggest that multiple neurotransmitter systems may be faulty. CNS cells are more vulnerable to the toxic effects of free radicals because they have a high rate of catecholamine oxidative metabolic activity. Neurotransmitters, like glutamate, can induce the same metabolic processes that increase free radical production and can lead to impaired dopamine-glutamate balance. These results question the role of this imbalance in the biochemical basis evoked in the etipathogenic mechanisms of schizophrenia, as well as the role of antioxidants in the therapeutic strategy and their implication in preventive and early intervention approaches in populations at risk for schizophrenia.

[Repeat suicide attempts: characteristics of repeaters versus first-time attempters admitted in the emergency of a Tunisian general hospital]

Repeat suicide attempts constitute a special problem in suicidology. It seems that the excess mortality by suicide is even higher among the suicide repeaters. The objectives of this study were to estimate repeat suicide attempts frequency among a sample of suicide attempters admitted in the University Hospital Emergency of Monastir (Tunisia), to compare their features to those of first-time attempters and to determine factors associated with repeat suicide.

METHOD

A transversal survey involves a review of all patients committing suicide attempt and who are admitted in the emergency service during the second semester of 1999. Study variables included: demographic parameters, family and personal psychiatric history, axis I psychiatric disorder and circumstances of the present suicide attempt. Also, subjects were evaluated with the following scales: Montgomery and Asberg Depression Rating Scale (MADRS) and The Social Readjustment Rating Scale of Holms and Rahe.

RESULT

Among the 90 suicide attempters, 42.2% (n = 38) had made at least one previous suicide attempt. More repeaters than first-time attempters were divorced or separated: 21.1% versus 5.8% (p = 0.05). Belonging to a numerous family (n > or = 4) was more frequent in the repeaters group: 73.7% versus 46.2% (p = 0.01). The two groups did not differ as to level of education but were significantly different with regard to their professional activity: 60.5% of repeaters were unemployed versus 34.6% of first-time attempters (p = 0.01). Repeaters had more loaded family psychiatric disorders: 26.3% versus 7.7% (p = 0.03). However there were practically no differences between repeaters and first-time attempters in regard of suicide in their families. Personal previous history of repeaters was characterized by frequency of psychiatric hospitalization: 50% versus 11.5% (p = 0.00005). Sexual abuse was more frequent in repeaters group but this difference was not significant. Alcohol and drug abuse were not frequent in the two groups. Concerning the actual suicide attempt, the most frequently diagnosed disorder was adjustment disorders. However depressive and psychotic disorders were significantly more frequent in the repeaters group: 34.2% versus 13.4% (p = 0.05). Repeaters had more frequently elevated scores (> 14) in MADRS: 71.1% versus 48.1% (p = 0.01), and raised intensity of stress factors lived during the six months preceding actual suicide attempt: 68.4% versus 42.3% (p = 0.04). Nevertheless we hadn't noticed any differences between the two groups regarding the methods used or the motives.

CONCLUSION

Differences in the characteristics of repeaters and first-time attempters are therefore of interest when discussing future suicidal risk and should clear on preventive actions in order to face the increase of suicidal recidivism. A broad based, multidisciplinary intervention approach is recommended.

[Bipolarity correlated factors in major depression: about 155 Tunisian inpatients]

The distinction between the depressive troubles according to their inclusion in bipolar disorders or in recurrent depressive disorders offers an evident practical interest. In fact, the curative and mainly the preventive treatment of these troubles are different. So it is necessary to identify the predictive factors of bipolar development in case of inaugural depressive episode. In 1983, Akiskal was the first who identified those factors: pharmacological hypomania, puerperal depression, onset at early age (<25 years), presence of psychotic characteristics, hypersomnia and psychomotor inhibition. Through this study, the authors try to compare the epidemiological, clinical and evolution characteristics of major depression in bipolar disorders to recurrent depressive disorders in order to indicate the correlated factors with bipolarity. It is a retrospective and comparative study based on about 155 inpatients for major depressive episode during the period between January 1994 and December 1998. These patients were divided into two groups according the DSM IV criteria: bipolar group (96 patients) and recurrent depressive group (59 patients). Both groups were compared according to socio-demographic data, life events in childhood, personal and family history, clinical and evolution characteristics of the index depressive episode. The predictive factors proposed by Akiskal were systematically examined. It was found out that the following factors were correlated with bipolarity: high rate of separation and divorce (17.7% versus 5.1%; p=0.02), family history of psychiatric disorders (56.3% versus 35.6%; p=0.012) especially bipolar ones (29.2% versus 3.4%; p=0,00008), onset at early age (mean age of onset: 24.8 8.2 years versus 34.1 12.6 years; p=0.000004), number of affective episode significantly more frequent (mean 3.6 versus 2.5; p=0.03), sudden onset of depressive episode (44.8% versus 15.9%; p=0.0003) and presence of psychotic characteristics (69.8% versus 16.7%; p=0.0001) catatonic characteristics (37.3% versus 20.3%; p=0.03), hypersomnia (51% versus 20.3%; p=0.03) and psychomotor inhibition (83.3% versus 42.4%; p=0.00007). Negatively correlated factors of bipolar depression were: somatic comorbidity such as diabetes, hypertension and rhumatismal diseases (12.5% versus 28.8%; p=0.012) and association with dysthymic disorders (2.2% versus 12.1%; p=0.029). No correlation was found between bipolarity and life events in childhood, seasonal character, alcoholic dependence and suicide attempt. Concerning the validity of predictive factors of bipolarity proposed by Akiskal, we found: history of bipolar disorders (Sensibility: 29.2%, specificity: 96.6%, Positive Predictive Value (PPV): 93%), hypersomnia (Sensibility: 51%, specificity: 80%, PPV: 80%), onset before the age of 25 years (Sensibility: 62.5%, specificity: 70%, PPV: 77%), psychomotor inhibition (Sensibility: 83.3%, specificity 58%, PPV: 76%), and psychotic characteristics (Sensibility: 69.8%, specificity: 62.7%, PPV: 75%). In spite of methodological differences, our results tallied with the other studies. We focus on the importance of the bipolar family history criterion, which has the highest PPV, and the limits of psychotic characteristics criterion which has the lowest PPV. This may be explained by the frequency of these characteristics of affective disorders in our cultural context. The association of the hypersomnia and psychomotor inhibition in one criterion in order to increase their diagnostic power. Our study helps us to identify the factors that would predict the bipolar evolution of a depressive episode allowing the use of specific treatment and ensuring the improvement of prognostic.

[Pharmacological modulation of the effects induced by ketamine at subanesthetic doses]

The similarity between ketamine effects and endogenous psychoses has created interest in the capacity of antipsychotic medications to block ketamine effects. In healthy subjects, a sub-anaesthetic single dose of lorazepam, typical neuroleptics, such as haloperidol, and atypical neuroleptics, such as clozapine and olanzapine, failed to block ketamine-induced positive and negative symptoms resembling schizophrenia. However, haloperidol is able to decrease ketamine-induced impairment in executive cognitive functions. Recently, lamotrigine reduced ketamine-induced psychotic symptoms, perceptual alterations, and cognitive impairments. In schizophrenic subjects, single doses of olanzapine do not decrease the effects of ketamine. However, long term treatment with clozapine has been reported to decrease ketamine-induced positive symptoms. Pharmacological modulation of the effects of NMDA receptor antagonists, such as ketamine, may lead to development of novel therapeutic agents for psychiatric illnesses such as schizophrenia.

[Glutaminergic hypothesis of schizophrenia: clinical research studies with ketamine]

Several lines of evidence suggest that the glutamatergic N-methyl-D-aspartate (NMDA) receptor is involved in schizophrenia pathophysiology. Post-mortem studies have revealed a lower density of glutamatergic receptors in patients with schizophrenia. Other studies of cerebrospinal fluid reported lower levels of glutamate in patients with schizophrenia in healthy comparison subjects. The most compelling evidence is provided by the psychomimetic effects of the NMDA antagonists phencyclidine and ketamine. Recently, much interest has been given to the study related to the role of NMDA receptor in pathophysiology of schizophrenia by administration of sub-anesthetic doses of ketamine. A phencyclidine hydrochloride derivate, ketamine, is a dissociative anesthetic and a non competitive antagonist of the NMDA receptor. In healthy subjects, ketamine produces: 1) positive symptoms of psychosis, such as illusions, thought disorder and delusions; 2) negative symptoms similar to those associated with schizophrenia including blunted emotional responses, emotional detachment, and psychomotor retardation; 3) cognitive impairments, in particular impairments on tests of frontal cortical function including increased distractibility, reduced verbal fluency and poorer performance on the Wisconsin Card Sorting Test. During smooth pursuit eye tracking, ketamine induces nystagmus as well as abnormalities which are among the characteristics of schizophrenia. In patients with schizophrenia, the administration of ketamine produces an activation of their psychotic symptoms, which have striking similarities to symptoms of their usual psychotic episodes. Ketamine effects on memory and other cognitive functions in schizophrenic patients are controversial. The psychomimetic effects of ketamine are transitional, reversible and influenced by time, dose and administration conditions. Susceptibility to the psychotomimetic effects of ketamine is minimal or absent in children and becomes maximal in early adulthood. The similarity between ketamine effects and endogenous psychoses created interest in the capacity of antipsychotic medications to block ketamine effects. Haloperidol failed to block this ketamine-induced psychomimetic effects in healthy subjects and in schizophrenic patients. However, clozapine, the prototype of atypical antipsychotic agents significantly reduced the ketamine-induced increase in positive symptoms in schizophrenic patients. Recently, lamotrigine significantly decreased ketamine-induced positive and negative symptoms in healthy subjects. Brain regions responsible for NMDA-mediated psychosis have not been established. Using positron emission tomography and [18F] fluorodeoxyglucose, the sub-anesthetic ketamine administration produces bilateral increases in metabolic activity in the prefrontal cortex. In a [15O] H2O positron emission tomography study, ketamine selectively increases cerebral blood flow in the anterior cingulate cortex and reduces cerebral blood flow in the hippocampus and primary visual cortex. The mechanism of neuropsychiatric effects of sub-anesthetic ketamine is not clear. A dysfunction in glutamate-dopaminergic interactions has been suggested as a mechanism for these effects of ketamine. Ketamine has been reported to primarily block NMDA receptor complex giving support to a glutamate deficiency hypothesis in schizophrenia. In addition, ketamine caused increases in cortical and striatal synaptic dopamine concentrations. The effects of NMDA receptor antagonist administration are argued to support a neurobiological hypothesis of schizophrenia, which includes pathophysiology within several neurotransmitter systems, manifested in behavioral pathology. Pharmacological modulation of the effects of NMDA receptor antagonists, such as ketamine, may lead to development of novel therapeutic agents for psychiatric illnesses such as schizophrenia.

[Acute nuptial psychosis: apropos of 16 cases]

The marriage, an over-invested social event in our Maghrebin cultural context, can, in certain cases, generate major psychiatric disorders especially of psychotic types. The aim of our study is to describe the clinical specifications of these psychotic disorders and to discuss the surroundings and individuals factors incriminated in their genesis. Our retrospective study concerns sixteen patients suffering from acute psychotic disorders precipitated by marriage. Male subjects represented 75% of cases with an average age of 26.8 years. 62.5% of them have no psychiatric background. The disorders first appeared after the marriage in 75% of cases, often during the first week. 68% of cases have delirious syndrome. Schizophreniform and brief psychotic disorders were often reported. The importance of the cultural factors was particularly prominent in the starting of these disorders.