Si les murs pouvaient parler… Contenance et enveloppes d’un lieu de soins ambulatoires en addictologie, étude qualitative par la photo-élicitation

Les addictions sont un enjeu majeur de santé publique. Leur prise en charge thérapeutique au sein de lieux de soins spécialisés fait en priorité appel à la capacité contenante de l’institution. L’objet de cette étude a été de préciser le regard porté par les patients d’un centre de soins, d’accompagnement et de prévention en addictologie sur leur lieu de soin à travers une méthode de photo-élicitation. Les patients participants ont été invités à prendre des photos des lieux. Dix entretiens individuels ont été réalisés, centrés sur deux photos par patient. L’analyse du discours recueilli a été menée selon l’Interpretative Phenomenological Analysis, en s’appuyant en particulier sur les métaphores des lieux suscitées par les photos, pour décrire les qualités et défaillances des phénomènes de contenance et d’enveloppement à l’œuvre dans leur lieu de soin chez les sujets rencontrés. Les résultats rendent compte de la potentielle portée symbolique des murs et des objets qui composent le lieu et de sa capacité à fournir des enveloppes aux patients. Le lieu de soin est décrit comme protecteur (abri et refuge, garant du secret, pourvoyeur d’espaces intermédiaires) et menaçant (lieu de restriction de liberté et d’enfermement, source d’exposition, lieu de duel). L’abord par les lieux s’avère pertinent, révélant ses qualités projectives : projection des représentations de l’altération des propres enveloppes psychiques et corporelles des patients et support d’expression de conflits potentiellement à l’œuvre dans la relation de soin avec les sujets souffrant d’addiction. Le détour par les lieux a permis de recueillir un matériel riche et original et la photo-élicitation s’est révélée être une méthode de recherche particulièrement contenante pour les participants. Ces résultats présentent également des perspectives cliniques car ils supportent l’intérêt de l’élaboration institutionnelle de l’aménagement du lieu de soin. Premier contenant offert à la relation de soin, remplissant les conditions de solidité et de pare-excitation préalables à l’exercice de la fonction conteneur du soin (Kaës, 1979), le lieu se prête à un remodelage dynamique à l’image des valeurs soignantes de l’équipe qui l’habite, pour acquérir ses propriétés d’enveloppe thérapeutique adjuvante, à l’articulation entre le collectif et le singulier.

Clinical relevance of electroconvulsive therapy (ECT) in adolescents with severe mood disorder: evidence from a follow-up study

Given the limited knowledge on the long-term outcome of adolescents who receive electroconvulsive therapy (ECT), the study aimed to follow-up adolescents treated with ECT for severe mood disorder. Eleven subjects treated during adolescence with bilateral ECT for psychotic depression (n = 6) or mania (n = 5), and ten psychiatric controls matched for sex, age, school level, and clinical diagnosis, completed at least 1 year after treatment a clinical and social evaluation. Mean duration between time of index episode and time of follow-up evaluation was 5.2 years (range 2-9 years). At follow-up: (1) all patients except two in the control group received a diagnosis of bipolar disorder. (2) Fifteen patients had had more than one episode of mood disorder. (3) The two groups did not differ in social functioning nor school achievement. (4) Impact on school achievement was related to the severity of the mood disorder rather than ECT treatment. The results suggest that adolescents given ECT for bipolar disorder, depressed or manic, do not differ in subsequent school and social functioning from carefully matched controls.

Electroconvulsive therapy in adolescents with mood disorder: patients' and parents' attitudes

The aim of the study was to assess retrospectively patients' and parents' experiences and attitudes towards the use of electroconvulsive therapy (ECT) in adolescence. The experiences of subjects (n=10) who were administered ECT in adolescence for a severe mood disorder and their parents (n=18) were assessed using a semi-structured interview after a mean of 4.5 years (range, 19 months to 9 years). Their attitudes were mostly positive and ECT was considered a helpful treatment. Concerns were frequently expressed, probably because ECT was not fully understood by the patients and their families. Most complaints were of transitory memory impairment. The parents were satisfied with the consent procedure, while all but one patient did not remember the consent procedure. We concluded that, despite negative views about ECT in public opinion, adolescent recipients and their parents shared overall positive attitudes towards the use of ECT in this age range.

Borna disease virus and psychiatry

Borna disease virus (BDV), a noncytolytic neurotropic nonsegmented negative-stranded RNA virus with a wide geographic distribution, infects several vertebrate animal species and causes an immune-mediated central nervous system (CNS) disease with various manifestations, depending on both host and viral factors. In animal infections, BDV can persist in the CNS and induce alterations in brain cell functions, neurodevelopmental abnormalities and behavioral disturbances. An association between BDV and psychiatric disorders (essentially schizophrenia and affective disorders) has been suggested by some serologic and molecular studies but further investigations are required to substantiate the possible contribution of this virus to the pathogenesis of these disorders.

Electroconvulsive therapy in adolescence

The aim of this work is to discuss the ethical issues regarding the use of electroconvulsive therapy (ECT) in adolescents. Ethical implications of ECT in adolescents are analyzed in the light of general medical ethics, which include five prominent principles with respect to autonomy, nonmaleficence, beneficence, justice, and cautiousness. As adults, adolescents with acute psychotic impairment raise an inherent conflict between the respect for the patient's autonomy, on the one side, and the principle of beneficence on the other. However, this age group presents particular dilemmas: (i) As any adolescent suffering from a psychiatric illness is a highly vulnerable subject, society asks for particular attention. The consequence of potential overprotection is that the adolescent may remain untreated because of unrealistic fears regarding ECT. (ii) Some of these fears are linked to the cognitive secondary effects of ECT. Although preliminary data are reassuring, more empirical research on this population should be encouraged. (iii) Cautiousness recommends the use of ECT in limited indications catatonia, mood disorders, and intractable acute psychotic disorders. We conclude that there is no ethical reason to ban the use of ECT in adolescents. Ethical options in clinical practice must be evaluated empirically with respect to the consequences for the patient. Dogmatic views should be set aside.

Absence of cognitive impairment at long-term follow-up in adolescents treated with ECT for severe mood disorder

OBJECTIVE

Cognitive functions of adolescents treated with ECT for mood disorder were evaluated at long-term follow-up.

METHOD

At an average of 3.5 years (SD=1.7) after the last ECT, 10 subjects treated during adolescence with bilateral ECT for severe mood disorder completed a clinical and cognitive evaluation, including the California Verbal Learning Test and Squire's Subjective Memory Questionnaire. The same assessments were given to 10 psychiatric comparison subjects matched for sex, age, and diagnosis.

RESULTS

All cognitive test scores of the patients treated with ECT were similar to those of the comparison subjects and did not differ from norms from the community. Six of the 10 ECT-treated patients reported having had memory losses immediately after the ECT course, but only one complained of subjective memory impairment at follow-up.

CONCLUSIONS

The results suggest that adolescents given ECT for severe mood disorder do not suffer measurable cognitive impairment at long-term follow-up.