Effectiveness of a French Program to Prevent Suicide Reattempt (VigilanS)

AIM

Brief contact interventions (such as letters, green cards, telephone calls or postcards) for reducing suicide reattempt (SR) and suicide have been evaluated since the 1980s, but results have been inconsistent. VigilanS is one of these programs that has benefited patients hospitalized for suicide attempt (SA) after discharge in 2 departments of northern France since 2015. The purpose of this study is to demonstrate its effectiveness in reducing SR.

METHODS

Patients exposed to VigilanS in 2016 were recruited from the medical administrative database of the program, and the nonexposed patients from a database of the medico-surgical ward outside the scope of the program. First, a Cox model was used to compare the probability of SR during the 12-month follow-up period between the 2 groups. Second, a propensity score using the variables sex, age, source, SA history and SA method was used to match the VigilanS-exposed and the nonexposed patients. A Cox model propensity score adjusted analysis was reiterated on the matched data.

RESULTS

The exposed and nonexposed groups included 3,068 and 3,694 individuals, respectively. In the bivariate analyses, the cumulative probability of SR at 12 months was significantly lower in the exposed group (6.0%, 95% confidence interval (CI): 5.5-6.5%) than in the nonexposed group (16.8%, 95% CI: 15.9-17.7%; p < 0.001). In the Cox model, the hazard ratio of SR was 0.38 in the exposed patients (95% CI: 0.36-0.40, p < 0.001). After matching, the cumulative probability of SR at 12 months was 5.2% in exposed versus 22.2% in nonexposed patients (p < 0.001). In the propensity score-adjusted Cox model, the hazard ratio of SR in the exposed patients was 0.19 (95% CI: 0.14-0.24, p < 0.001).

CONCLUSION

The results suggest the effectiveness of this real-life program for reducing SR. However, VigilanS only benefits a portion of the patients hospitalized for SA and therefore could be extended.

[Risk of incarceration of persons undergoing psychiatric care. A retrospective longitudinal study on the French department of Oise using information from a psychiatric hospital discharge database]

INTRODUCTION

Compared to the general population, persons with mental disorders are overrepresented in prison. In a study carried out in Picardy (northern France) in 2017, a quarter of those entering prison had had contact with a psychiatric service prior to their incarceration. Since to our knowledge no work on this subject has been published in France, we conducted a retrospective study, the main objective of which was to propose an estimate measure of incarceration likelihood in people with mental disorders.

METHODS

Using data from a psychiatric hospital discharge database (Recueil d'informations médicalisé en psychiatrie, RimP), we searched for patients aged 18 and older who had received psychiatric care (except for those who were incarcerated at baseline) at the Oise psychiatric hospital in 2015-2016 and identified those who had also been registered by the psychiatric care tool (DSP) in liaison with the same hospital. As a marker of incarceration, registration was the event to be investigated. Survival analyses (Kaplan-Meier), first simple and then stratified by age, gender, past history, main diagnosis and intensity of care outside of prison were carried out to calculate likelihood of incarceration. A multivariate Cox model was used in order to identify the factors associated with incarceration.

RESULTS

Among the 25,029 patients monitored in the Oise psychiatric hospital in 2015-2016, 126 had experienced incarceration during the 12 months following their inclusion in the study, i.e. an incarceration probability of 0.45% (95 % confidence interval: 0.37-0.55%). The incarcerated patients were younger (36.6 years in average versus 44.7-Pt-test<0.0001), more often male (96.8% versus 43.7% - P<0.0001), and had a more frequent history of detention (11.1% versus 0.6% - P <0.0001) and psychiatric care (20.6% versus 10.1% - P<0.0001) than the general population. The probability of incarceration at 12 months for the population followed in the psychiatry unit was 3.2 times higher than the detention rate of the general population in Oise over the same period.

CONCLUSION

Our study confirms the pronouncedly high incarceration rate of people with mental disorders. Scheduled to begin in 2020, coding in the RimP of a single nationwide patient identifier for all the procedures and stays described will allow the generalized measurement by means of the proposed indicator throughout France.

Validation d’une grille d’évaluation qualitative d’articles de presse écrite sur le suicide, dans le cadre du programme Papageno

Contexte

La couverture médiatique d’un fait suicidaire influence le taux de suicide par le biais d’un effet d’incitation, aussi nommé « effet Werther » (EW) ou d’un potentiel rôle préventif via « l’effet Papageno » (EP) . L’objectif du programme national français Papageno est d’améliorer les propriétés qualitatives du contenu médiatique dont dépendent principalement l’EW et l’EP, via l’application des recommandations de l’Organisation mondiale de la Santé (OMS) pour un traitement journalistique plus responsable du suicide. L’évaluation de l’efficacité du programme est donc un enjeu de prévention qui nécessite un outil d’analyse fidèle à ces recommandations.

Objectifs

Élaborer et valider une grille d’analyse qualitative permettant, pour chaque article de presse traitant du suicide, de mesurer le degré de compliance aux recommandations de l’OMS et de quantifier le risque d’EW et le potentiel EP.

Méthode

La grille d’évaluation PReSS (Print media Reporting on Suicide Scale) combine 10 items descriptifs et 19 items qualitatifs issus de l’opérationnalisation des 11 recommandations de l’OMS. La validation de la fiabilité interjuges a été obtenue par séries de double cotation-correction de 25 articles traitant du suicide. Les critères de satisfaction des items ont été affinés après chaque série jusqu’à obtention d’un coefficient de kappa ≥ 0.7 pour chacun. À titre d’illustration, le traitement médiatique du supposé suicide du pilote d’avion A. Lubitz en mars 2015 a été analysé grâce à la PReSS.

Résultats

Trois séries de cotation-correction ont été nécessaires pour valider la grille. L’analyse de la couverture du suicide présumé d’A. Lubitz montre un compliance faible aux recommandations, un score Papageno bas et un score Werther élevé.

Conclusion

La grille d’évaluation PReSS est un outil fiable et utile pour mesurer la compliance aux recommandations de l’OMS concernant la couverture médiatique du suicide.

Étude du sentiment de familiarité dans l’alcoolo-dépendance : une hyperfamiliarité aux visages

L’alcoolo-dépendance est une maladie chronique hautement récidivante dont l’enjeu principal est la prévention des rechutes. Les rechutes sont favorisées par le ressenti du sujet vis-à-vis de son environnement social [1]. L’alcoolo-dépendance entraîne des troubles cognitivo-comportementaux dont des déficits de reconnaissance émotionnelle et une altération des interactions sociales [2] majorant le risque de rechutes [3]. Ces troubles pourraient être liés à une altération du sentiment de familiarité. La familiarité se définit comme un sentiment de connaissance préalable d’un stimulus générant une émotion inconsciente, sans souvenir conscient de son identité [4]. Nous nous proposons d’étudier la familiarité aux visages dans l’alcoolo-dépendance. Douze patients alcoolo-dépendants (AD) étaient appariés en sexe et en âge à 12 témoins (T). Les participants ne présentaient ni trouble psychiatrique, ni neurologique, ni addiction en dehors d’un trouble d’usage sévère d’alcool pour le groupe AD (classification DSM-5). Des morphes entre visages familiers et inconnus (contenant 5 à 95 % du visage familier) étaient présentés. Les sujets devaient indiquer les visages leur semblant familiers. Un pourcentage de réponse « familier » était alors calculé par niveau de familiarité, permettant de construire une fonction psychométrique par sujet, et d’en déduire le seuil de familiarité (pourcentage de familiarité contenue dans le morphe pour lequel 50 % des stimuli étaient considérés comme familiers). Les interactions sociales étaient évaluées par une échelle de cognition sociale (MASC). Le seuil de familiarité était significativement plus faible dans le groupe AD que dans le groupe T (48,79 % versus 54,94 % – p = 0,025). Parallèlement les 2 groupes différaient sur les scores au MASC (AD : 26/45 ; T : 31/45 – p = 0,015). Ces résultats démontrent une hyperfamiliarité dans l’alcoolo-dépendance, associée à une altération de la cognition sociale. L’implication de l’altération de ces deux processus sur les risques de rechute est abordée.

Changes in heart rate variability to emotional information in short- and long-term alcohol abstinent patients

Introduction

Severe alcohol use disorders (AUD, DSM5 criteria, 2013) are associated with changes in the dynamics of emotional processes and emotional experience [1]. The aim of the study was to compare emotional information processing in patients with AUD in short-term abstinence (STA, less than 1 month) and in long-term abstinence (LTA, at least 6 months) with control participants (C). We studied the parasympathetic branch of the autonomic nervous system with the heart rate variability (HRV) and more particularly high frequencies (HF). This indicator is recognized as a reliable marker of physiological activation in reaction to emotional stimuli and as a good marker of vulnerability to AUD [2].

Method

The recording was performed for all participants during presentation of high emotional inducing stimuli presenting human interactions [3]. For each participant HRV was recorded before, during and after induction. Participants were asked to evaluate the intensity and the valence of emotional stimuli. In addition, a clinical and cognitive assessment was performed. We proposed in this study for abstinence in short- and in long-term to combine both behavioral and cognitive measures to this physiological indicator.

Results

We observed:

– significant differences in HF-HRV between LTA and STA groups, controls and STA groups but not between LTA and C groups;

– significant correlations between craving scores [4] and HF-HRV results in LTA and STA groups.

Prospect

The results support the relationship between the ability to process emotional information and the risk of relapse. HF-HRV results indicate specific deficits in regulation in STA group and also recoveries in LTA group. It suggests specific different therapeutic interventions in preventing the risk of relapse or maintenance of addiction.

Le Questionnaire d’évaluation des connaissances sur le suicide (QECS)

L’accès aux soins des personnes à risque constitue un pilier essentiel de la prévention du suicide. Cependant, les idées reçues véhiculées autour des conduites suicidaires y opposent un obstacle significatif. Afin de cibler au mieux les campagnes d’information qui dissiperaient ces mythes, et pour en évaluer l’efficacité, les connaissances sur le suicide devraient pouvoir être quantifiées de façon fiable. À ce jour, seules quelques études anglo-saxonnes dédiées ont été validées. La limite décisive à leur interprétation tient cependant à ce qu’elles ne permettent pas d’approche normative. En effet, l’exactitude de leurs propositions n’est validée par aucun étalon officiel, alors même que certaines relèvent plus de l’expérience clinique que de connaissances issues de la littérature. Notre objectif consiste à palier cette limite en proposant une échelle dont la cotation est adaptée à l’évaluation d’un savoir normé. Le Questionnaire d’Évaluation des Connaissances sur le Suicide (QECS) est un auto-questionnaire qui explore, en 35 items, les principales connaissances relatives à l’épidémiologie et aux mythes communs concernant le suicide. Les réponses y sont recueillies par échelle visuelle analogique. La cotation finale se fait en confrontant ces réponses à celles d’un panel de référence constitué de spécialistes en suicidologie (n = 47). Nous présentons ici les résultats de ce panel, ainsi qu’une illustration des potentialités d’interprétation du QECS, via l’évaluation des connaissances d’un échantillon test d’étudiants en journalisme (n = 111). Les réponses du panel de référence étaient significativement différentes de « ni accord, ni désaccord » pour 27 des 29 items dédiés aux mythes. Pour 25 de ces items, une différence significative était retrouvée entre l’échantillon test et le panel de référence. Ainsi attestée, l’existence d’un avis expertal spécifique a servi d’étalon pour 2 modes de cotation des réponses de l’échantillon test : un score de véracité et un score de concordance aux experts.

[Determine the patient's position towards psychiatric care: a simple tool to estimate the alliance and the motivation]

OBJECTIVES

For the brief systemic therapy (BST), the evaluation of the patient's position towards the care is a prerequisite to psychotherapy. Three positions of the patient are described. The "tourist's" position: the patient claims to have no problem and doesn't suffer. Someone asks him to make an appointment, sometimes with threats. The "complaint's" position: the patient claims to suffer, but attributes the responsibility of this suffering to others. These two positions are not good for beginning a therapy. The "customer's" position differs from both previous positions. The "customer" considers that he has a psychological problem which depends on him and he is motivated in the resolution of it. In theory, the "customer" is more motivated and the therapeutic alliance is better. It is for this reason that the BST estimates the position of the patient at first, to bring the patient to the "customer's" position. The objective of this study is to assess an interview which identifies the patient's position towards the care, and to validate the theoretical elaborations of the brief systemic therapy.

METHOD

The study concerns the follow-up of outpatients who consult a psychiatrist for the first time. The evaluation of the patients checks their position towards care using the Tourist-Complaint-Customer (TCC) inventory, how they suffer, the therapeutic alliance (scale Haq-2) and the compliance during care. The evaluation by the psychiatrists checks the suffering perceived, the motivation perceived and the diagnoses according to the DSM.

RESULTS

The typology of these patients is made up of one half "complaint", a quarter of "tourist" and a quarter of "customer". The "customer's" position is correlated with the therapeutic alliance and the motivation perceived by the psychiatrist. The motivation perceived by the psychiatrist is correlated with the therapeutic alliance. These results correspond to the theoretical elaborations of the BST.

CONCLUSION

the TCC inventory provides information on the motivation and the therapeutic alliance. If the patient is in "tourist" or "complaint" position, we recommend that the psychiatrist "work" to bring the patient to "customer" position. The evaluation of the position of the patient is simple and rich in information. We recommend that it be given a place in the daily practice of psychiatry.

Calcitonin levels do not decrease with weaning in chronic alcoholism

OBJECTIVE

Alcohol might increase calcitonin but this assertion is mainly based on the acute effect of the drug in small animals and humans. The aim of this study was to investigate the effect of chronic alcoholic intoxication on plasma calcitonin (CT) levels.

DESIGN

20 smoking male subjects admitted to be weaned from chronic daily alcohol consumption >100 g were included after informed consent. Blood was sampled upon admission (T0) and after 5 (T5) and 21 (T21) days of alcohol weaning to measure mean erythrocyte volume, gamma-glutamyltransferase (GGT), calcium, gastrin, and CT levels. The control group consisted of 30 male subjects with daily alcohol consumption <20 g.

MAIN OUTCOME

The characteristics of the alcohol group were as follows (mean +/- SD): age 41.2 +/- 13 years old; mean erythrocyte volume: 96.0 +/- 4.2 microm(3) (N: 85-95); calcium level: 94.7 +/- 3.7 mg/L (N: 85-105); gastrinemia: 59.3 +/- 14.9 ng/mL (N: <120). At T0 and T21, three alcoholic subjects had CT levels above 10 pg/mL, usually considered as the normal cut-off value. There was no correlation between CT and the different biochemical parameters at T0, T5, and T21. There was no difference between CT levels at the different stages in the alcohol group (T0: 6.4 +/- 3.6 pg/mL; T5: 6.5 +/- 5.3 pg/mL; T21: 8.4 +/- 5.6), although GGT significantly decreased with weaning duration (T0: 248 +/- 354 IU/L; T5: 211 +/- 290 IU/L; T21: 79 +/- 90 IU/L; ANOVA, p <0.05). But a significant difference was found between mean CT levels in the alcohol group and in the control group (3.1 +/- 0.7 pg/mL, p <0.0001).

CONCLUSIONS

This study suggests that mean CT levels of chronically alcoholic smoking male subjects are higher than those of an age- and sex-matched control group. However, most alcoholic patients exhibited CT levels <10 pg/mL. No decrease in CT levels was noted over a short period of alcohol weaning. As CT measurement is currently recommended in thyroid nodule assessment, this finding may be important to know how to decipher borderline values of CT.

Conséquences à court et long terme d’une exposition prénatale au cannabis

OBJECTIVE

Cannabis is one of the most commonly used drugs by pregnant women. The objective of this review of literature was to examine the association between cannabis use during pregnancy and effects upon growth, cognitive development (memory, attention, executive functions...) and behavior of newborns, children and teenagers.

MATERIAL AND METHODS

We searched for articles indexed in the medline database from 1970 to 2005. The following terms were used in the literature search: cannabis/marijuana, pregnancy, fetal development, newborn, prenatal exposure, neurobehavioral deficits, cognitive deficits, executive functions, cannabinoids, reproduction. Most of the articles were published in English.

RESULTS

Cannabis use during pregnancy is related to diverse neurobehavioral and cognitive outcomes, including symptoms of inattention, impulsivity, deficits in learning and memory, and a deficiency in aspects of executive functions. It seems difficult to identify complications, such as lower birth weight, only attributable to cannabis as opposed to the multiple perinatal complications associated with tobacco smoking.

CONCLUSION

In addition to alcohol and cigarettes, information should be given to women about the potentially harmful effects on fetal development, newborns, children and teenagers of smoking cannabis. Therefore, it seems necessary to develop prevention programs on this subject.

[Progressive cannabis-induced arteritis: a clinical thromboangiitis obliterans sub-group?]

INTRODUCTION

Since the end of the nineteen-nineties, cannabis is not only incriminated in the onset of thromboangiitis obliterans but also in inducing artheromatous lesions in young subjects.

OBSERVATION

A young, Caucasian, 18 year-old man was referred for cannabis withdrawal in the treatment of arteritis of the left leg.

DISCUSSION

Cannabis is by far the illicite psychoactive substance most consumed by the 15-25 year-olds. Data in the literature, notably since the end of the nineteen-nineties, show that cannabis is accused of provoking arterial disease similar to that which is found in Buerger's disease (or thromboangiitis obliterans) in young subjects of whichever sex.

Pharmacodynamic effects of acamprosate on markers of cerebral function in alcohol-dependent subjects administered as pretreatment and during alcohol abstinence

Animal studies suggested that acamprosate modulates neuronal hyperexcitability of acute alcohol withdrawal, acting through the glutamatergic neurotransmission. In the present study, we further investigated whether treatment with acamprosate could attenuate the post-alcohol withdrawal hyperexcitability or hyperarousal in humans using brain magnetoencephalography mapping of spontaneous fields. A double-blind, randomised, placebo-controlled study with a parallel group design comparing 2,000 mg/day of acamprosate versus placebo was conducted in alcohol-dependent subjects meeting DSM-IV criteria for alcohol dependence. Treatments were initiated 8 days before alcohol withdrawal and prolonged during the 15 following (abstinence) days. The study demonstrated that during alcohol withdrawal, acamprosate decreased the arousal level as reflected by alpha slow-wave index (ASI) measurement. This effect was mostly evidenced in left parietotemporal regions and, to a lesser extent, in the contiguous anterior, posterior and right-sided regions. In the placebo group, on the contrary, ASI measures increased between day 2 (acute withdrawal) and day 14 (prolonged withdrawal). The present results suggest a sustained effect of acamprosate on the hyperexcitability state due to alcohol withdrawal in alcohol-dependent patients and that acamprosate may have a protective effect when administered 8 days before alcohol withdrawal.

The effects of ethanol on the glycosylation of human transferrin

Appearance of a hyposialylated transferrin fraction in the plasma during chronic alcohol exposure is a well-known phenomenon, and it represents the best available marker of chronic alcohol consumption. The mechanisms of its appearance are still not well understood and are extremely complex, involving biosynthesis and catabolism alterations, although the only structural abnormality described corresponds to the loss of an entire glycan chain. We analyzed and compared the oligosaccharides present on the different isoforms of purified transferrin isolated from control and patients with severe alcohol abuse by fluorescent carbohydrate electrophoresis and matrix-assisted laser desorption ionization mass spectrometry. Our data indicate that the major modification observed is the loss of an entire oligosaccharide chain; we also demonstrate that there is a modification of terminal sialylation. Carbohydrate-deficient transferrin (CDT) is the result of multiple alterations of glycosylation. These results give a partial explanation to the poor sensitivity of the measurement of CDT and its controversial use as a marker of chronic alcohol consumption.

Financial costs of alcoholism treatment programs: a longitudinal and comparative evaluation among four specialized centers

BACKGROUND

Alcoholism is a worldwide problem. Many strategies for alcohol detoxification and relapse prevention exist, but each alcohol treatment center has its own program. The objective of this study was to analyze and compare the financial cost and effectiveness of alcohol treatment programs from inpatient stay to follow-up 1 year later. This was a prospective, open, nonrandomized study of 4 specialized alcohol treatment centers and 267 patients admitted for alcohol detoxification.

METHODS

We recorded all medical and nonmedical interventions related to the program during patient stay in the hospital and every 3 months after discharge for 1 year and recorded the occurrence of alcohol relapse. Financial evaluation was based on the prices of refund from the French national health insurance service.

RESULTS

The mean cost of hospitalization ranged from 1326 euros to 1917 euros(p = 0.001), a variation mainly due to the difference in the length of hospital stay but also to the cost of the inpatient program, routine medical checkups, and drugs administered. The mean cost of 1 year of follow-up per patient ranged from 419 euros to 1704 euros (p = 0.001). The efficiency, corresponding to the money spent to prevent the relapse of one patient during 1 month, was approximately 500 euros/month in three centers and 658 euros in the fourth. However, for a similar efficiency, the effectiveness, assessed by the mean time without relapse, was significantly (p = 0.001) different; center 1, which had the highest total cost, had an effectiveness 1.56 times higher than center 3, which had the lowest cost.

CONCLUSIONS

This work emphasizes the heterogeneity of the costs and effectiveness of alcoholism treatment programs and suggests that research should be conducted to determine which program is the most rational, cost-efficient, and beneficial for patients and the public health office economy.

[Alcohol, chronobiology and sleep]

Chronobiology is the scientific discipline of biologic rhythm study. Applications of the emerging concepts of chronobiology are now use in several fields of clinical medicine. Alcohol related disorders seems to be clarified with the main concepts of chronobiology. Thus chronopharmacology (specially chronokinetics and time-related differences in drug effects) clears up variations of blood alcohol levels and toxicity of ethanol during the 24 h, chronesthesy explains the action of ethanol on biological rhythms of hormone secretions and sleep, and the concept of chronopathology seems to be apply to alcohol dependence. We review in this article some applications in alcohol related disorders of the main concepts of chronobiology.

The effect of alcohol consumption on the circadian control of human core body temperature is time dependent

The few controlled studies dealing with the action of alcohol on core body temperature in humans have focused on the effect of a single dose of ethanol and reported that it has a hypothermic effect. No studies report the effects of repeated ethanol intake over a 24-h period, a pattern of consumption much closer to the clinical condition of chronic alcoholism. We therefore designed a trial in which alcohol was repeatedly and regularly administered, with a total dose of 256 g. Nine healthy male volunteers (mean age 23.3 +/- 2.9 yr; range 21-30) each served as his own control. The circadian temperature rhythm was studied by a single-blind, randomized, crossover study that compared a 26-h alcohol session to a 26-h placebo session. The trial controlled for so-called masking effects known to affect temperature. The volunteers were in bed; the ambient temperature was maintained between 20 and 22 degrees C. Meals were standardized. And light was controlled during the night. All sessions took place between November and April. The two sessions were separated by 2 to 5 wk. Rectal temperature was monitored every 20 min throughout the trial. We found the standard hypothermic effect of alcohol in the early hours of the trial, during the daytime, but our principal result is that alcohol consumption induced a very significant hyperthermic effect (+0.36 degrees C) during the night and thereby reduced the circadian amplitude of core body temperature by 43%. The dramatic decrease of the amplitude of circadian temperature rhythm that we observed may explain, at least in part, some clinical signs observed in alcoholic patients, including sleep and mood disorders. We suggest that jet lag, shift work, and aging, which are known to alter body temperature, are aggravated by alcohol consumption.

[A case of delusional melancholia: "a variant of loss of psychological self-activation"?]

A 62 year-old man presented with melancholia with delusions, possibly resulting from lenticular lesion in the left and frontal damages in the right. Atypical signs of our observation led us to consider our patient not as suffering of affective disorder. We suggest that melancholia could be a consequence of a certain type of stereotyped mental activity, and we would compare this stereotyped mental activity to mental compulsive activity described in "loss of psychic self activation" of D. Laplane. In this perspective our observation would be a variant of "Loss of psychic self-activation". Heuristic value of this concept is discussed.

[Mood disorders and right hemisphere infarction]

Persistent depression of mood following stroke and acute psychiatric disturbances in conjunction with infarcts in the right hemisphere has been well reported. Sometimes its psychiatric features were most salient although neurological signs could not be elicited. We treated two patients with infarcts in the right hemisphere. The first developed depression with melancholia, the second a bipolar disorder. We question whether aprosodia or mood neglect may give a melancholic profile of depression following right hemisphere damage.