Encephale
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Few studies have been devoted to in-patients' suicides. This covers all suicides that occurred during hospitalisation, whatever the place (inside or outside the institution) and often, for psychiatric in-patients, suicides carried out within 24 hours after leaving the institution. ⋯ However, the incidence of suicide in hospital is high, higher than that observed in the general population. It is 250 per 100,000 admissions in psychiatric hospitals and 1.8 per 100,000 admissions in general hospitals, which is four to five times more than in general population. Five to 6.5% of suicides are committed in the hospital: 3 to 5.5% occur in psychiatric hospitals and about 2% in general hospitals. Many risk factors for suicide were identified in this context. The accessibility to one or more means of suicide (water, rail, high floor [third floor or beyond], knives, possibility of hanging...) is a recognized factor in psychiatric institutions. In the psychiatric environment, hospitalisation period also determines the risk of suicide: it is highest during the 1st week of hospitalisation and within 2 weeks after leaving. The same is true for the conditions of care: inadequate supervision, the underestimation of the risk of suicide by teams, poor communication within the teams and the lack of intensive care unit promote suicide risk. The controlled studies conducted in a psychiatric environment distinguish two periods for identifying risk factors. The first period is the time of hospitalisation. Are recognized as risk factors: the existence of suicidal personal history (but also family) and attempted suicide shortly before admission, the diagnosis of schizophrenia or mood disorder (non-controlled studies also emphasize the importance of alcoholic comorbidity), being hospitalised without consent, living alone, absence from the service without permission. The second period covers the time-period immediately following the hospitalisation. For this period, risk factors are: the existence of personal history of suicide and suicidal ideation or attempt of suicide shortly before admission (but also attempt of suicide during hospitalisation), the existence of relational difficulties, the existence of stress or loss of employment, living alone, a decision on leaving the hospital unplanned and lack of contact with nursing in the immediate postdischarge period. In general hospitals, the chronicity and severity of the somatic disease, the personality of the patient and the existence of a psychiatric comorbidity are the suicidal factors most often quoted. Furthermore, we also found only a low rate of psychiatric consultation during the hospitalisation of patient who will commit suicide. Among the countries which have a national program of suicide prevention, only England registered the question of the in-patients suicide among its priorities. The elements of a prevention policy appear however in certain scientific publications and some programs of local or regional initiative. These elements can be grouped under five items: securing the hospital environment, optimisation of the care of the patients at suicidal risk, training of the medical teams in the detection of the risk and in the care of the suicidal subjects, involvement of the families in the care and implementation of post-event procedures following a completed suicide or an attempt.
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Controlled Clinical Trial
[Long-term impact of the diagnostic announcement on the insight of patients suffering from schizophrenic disorders].
The importance of insight in patients with schizophrenia is linked to the notion that few subjects are conscious of their pathology and that some treatments fail due to a lack of consciousness of the necessity of medication. Since then, studies have been frequently undertaken into the insight of schizophrenic patients. It is believed that a good degree of insight could influence the quality of acceptance by the patient of the disease. This would facilitate closer medicinal supervision, resulting in fewer relapses and thus a decrease in the number of hospitalizations and subsequent improved quality of life for the patients. In 2002, a protocol of diagnostic announcement was set up for schizophrenic patients in the Ville-Evrard Hospital. Two years later, we observed a high level of compliance in these patients (70 %). ⋯ In conclusion, the protocol of diagnostic announcement and psycho-education have helped stabilize schizophrenic patients in order to improve their insight, without increasing the intensity of this disease in the short- or long-term. Work on insight should allow a new understanding of the patient's relation with the disease along with the medical team and his close relations.
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Case Reports
[Serotoninergic antidepressants and opiate analgesics: a sometimes-painful association. A case report].
We report a case of serotonin syndrome caused by interaction between nasal fentanyl, oxycodone and escitalopram. Due to chronic painful episodes with paroxistic level of pain, a 66-year-old patient, treated for prostate adenocarcinoma and bone metastases received an association of major opiate analgesics (oxycodone 120 mg/day for 6 months, and fentanyl nasal spray four puff of 200 microg/puff). After the addition, for mood disorders, of a small dose of escitalopram (5 mg/day), he developed severe serotoninergic features including diaphoresis, night sweating, tremor, diarrhea, visual disorders with mydriasis and weight loss of 8.8 lbs (4 kg). Discontinuation of escitalopram resulted in complete resolution of his symptoms within 48 h except for persistent blurred vision. ⋯ Clinicians and especially psychiatrists should be aware of possible interaction and the risk of serotonin syndrome when a patient receives a combination of different opioid analgesics and serotonin reuptake inhibitor antidepressants. Improved information and collaboration with somatic and pain specialists and the general practitioners could help reduce the occurrence of this syndrome which can have dreadful consequences. Patients must be informed of such complications, which means that patients should be asked for a history of such events and monitored for serotoninergic adverse events, in order to avoid delays in this diagnosis.
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Atypical antipsychotics have a favourable risk/benefit profile in early onset schizophrenia (EOS). However, despite increasing use of psychotropic medication in children and adolescents, their endocrine and metabolic side-effects (weight gain, obesity, and related metabolic abnormalities such as hyperglycaemia and dyslipidemia) are of particular concern, especially within this paediatric population that appears to be at greater risk as compared with adults for antipsychotic-induced metabolic adverse effects. In addition to medication, many factors contribute to weigh gain in psychiatric patients, including sedentary lifestyle and poor diet. Excessive weigh gain has several deleterious effects in psychiatric patients, including stigmatization and further social withdrawal, and non compliance with medication. Furthermore, excessive corpulence may evolve to a metabolic syndrome with a high-risk state for future cardiovascular morbidity and mortality in adult age. Because youths are still developing at the time of psychotropic drug exposure, in a context of physiological changes in hormonal and endocrines levels and body composition, most reference values need to be adjusted for gender, age and growth charts. Hence, sex- and age-adjusted BMI percentiles and BMI Z scores are crucial to assess weight gain in children and adolescents. ⋯ Alternative treatment should be considered in some cases. Other antipsychotics, like aripiprazole, may have a better benefit/risk ratio and then may be prescribed as a first prescription or as a switch. Associations of antipsychotics may also be of interest but we lack controlled studies in children and adolescents. In some cases, alternative treatments like repetitive trans-cranial magnetic stimulations (rTMS) may be required. Their efficacy and their place in the therapeutic strategy of pharmacoresistant schizophrenia in children and adolescents have to be assessed in regard to metabolic and blood side effects of clozapine.
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The potential benefits of the application of an electronic medical record (EMR) in medical care are well recognized. However, if these benefits are to be accomplished, professionals must adopt and utilize EMR as a part of their practice. The aim of this study was to assess the evolution of the health care professionals' opinions of EMR and their use on a period of 1 year in a French Public Psychiatric Hospital. ⋯ This study allowed us to identify the residual problems which each hospital could face, 1 year after setting up an EMR. This preliminary work constitutes the first step in the development of a measurement tool of the use and perception of the EMR by health care professionals.