Encephale
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Review
[Treatment of manic phases of bipolar disorder: critical synthesis of international guidelines].
Bipolar disorder (BD) is the seventh leading cause of disability per year of life among all diseases in the population aged 15 to 44. It is a group of heterogeneous diseases, with frequent comorbid psychiatric or somatic disorders, variable treatment response and frequent residual symptoms between episodes. The major impairment associated with this disorder is related to the high relapse and recurrence rates, the functional impact of comorbidities and cognitive impairment between episodes. The prognosis of the disease relies on the efficacy of relapse and recurrence prevention interventions. Given the heterogeneity of the disorder, relapse and recurrence prevention needs to develop a personalized care plan from the start of the acute phase. In such a complex situation, guideline-driven algorithms of decision are known to improve overall care of patients with bipolar disorder, compared to standard treatment decisions. Although guidelines do not account for all the situations encountered with patients, this systematic approach contributes to the development of personalized medicine. ⋯ Guidelines utilization has shown that the systemic use by clinicians of decision algorithms in comparison to "treatment as usual" modality improves the overall care of patients with BD. Future data from cohorts of patients seem necessary to complement the existing data from clinical trials. These cohort studies will help to take into account the different individual profiles of BD and thus may help to propose a more personalized medicine.
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Alcoholism causes psychological, behavioral and cognitive symptoms that need to be addressed together. The neuropsychological alterations among alcohol-dependent people are considered to make the therapeutic work complex and longer. A cognitive rehabilitation program is sometimes difficult to achieve with these patients. Functional results are often difficult to anticipate. However, the consequences of this therapeutic approach are multiple and there are many interactions between psycho-affective, behavioral and cognitive components. A neuropsychological approach can be used like a tool to improve metacognition. A bad contribution to treatment programs is often secondary to the illusion of a satisfying intellectual functioning. Patients' motivation for the therapeutic work is very changeable. A complete consciousness of impairments can help them to stay involved. ⋯ All the cognitive assessments and rehabilitation results seem to have increased his participation in the global therapeutic care. Therapeutic tools used for cognitive work give a concrete picture of the consequences of alcohol consumption and the necessary time to retrieve brain capacities. Visible improvements in terms of reduction in disability-handicaps encouraged the patient, valued his efforts, and increased his determination to solve his alcohol related problem. Thus, cognitive programs can help to reduce passiveness and develop activeness. This patient regarded therapeutic difficulties as a challenge, not as an obstacle. We can reasonably assume the effect of the cognitive rehabilitation on the Persistence of the Cloninger's biosocial model. This increase in temperament corresponds to a certain form of tenacity, which would facilitate abstinence.
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Supported employment programs are highly effective in helping people with severe mental illness obtain competitive jobs quickly. However, job tenure is often a problem for many. Of the various obstacles to job tenure documented, dysfunctional beliefs regarding the workplace and one's own abilities has been proposed as a therapeutic target. ⋯ The preliminary results support previous studies where on average 50 % of people registered in supported employment programs obtain competitive work. We confirmed that the intervention was feasible and acceptable. Preliminary data suggest that the CBT-SE intervention might help people with severe mental illness use skills and gain the needed confidence enabling them to work longer hours and consecutive weeks. These results should be considered with caution given that only 24 participants were looked at whereas the final sample size will be of 160 participants. Nonetheless, these preliminary results are promising. Furthermore, additional information regarding the impact of the CBT-SE intervention on the capacity to overcome obstacles at work, self-esteem as a worker, as well as other work-related variables have been collected but have not been investigated here. Once the study is completed, the results should enlighten us regarding the usefulness of offering CBT-SE not only in terms of work outcomes but also in improving various psychosocial domains linked to workplace satisfaction.
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Comparative Study
[Two "hybrid" vocational services for people with a severe mental illness in France and Quebec].
Many different types of vocational programs (services) exist to help people with severe mental disorders (e.g., schizophrenia) integrate the regular labor market: sheltered workshops, social enterprises, and supported employment programs to name a few. Each type of vocational services has its specificities: on one hand, some of them are following the "train and place" approach. For example, sheltered workshops offer to people with a severe mental illness a training during a long period of, with a small proportion obtaining competitive employment. ⋯ Meetings in groups, practicums in the workplace, and the utilization of job search strategies are essential ingredients of Accès-Cible SMT, which are also efficient tools to develop a better empowerment of the person. Indeed, the common ingredients/elements of these two vocational services, Messidor and Accès-Cible SMT, seem to be the development of empowerment for people with severe mental disorders. The scientific literature supports that empowerment is one of the key factors of recovery for people with a mental illness, a recovery process that can be illustrated by their work integration in the regular labor market as a final goal.
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Review Meta Analysis
[Awareness disorders in Alzheimer's disease and in mild cognitive impairment].
Awareness disorders in Alzheimer's disease still remains unclear despite much research regarding this phenomenon. Papers report various and contrasted results with varying frequency from one study to another. Hence, the interest in awareness in Alzheimer's disease remains limited. Nevertheless, this symptom is closely associated with caregivers' burden and increases the patient's dependency, since the patient is unable to avoid dangers, requiring some care services or institutionalization The purpose of this current review is to recall the main neuro-anatomical and theoretical basis of awareness disorders, and to highlight the recent findings in Alzheimer's disease and in its pre-clinical stages. ⋯ These controversial results are due to the heterogeneity of Alzheimer patients and in particular of MCI patients, but also to various conceptions of awareness disorders in Alzheimer's disease; none of them, however, taking into account all its diversity and complexity. Thus, neurological approaches underline neuropsychological dysfunctions linked to right frontal and/or hemispheric damage but are based on brain injury or strokes, which are events that differ greatly from a neurodegenerative disease involving progressive cognitive, emotional and social disturbances. Psychiatric approaches have taken into account the various aspects of insight, which before were often forbidden and reduced to a categorical point of view, and so could contribute to a better understanding of awareness disorders in Alzheimer's disease. However, these aspects have been conceptualized for psychiatric patients, suffering from positive symptoms, where compliance in treatment is the central key. Insight in neurological diseases is more focused on negative symptoms and generally concerns a basic perception of impairments in mainly cognitive domains. Moreover, modeling has often opposed neurological and psychological mechanisms, so awareness disorders are out of scope of a primary and secondary symptomatology. Although some authors have proposed to take into account these two mechanisms (unawareness and denial), clinical practice has shown that it was impossible to distinguish them both. Finally, some social cognitive approaches are able to demonstrate that there is no correlation between severity of dementia and awareness disorders. Nevertheless, the Self-concept, underlying this point of view, does not permit distinguishing neuropsychological from psycho-social factors. Moreover, only one evaluation tool based on Self-modeling in Alzheimer's disease exists, and to conceptualize Self in a specific pathology does not permit the comparison of this pathology to others or to healthy control subjects. So, the authors present the multidimensional model proposed by Clare et al., and some perspectives to stimulate future research, and perform potential meta-analyses.