Psicosis epiléptica periictal,una causa de psicosis reversible

Introduction

Epileptic psychoses are categorised as peri-ictal and interictal according to their relationship with the occurrence of seizures. There is a close temporal relationship between peri-ictal psychosis and seizures, and psychosis may present before (preictal), during (ictal) or after seizures (postictal). Epileptic psychoses usually have acute initial and final phases, with a short symptom duration and complete remission with a risk of recurrence. There is no temporal relationship between interictal or chronic psychosis and epileptic seizures. Another type of epileptic psychosis is related to the response to epilepsy treatment: epileptic psychosis caused by the phenomenon of forced normalisation (alternative psychosis), which includes epileptic psychosis secondary to epilepsy surgery. Although combination treatment with antiepileptic and neuroleptic drugs is now widely used to manage this condition, there are no standard treatment guidelines for epileptic psychosis.

Clinical cases

We present 5 cases of peri-ictal epileptic psychosis in which we observed an excellent response to treatment with levetiracetam. Good control was achieved over both seizures and psychotic episodes. Levetiracetam was used in association with neuroleptic drugs with no adverse effects, and our patients did not require high doses of the latter.

Conclusions

Categorising psychotic states associated with epilepsy according to their temporal relationship with seizures is clinically and prognostically useful because it provides important information regarding disease treatment and progression. The treatment of peri-ictal or acute mental disorders is based on epileptic seizure control, while the treatment of interictal or chronic disorders has more in common with managing disorders which are purely psychiatric in origin. In addition to improving the patient's quality of life and reducing disability, achieving strict control over seizures may also prevent the development of interictal psychosis. For this reason, we believe that establishing a treatment protocol for such cases is necessary.     

A review of the interplay between tuberculosis and mental health

Aims

Tuberculosis and mental illness share common risk factors including homelessness, HIV positive serology, alcohol/substance abuse and migrant status leading to frequent comorbidity. We sought to generate a comprehensive literature review that examines the complex relationship between tuberculosis and mental illness.

Methods

A literature search was conducted in MedLine, Ovid and Psychinfo, with further examination of the references of these articles. In total 316 articles were identified. It was not possible to conduct a formal meta-analysis due to the absence of randomised controlled data.

Results

Rates of mental illness of up to 70% have been identified in tuberculosis patients. Medications used in the treatment of common mental illnesses, such as depression, may have significant interactions with anti-tuberculosis agents, especially isoniazid and increasingly linezolid. Many medications used in the treatment of tuberculosis can have significant adverse psychiatric effects and some medications such as rifampicin may reduce the effective doses of anti-psychotics y their enzyme induction actions. Treatment with agents such as cycloserine has been associated with depression, and there have been reported cases of psychosis with most anti-tuberculous agents. Mental illness and substance abuse may also affect compliance with treatment, with attendant public health concerns.

Conclusions

As a result of the common co-morbidity of mental illness and tuberculosis, it is probable that physicians will encounter previously undiagnosed mental illness among patients with tuberculosis. Similarly, psychiatrists are likely to meet tuberculosis among their patients. It is important that both psychiatrists and physicians are aware of the potential for interactions between the drugs used to treat tuberculosis and psychiatric conditions.     

La nécessaire évolution de définition de la « conversion hystérique »

Background

Technology is omnipresent in our world today and mental disorders are examined using modern genetic, biological, neurophysiological and functional brain imaging exploratory techniques. Conversion is not just external, it can also be glimpsed at in images that look at brain functioning.

Objectives

Do modern biological and radiological investigation elements discuss classic psychopathological conceptions of conversion and hence offer a new definition?

Methods

Recently published neuroscientific studies have re-evaluated our traditional ideas of hysterical conversion with a critical eye.

Results

Freud had the intelligence of differentiating conversion and simulation as two nosological frameworks that could not be superimposed: neurobiology scientifically confirmed the intervention of distinct brain mechanisms. Freud had the merit of defining conversion using a positive psychopathological diagnostic strategy, and not just by simply eliminating the organicity: with the same positive ethics, a distinction between somatic illnesses and conversive disorders can be established with imaging techniques. Furthermore, the possibility of conversive attacks caused by a psychotraumatic mnemic determination has found an echo in very recent studies which have objectified, in the conversive physiopathology, the intervention of cerebral structures involved in emotional memories. Finally, research looking at neurofunctional mechanisms that determine dissociative and conversive disorders confirm their close relationship.

Discussion

The most recent neuroimaging studies validate the hypothesis of a biological carrier of conversive phenomena. If this new data should incite us to redefine conversion, it is also the definition of the signifier “psychogenic” which has evolved due to the advances in neuroimaging techniques. Is any psychological or somatic manifestation not also of neuronal and signified origin?

Conclusion

These studies show that science can validate or specify some of our classical psychopathological paradigms.     

Considération critique sur l’extension de la bipolarité, psychopathologie des mouvements d’humeur et de l’euphorie morbide

Objectives

From manic-depressive psychosis to bipolar spectrum, today's psychiatry allows us to observe a widening of bipolar criteria. This article aims at studying this evolution, its consequences with a critical look and the psychopathology of mood changes and morbid euphoria.

Methods

All of our considerations refer to current data on bipolar disorders (review with Medline and Science Direct) compared with studies from classical psychiatrists (Kraepelin, Ey) and various authors inspired by psychoanalysis (Freud, Racamier) and phenomenology (Binswanger, Tellenbach, Tatossian).

Results

Many contemporary authors encourage clinicians to detect bipolar disorders from symptoms, early signs and attenuated or atypical expressions. The concept of a widened spectrum is supposed to be closer to clinical reality and it would be an opportunity to diagnose this disease and its deleterious consequences better and thus to set up an appropriate therapy at an early stage. Other authors, on the other hand, deplore a dilution of bipolar disorders together with harmful diagnostic inflation around a concept that has become too heterogeneous to be effective, that subjugates or interferes with other pathologic entities in an excessive manner and abandoning a psychopathological approach. In this view, we shall analyze the nosographic shifts of bipolar disorders throughout the history of psychiatry, from manic-depressive psychosis to bipolar disorder and spectrum. We shall then scrutinize the autonomy and limitations related to bipolar disorders as opposed to normality, confusing clinical presentations and other major mental diseases: Psychosis, depression, pathological personality, anxiety, impulse-control, attention deficit-hyperactivity, addiction and psycho-organic disorders. This work shall first introduce a discussion on the concept of bipolar disorders for children, and then through the case of some historical figures. Then we will deal with the contemporary social factors that are currently furthering the extension of this diagnosis. Last, this article sheds a light on psychopathological specificities of mania – the cornerstone in bipolar disorders – mood changes and morbid euphoria.

Conclusion

We think that classic psychiatry, phenomenology and psychoanalysis would act as a guiding light through this debate and could help the clinician in this daily practice. Mood variations require a careful clinical observation and a rigorous set of interpretation, before being specified too excessively or hastily as a symptom of a real bipolarity.     

La rééducation du membre supérieur assistée par robot contribue-t-elle à améliorer le pronostic de l’hémiparésie vasculaire ?

Introduction

Upper limb robot-assisted rehabilitation is a novel physical treatment for neurological motor impairments. During the last decade, this rehabilitation option utilizing technological tools has been evaluated in hemiparetic patients, mostly after stroke.

State of art

Studies at acute and chronic stages suggested good tolerance and a significant and persistent reduction of motor impairment; a real impact on disability has been shown in acute/sub acute patients.

Perspectives

Improved access to rehabilitation robots and an optimal use will probably be associated with higher efficiency of rehabilitative work in the paretic upper limb.

Conclusions

Even if this treatment is still confined to a narrow circle of users, the device's biomechanical properties and clinical suggestions from the literature may show promise for the future of rehabilitation.     

Les troubles mentaux dans les écrits médicaux anciens : méthodes de caractérisation et application aux consultations françaises du xvi siècle au xviii siècle

Objectives

Like cross-cultural studies, research on ancient medical writings allows psychiatrists to identify constant and variable expressions of mental disorders; this may in turn allow discrimination between pathogenesis mainly of a biological nature and that mainly of a socio-cultural nature. However, the study of these writings presents many problems which require the development of specific and rigorous research methodologies. In particular, close attention is needed for the identification and characterization of mental disorders, a process which is usually referred to as “retrospective diagnosis”. This paper tackles the difficult problem of retrospective diagnosis and pathological categorization of mental disorders described in historical medical writings and proposes a pragmatic and operational approach to these issues.

Patients and methods

We propose going beyond the simplistic contraposition of essentialist and constructivist approaches to mental disorders. First, history research questions involving individual diagnosis, either to ascertain whether a given disease or nosological entity is present in a given historical population (situations A1) or to understand a behavior of an individual or group in a given historical context (situations A2), should be distinguished from questions in which the health of a population or a subgroup is of interest (situations B). Situations of type (A1) require the use of all medical knowledge to make a tentative retrospective diagnosis; situations of type (A2) require considering retrolective diagnoses which could have been made at the time the disorder was managed/reported; and situations of type (B) require using robust pathological categorizations and classifications like those used in contemporary epidemiology to allow comparisons between populations. This conceptual and methodological framework was applied to the study a corpus of more than 2000 reports of consultations of French physicians, written during 16th–18th centuries. Retrospective diagnosis was attempted by a group of psychiatrists and historians on the basis of DSM-IV-TR diagnostic criteria for common mental disorders.

Results

Mental disorders accounted for nearly 4% of the medical conditions dealt with in the consultations; there was no trend for change during the study period. Minor mental disorders, such as depressive, anxiety and somatoform disorders were the most frequent. Serious conditions, characterized by symptoms corresponding to the contemporary categories of bipolar disorder, major depressive disorder and schizophrenia, were also suggested.

Conclusions

This study evidences the presence, in the early modern French population, of many mental disorders fitting into the categories of contemporary psychiatric nosology. It also demonstrates the feasibility of pathological categorization, and in some cases retrospective diagnosis, of mental disorders described in historical medical writings. These findings have implications for historical research in psychiatry.     

Psychotic episode secondary to metronidazole use

Objective

Psychosis is a recognized but often forgotten side effect of many commonly prescribed medications.

Method

A case of psychosis in a 27-year-old female related to metronidazole treatment is presented along with review of possible mechanisms.

Results

The onset and resolution of psychosis appeared to coincide with metronidazole treatment.

Conclusions

Clinicians should be aware of medication-related psychosis.     

Enquête sur le syndrome d’épuisement professionnel chez les personnels d’anesthésie réanimation de quatre hôpitaux universitaires marocains

Background

Burn out syndrome consists in physical and mental exhaustion observed in professionals whose work involves continuous contact with other people in response to chronic stress. Healthcare providers in intensive care units are exposed to this risk. Our objective is to assess the prevalence and identify risk factors of burn out among the medical and paramedical staff in intensive care unit.

Methods

A multicenter analytical cross-sectional study was conducted among practitioners in four Anesthesia and Intensive Care units in Moroccan University Hospitals. The Maslach Burn out Inventory and a general questionnaire on demographic and professional variables data were used.

Results

High scores for emotional exhaustion, depersonalization, and low score for professional accomplishment were observed in, respectively, 48%, 21% and 43% of cases corresponding to a high score of burn out of 70%. In multivariate analysis, resident physicians and nurses were most at risk of burn out. Disorganization of work, fear of malpractice and the unsatisfactory salaries were associated to a relative risk of burn out respectively of 1.88, 2.09 and 1.93.

Conclusion

This study documents evidences of burn out syndrome in healthcare providers working in intensive care units, preventive strategies are therefore required based on an improvement in the organization of care.     

La Classification internationale du fonctionnement : une victoire militante dissimulée

Aims

To present the conceptual framework of the International Classification of Functioning (ICF), often cited in a misleading way, because the authors only refer to the introduction to the Manual.

Method

The entire Manual is analysed, including the coding guidelines and the only article cited in the Manual.

Results

The conceptual framework and policy implications differ from what is usually claimed. They refer to the disability studies movement. The purpose of the ICF is to oppose the categorisation of persons and to promote the universal adaptation of the environment. This is why several aspects of the ICF do not conform to the usual rules for classifications.

Discussion

The conceptual framework and policy implications are concealed by three means: a different vocabulary is used in the introduction and in the coding guidelines, the conceptual framework is not described in the long introduction but only in the coding guidelines, and the detailed guidelines suggest that users build their own classification for their own purpose. This concealment is necessary in order obtain a large circulation of the classification.

Conclusions

Careful analysis of the Manual and of the only cited article shows the advocacy beliefs of the group of experts who steered the classification.     

Olanzapine treatment of premenstrual onset psychosis: a case report

Objective

Premenstrual onset psychosis is a rare condition of unknown etiology for which no treatment trials have been conducted and whose existence as a definitive diagnosis continues to be debated. The literature includes individual case reports and small case series, leaving psychiatrists to make decisions about prescribing antipsychotic agents on a case-by-case basis. Moreover, researchers continue to debate the efficacy of antipsychotic agents in the treatment of premenstrual onset psychosis.

Method

Case report.

Results

We report the case of a 17-year-old female with recurrent premenstrual onset psychosis that was successfully treated with olanzapine monotherapy (20 mg/day).

Conclusion

These findings may serve as a reminder to physicians to rethink the suitability of a more traditionally accepted diagnosis, including premenstrual exacerbation of bipolar disorder or schizophrenia, and the potentially important role of antipsychotic agents, especially prolactin-sparing ones, in premenstrual onset psychosis.     

Troubles obsessionnels compulsifs résistants et antipsychotiques : données neurobiologiques et thérapeutiques actuelles

Introduction

Forty to sixty percent of patients with obsessive compulsive disorder (OCD) are resistant to well conducted treatment with selective serotonin reuptake inhibitors (SSRIs) over 8 weeks. The data concerning effectiveness of the addition of antipsychotics in this indication is controversial.

Aims of the study

To synthesize the neurobiological mechanisms at work in order to understand the action of pharmacological treatments in this disease and to propose a systematic review of the literature on effectiveness of different antipsychotic drugs according to their pharmacological profiles, in monotherapy or in combination with SSRIs in OCD.

Method

We conducted a systematic review of the literature using the criteria according to the PRISMA research paradigm “obsessive compulsive disorder AND antipsychotic agents”. Research bases MEDLINE, Cochrane and Web of science have been explored.

Results

Unlike the classical serotonergic hypothesis, OCD may result from striatal dopaminergic hyperactivity, modulated in some patients by an underlying serotonergic hypoactivity. Most studies report effectiveness of first-generation antipsychotics (amisulpride and haloperidol) and some second-generation antipsychotics (risperidone, olanzapine, aripiprazole, quetiapine) in combination with an SSRI in the treatment of resistant OCD. Recrudescence or onset of OCD in patients with schizophrenia have been described in a relay from first generation antipsychotic to olanzapine, risperidone, aripiprazole or clozapine in case reports, but not amisulpride and quetiapine.     

Mental health outcomes following naltrexone implant treatment for heroin-dependence

Background

Oral naltrexone is an approved treatment for opioid dependence. However, the impact of sustained release naltrexone on the mental health of treated opioid users has not been studied.

Aims

To assess if naltrexone via implant treatment was associated with any change in (i) risk, (ii) rate, and (iii) duration for hospital morbidity related to several categories of mental disorders among treated heroin users.

Method

A cohort of 359 heroin users treated with sustained release naltrexone via implants in Western Australia was retrospectively followed up for mental health related outcomes via a health record linkage system over an average period of 1.78 years post-treatment.

Results

Individual patient's risk for hospital mental diagnoses was not altered after naltrexone implant. On a population cohort level, hospital admission rates related to all mental health problems, except mood disorders, declined significantly post-treatment; however, length of hospital stay did not improve. Overall, young, female patients or those with pre-existing mental illness were more likely than other patients to require hospital care for mental health issues following treatment. Longer period of heroin use was associated with poorer mood outcomes.

Conclusions

Naltrexone implants were not associated with an increased risk for hospitalisation due to mental illness, and in most cases, were associated with a decrease in mental related hospital admission rate.     

Importancia del tamaño de las tuberosidades en las complicaciones del complejo esclerosis tuberosa

Introduction

Tuberous sclerosis complex (TSC) is one of the most frequent neurocutaneous disorders. Cortical tubers are the most common pathological changes in TSC and they are directly related to the disease's main clinical manifestations: seizures, mental retardation, and autistic behaviour.

Objective

The aim of this study is to establish a correlation between tuber size and the severity of clinical features in TSC.

Material and methods

We performed a retrospective study of the clinical and imaging findings from 45 TSC patients (22 females and 23 males) and compared the clinical features with the location, size, and number of the cortical tubers in each patient.

Results

Four patients had voluminous tubers located in 1 or both cerebral hemispheres. All of these patients had intractable seizures and severe mental retardation; 3 of these cases also presented with autistic behaviour, despite tubers having been resected in all 4 patients. Thirteen patients had tubers of large-to-average size, and all patients in this group showed intractable seizures and mental retardation. Nine patients who had experienced infantile spasms during the first year of life presented autistic behaviour. Multiple tubers of small to average size were found in 28 patients. In general, this group had seizures that responded well to antiepileptic drugs and a low prevalence of autism. In 3 patients who all presented good seizure control and normal intelligence, single cortical/subcortical tubers were located in the frontal or occipital lobes. Of the total of 45 patients, 13 had cerebellar as well as cerebral tubers; these were generally present in cases with more severe clinical features.

Conclusions

Although large tubers are less common than small to medium-sized ones, they are much more likely to be accompanied by severe clinical symptoms (seizures, mental retardation and autistic behaviour), even when the smaller tubers are quite numerous.     

Cycloserine-induced psychosis in a young female with drug-resistant tuberculosis

Objective

To report a case of cycloserine-induced acute psychosis in a young female while on second line antitubercular treatment (ATT) for tubercular meningitis.

Method

Case report.

Results

A 20-year-old female, known case of tubercular meningitis on ATT since 8 months, presented with a 10-days history of headache, vomiting, and photophobia. A provisional diagnosis of drug-resistant tuberculosis was made, and second-line ATT including cycloserine (750 mg/day) and levofloxacin (750 mg/day) was added. Three days after the start of cycloserine and levofloxacin, the patient developed psychosis with delusions and hallucinations. Since the patient was on several drugs with potential to cause psychotic reaction, we considered a provisional diagnosis of drug-induced acute psychosis. Two days following cycloserine withdrawal, the patient improved significantly, and on the third day, she was absolutely normal with disappearance of psychotic symptoms.

Conclusion

Our case highlights the importance of awareness regarding psychiatric adverse events of antitubercular agents and the reversible nature of the adverse events on drug withdrawal. We also suggest that caution should be exercised while administering cycloserine in MDR-TB patients because of a higher risk of psychiatric adverse events.     

Entraînement aux habiletés sociales pour adolescents souffrant de troubles psychiatriques sévères : étude exploratoire de l’impact sur l’assertivité

Objectives

Adolescence is a crucial period involving numerous acquisitions of social skills. These skills were experienced in peer relationships. In this context, assertivity is a fundamental ability allowing individuals to act in function of their own interests and defend their point of view without denying the rights of others. However, for some adolescents such acquisition is not easy. Thus, anxiety, social withdraw or emotion regulation difficulties impaired the socialization process. More specifically, psychiatric illness (such as mood disorder, anxiety or psychosis disorder) during this period interferes dramatically with such acquisition. However, training targeting social skills improvement, in a population presenting psychiatric disorders may help to enhance interpersonal functioning. In this perspective, the present study aimed (1) to assess the effect on assertivity of the training and (2) to specify the patient's type which reports the most benefit of such training.

Materials and methods

Thirty-eight adolescents (19 suffering from anxiety/mood disorders and 19 suffering from psychotic disorders) participated in a social skill training. Their assertivity was assessed with the Rathus assertivity scale which is a 30-item self-report questionnaire. The participant respond on a Likert scale composed of 6 points (from “totally true” to “totally false”). The Rathus assertivity scale allows to differentiate adolescents in: Inhibited, assertive, assertive-aggressive. The scale was administered before and after the social skills training.

Results

A general improvement on assertivity after the social skills training (partial eta square (η2) = 0.131: moderate effect size) was observed. More specifically, adolescents suffering from anxiety/mood disorder (partial eta square (η2) = 0.206, moderate effect size) and the “inhibited” adolescents (η2 = 0.311, strong effect size) showed the higher benefit from the social skills training.

Conclusions

The social skill training was reported by the adolescents to be an effective treatment allowing enhancing the assertivity of these population. Furthermore, the patients with anxiety/mood disorders reported the highest benefit compared to the patients with psychosis. This result raised the question about the usefulness of self-report questionnaire, as the patients with psychosis were observed, at a clinical level, to have better social abilities after the treatment, but did not report such effect on the self-assessment. In addition, the inhibited patients reported the highest benefits of such treatment. Three main factors could help us to interpret the results: (a) the composition of the groups, (b) the therapeutic approach, and (c) the team giving the social skill training. Firstly, the composition of the groups is heterogeneous like in the social reality of the youths. Thus, the heterogeneity of the psychopathologies composing the groups involved that the youths experienced a wide variety of social interactions with peers. Furthermore, some adolescents could experiment to be a model for others. However, related to our results, we could assume that adolescents with anxious/mood disorders benefit the most from the heterogeneity of the groups and the fact to be a model for others. Secondly, the therapeutic tools used seem also to be an important factor. Indeed, the training is based on cognitive and behavioral approach (using tools like psycho-education, cognitive restructuration, etc.) and social learning which are frequently used in this type of training. Thus, psycho-education allows acquiring new knowledge about their difficulties, for example. In particular, we could understand the most important increase in adolescents with anxiety/mood disorders by the fact that relaxation exercises could reduce their symptoms and so increase their assertivity. In contrast, for adolescent with psychosis disorders, this is not sufficient. Perhaps, their dysfunctional believes had to be reduced before they could benefit from the social skills training. Thirdly, the team giving the social skill training is also important. They all receive a complete training and have a lot of experience in working with such population. More generally, learning new social abilities in protected context, through experiencing positive social interaction may be beneficial for interpersonal function of the patients.     

Soins intensifs à domicile : modèles internationaux et niveau de preuve

Introduction

Despite recent legislation favouring home treatment services, international literature contrasts with its development in France, where those programs stay rare. They were implemented since the deinstitutionalization movement of the 1970s, to provide care to severe mentally ill outpatients, who used to stay in long-term inpatient wards. Those home treatment programs can be divided in two groups: Assertive Community Treatment and crisis interventions teams.

Objectives

This article first aims to describe those two types of programs, and then to review their evidence level. Finally, we will discuss the actual controversy about effectiveness of home treatment.

Method

This article is a literature review of international research about home treatment programs for adults’ severe mental illness. It excluded children psychiatry, addictology and elderly psychiatry. We selected reviews and research articles taken from international publications, using a PubMed research.

Results

This article concerns home treatment programs, belonging to “mobile teams”, which is a group of psychiatric teams including varied goals: Improving continuity of care, community assessment, avoiding admissions to psychiatric hospital, improving skills in community living, and supporting families. Those programs practice assertive outreach. Some provide care and others only assess and direct people to other services. Only the first ones are concerned by this article. We distinguish two types of home treatments: Assertive Community Treatment (ACT) and Crisis Intervention teams. Assertive Community Treatment, also named Assertive Outreach teams or Intensive Case Management, is a very well described model which aims to keep people with severe mental illness in the community. It is an intensive kind of Case Management. It is specially addressed to high services users, with frequent admissions. ACT consists in visiting people at home, providing cares and social support, developing skills to cope with daily living. It is provided by a 24-hour available multidisciplinary team, in an unlimited time. The first Stein and Test study showed benefits compared to standard treatment, but more recent trials failed in improving hospital use or clinical and social outcomes. Some even show and increased hospitalization rate. This variation can be explained by an improvement of standard care with time, and international heterogeneity. A higher fidelity to the original model could decrease bed use. Fidelity scales have been developed to compare different programs. ACT seems to be useful to improve engagement in care for people with a high level of needs, and to maintain them in housing. Studies also show a dilution of the effectiveness of ACT in routine practice. Those results limit its implementation. The second group of home treatments is crisis intervention and home treatment teams, also called crisis assessment teams. Those teams aim to treat crisis at home for severe mentally ill people. Crisis is defined as a symptomatic exacerbation in severe mental illness. Treatment is provided by a 24 hours available multidisciplinary team which assesses the situation, directs the patient and programs a crisis intervention. The intervention is time limited, about six weeks. It helps people to resolve crisis in the community. It could avoid 50% of psychiatric admissions, without increasing readmission rates. A recent study shows it could reduce the suicide rate. It also improves satisfaction with care and engagement.

Conclusions

Despite the controversy, home treatment services can be useful to improve engagement in care, user's satisfaction, and to avoid psychiatric admissions. Visiting patient at home and associating social interventions with medical treatment improve bed use outcomes. Less intensive but well organized community teams can also bring benefits. In the French context, the lack of visibility of home treatment teams can be explained by several hypotheses. We can cite the lack of systematic evaluation of care programs, the persistence of more inpatient beds than in other countries, the difficulty to implement home treatment in rural areas or the cultural use of hospital.