Quelles comorbidités psychiatriques dans la dépendance au cannabis à l’adolescence ? Comparaison de patients consultants et de témoins

Background

The use of illicit substances, in particular cannabis, among French adolescents and young adults has become an important public health concern. A better understanding of the mechanisms involved in pathological substance use is nowadays critical. Psychiatric comorbidities have been previously reported in adult substance abusers but are less documented in adolescents, especially regarding cannabis dependence.

Télémédecine et troubles du spectre de l’autisme de l’enfant et de l’adolescent : guide théorique et pratique

ObjectivesThe development of telemedicine for children and adolescents is a real need because of difficult accessibility of mental health and the paucity of childhood psychiatrists. Thus the American Academy for Child and Adolescent Psychiatry (AACAP) published in 2008 good practice recommendations for telepsychiatry in children and adolescents based on clinical consensus and scientific evidence. In France the legal framework defines four practical modalities according to the presence or not of a health professional or a psychologist with the practitioner accomplishing the teleconsultation act. Data exist about the outcome of children and adolescents who benefited from therapeutic interventions with technological media. Effect size is modest but it doesn’t justify ruling out these techniques. Children who present with a developmental disorder or who cannot cooperate are evaluated with a certain degree of uncertainty. By contrast, some children with severe Attention Deficit with or without Hyperactivity (ADHD), social anxiety or Autism Spectrum Disorders (ASD) can be more easily engaged within a teleconsultation model. Teleconsultations in autism spectrum disorders (ASD) are feasible because of the nature of diagnosis and the type of care recommended in this disorder. The behavioral nature of the disorder and the behavioral therapeutic approaches recommended in North America culture highlight the potential interest of telemedicine because these disorders are easily observable. Literature suggests new opportunities in order to facilitate the care process for the ASD person and his family: the first one is diagnosis with use of validated instruments such as the Autism Diagnostic Observation Schedule (ADOS) and the Autism Diagnostic Interview (ADI). Parental accompaniment is the second opportunity. Development of telemedicine for ASD could be a complementary approach for diagnosis and medical care.MethodSince 2015, a program called PROMETTED (PROgramme MEdical de Télépsychiatrie pour enfants et adolescents présentant un Trouble Envahissant du Développement) was supported by Regional Health Agency of Île-de-France. It was developed and managed by the team of a Diagnosis Center Evaluation for Autism (DCEA) of Paris area in collaboration with a DCEA of Île-de-France region. Five medico-social structures for children and adolescents with autistic disorders and the two diagnosis centers of evaluation for autism co-elaborated a scheme of intervention with telemedicine. The remote evaluation is a 4-step process: a first teleconsultation structured around the medical history of the subject in order to complete his medical file and the observation of the young subject; a second teleconsultation structured around the ADI-R interview with parents; the third teleconsultation is a mixed teleconsultation associating the medical expert of the DCEA and a psychologist trained in the use of the Childhood Autism Rating Scale (CARS) and the Vineland Adaptive Behavior Scales (VABS). The fourth teleconsultation consists of the psychiatrist giving feed-back to parents about the results of the observations of the DCEA team.ResultsThe four-step program is well-accepted and the use of validated instruments for diagnosis or functional evaluation appears feasible. Medical data were completed for 44% of cases; complementary genetic or medical investigations were prescribed for 50% of cases; medical advice about psychotropic or vitaminic medication was given for 31% of cases. Mean duration of evaluation was 11.1 weeks ± 9.4.ConclusionsThe PROMETTED program empirically validates the concept of remote evaluation for children and adolescents with ASD. The need to extend the use of telemedicine to tele-expertise for medicine monitoring or behavioral disorder management has been noted.     

Prise en charge de la dépression de l’enfant et l’adolescent en soins premiers : une métarevue systématique de la littérature

ObjectiveTo develop a practical guide for the management of child and adolescent depression for general practitioners (GPs), suited to their practice frame, that can be implemented on a website aimed to help GPs to manage the main mental disorders encountered in primary care.MethodA systematic meta-review was performed as recommended by the PRISMA statement. Each step, articles’ selection, inclusion, methodological assessment and data extraction for the narrative synthesis was independently performed by two researchers. A study protocol was registered on PROSPERO (number CRD42016042710). The databases Pubmed, Cochrane and Web of Science were explored. Each step was performed independently by two researchers following PRISMA. Meta-analyses and systematic reviews (including guidelines based on a systematic review), published between 2002 and 2015, in English or French, dealing with the therapeutic management, in primary care, of patients aged 6 to 18 years old with a major depressive disorder (MDD) were included. Grey literature was explored searching the websites of national and international health agencies, learned societies, and article references. The methodological and report qualities were assessed using the AGREE II, PRISMA checklist and R-AMSTAR grid. A narrative synthesis was performed to produce the practical guide, prioritizing data from the best evaluated articles. An expert group of GPs’ and one child psychiatrist validated the guide in its final form.ResultsThirty-eight studies were included: 12 recommendations, 5 systematic reviews and 21 meta-analyses. The best evaluated guideline had an AGREE-II assessment of 81%, and the best evaluated meta-analysis had an assessment of 86% for R-AMSTAR and 96% for PRISMA. The average scores of the R-AMSTAR and PRISMA assessments were 65% and 72% respectively. The average score of the AGREE II grid assessment was 57%. The data were synthesized into a practical guide for the GPs’ practice, corresponding to the different consultation times. MDD diagnosis should be done on the DSM or ICD basis. The Childrens’ Depression Rating Scale-revised or the Revised Beck Depression Inventory are useful in primary care for MDD appraisal in children and adolescents. For mild MDD a supportive psychotherapy and surveillance for 4 to 6 weeks is preconized in primary care. In the absence of improvement, a specific and structured psychotherapy is recommended, and the patient should be addressed to a child psychiatrist. For moderate to severe MDD, the young patient should be addressed to a specialist in child psychiatry. A psychotherapy, which can be associated with fluoxetine, especially in adolescents, is indicated with a revaluation of the pharmacological treatment between 4 to 8 weeks. A weekly follow-up by the GP is recommended during the first month, especially after the initiation of an antidepressant to assess the suicidal risk. Beyond the first month, a consultation should be scheduled every two weeks.ConclusionA clinical guide was created from the best evidence-based data to help GPs in the management of child and adolescent MDD. A French-language website, aimed to assist GPs in mental disease management and available during their consultation, will be created based on the compilation of this meta-review with other similar meta-reviews.     

De l’aliénation mentale de l’enfant et de l’adolescent à la pédopsychiatrie dans les communications à la Société Médico-Psychologique de 1852 à 1937

In 1848, the Société Médico-Psychologique was founded. Its aims is to promote the study and improvement of mental pathology. During the 19th century, François Arnaud (1858–1927), Claude-Etienne Bourdin (1815–1886), Michel Catsaras (1860–1939), Louis Delasiauve (1804–1893), Eugène Dally (1833–1887), Jules Fournet (1812–1888), Paul Garnier (1848–1905), Valentin Magnan (1835–1916), Jacques-Joseph Moreau De Tours (1805–1884), Emmanuel Régis (1855–1918), Paul Sollier (1861–1933), Edouard Toulouse (1865–1947), Auguste Voisin (1829–1898) and Jules Voisin (1844–1920) were the alienists or not, French or foreigners who succeeded at the chair of the Société Médico-Psychologique. This later presented observations of children or teenagers. The communications and discussions but also the issues raised by the alienists, neuro-psychiatrists then child psychiatrists will contribute to the reflections of members of the Société Médico-Psychologique over the course of the last century. But, they also forced us to take a more perceptive look at the child's mental health. Its communications and their authors belong to their time and to a time or even a place where they emerged. Apart from to looking into the topics pursued (deficiency, dementia praecox, epidemic encephalitis, autism, etc.) concerning the infantojuvenile psychiatry, we will carry out a work of communications contextualization focused on the child's mental health at the Société Médico-Psychologique during 170 years.     

Thérapies comportementales et cognitives et troubles de l’humeur

A large number of psychotherapies were proposed to depressed patients. The behavioural and cognitive therapies showed their efficacity. This short-term therapy improves quickly the symptoms and prevent around 30% of relapse. Many patients having suffered from depression undergo unipolar depression relapses during the 5 years following the treatment. Therefore international guidelines, including pharmacological and psychological interventions, were published to prevent these relapses. Nowadays a combined treatment is most often prescribed. This paper presents the behaviour and cognitive models of depression. This brief psychotherapy works on the depressed symptoms (engaging the patients in a large number of pleasant activities), on hopelessness cognitions and on the own psychological vulnerability (named cognitive schemata). The activation of depressed schemata is correlated with relapse. The indication of TCC in depressed patient is discussed after two ou three sessions (“case conceptualisation”) performed by a cognitive and behaviour therapist. This professional has preliminary learnt the theory and practice during a specific training. This article reviews main studies including the cognitive and behavioral therapy in depressed uni- and bipolar patients. Results are discussed in terms of acceptability, feasibility, and efficacy. A case study confirms the relevance of this approach. New cognitive and behaviour programmes were developed during 20 years with recurrently depressed patients, these included additional booster sessions sometimes combined with well-being therapy and even with mindfulness-based cognitive therapy. The new approaches were assessed in pilot studies and their results will have to be confirmed.     

La paranoïa à l’épreuve de la psychiatrie et de la justice. Traitement médical : médicaments et consentement

Traditional figure of the psychiatric dangerousness, the paranoia suffers from a particularly pejorative morbid load: “resistant”, “incurable”, “murderous”, “alienating”, “dangerous”. This article briefly explores the three poles of paranoid care: psychopathology, care and consent, evolution.     

Équipe mobile de pédopsychiatrie en territoire guyanais : questionnement de l’adolescent amérindien

IntroductionSince their French naturalization in 1969, Amerindians of French Guiana have been facing a full and fast reorganization of their way of life. Teenagers, at the forefront of this cultural transition, are challenging French school institutions, as well as cultural society and care system organizations in Amazonian French remote villages. Rates of autolytic behaviors such as toxic substance abuse or suicide attempts, but mostly completed suicides, are alarming among this adolescent population. To improve care delivery to those teenagers, a mobile child psychiatric team was implemented in 2013.MethodsWe describe this device, its activities and the problematics encountered.ResultsThis team's purpose is to lead a psychiatric evaluation of teenagers in order to determine a possible psychiatric diagnosis and elaborate a care plan. Although the results are mostly encouraging, this device seems to show some limitations: lack of time dedicated to these interventions, lack of psychiatric care available for follow-up in these villages, tremendous numbers of social distress situations implicated in psychological issues. Moreover, it appears that cultural aspects must be considered in the analysis of the Amerindian adolescent population's issues and the determination of providing care.ConclusionImplementation of actions based on more educational and social levels might be a solution.     

La place de la compréhension des proverbes et des métaphores dans la compréhension des troubles du cours de la pensée dans la schizophrénie : apport de l’évaluation clinique,de l’imagerie cérébrale fonctionnelle et de la neurophysiologie

According to Bleuler (1911), language impairments were indicative of thought disorders, a fundamental feature of schizophrenia. The objectives of the present review are twofold: (1) to present the clinical interest of the use of the tests of proverbs and metaphors comprehension for the evaluation of the characteristics of thought disorders in schizophrenia, and to highlight the heterogeneity of the forms of their interpretations; (2) to present the results from neuroimaging and neurophysiological studies of metaphor comprehension in order to identify the neurocognitive mechanisms underlying metaphorical language comprehension of patients with schizophrenic disorders. Results from the reviewed clinical applications of proverbs tests showed that thought disorders in individuals with schizophrenia are illustrated by different forms of proverb interpretations: literal, concrete, idiosyncratic, over-inclusiveness and unconventional. Results from the reviewed brain imaging and neurophysiological studies showed that these different forms of figurative misinterpretations may be related to different neurocognitive mechanisms: concreteness appears to be related to the dysfunction of the left inferior frontal gyrus and inverted brain lateralization during metaphor processing in individuals with schizophrenia compared to healthy individuals. During novel metaphor comprehension, which is highly effortful, individuals with schizophrenia, relative to controls, demonstrate increased activation of the right precuneus, a region that mediates complex and highly integrated functions including retrieval of episodic memory and mental imagery. These results may suggest that individuals with schizophrenia use mental imagery to support comprehension of both literal and metaphoric language. Furthermore, it was demonstrated that over-inclusive thinking, which is exhibited by individuals with schizophrenia during figurative language comprehension, could be related to very early right hemispheric hyper-activation (when a left early activation is expected) and to reduced bilateral brain activity during semantic processing. Such as reversed brain activation may explain why the individuals with schizophrenia are relatively over reliant on early-stage coarse or large semantic processing and may be prone to form meanings that are idiosyncratic and highly unconventional.     

L’avancée en âge des personnes atteintes de troubles du spectre de l’autisme. Éléments cliniques et psychopathologiques

ObjectivesThis article attempts, from a psychopathological perspective, to clarify the clinical evolution of patients with ASD during adulthood and into old age, and to assess the risks and the chances. In addition, the article also attempts to address the experiences of these people confronted with their own aging, the death of loved ones, and their own mortality. This study of a cohort of 314 elderly patients can provide some data concerning these changes.MethodThe study of the cohort of 314 adult and aging patients makes it possible to specify several aspects of ASD in adulthood: level of severity, associated disorders and co-morbidities (psychiatric disorders, intellectual deficit, epilepsy, neurosensory disorders, genetics). At the clinical and psychopathological level, the behavioral disorders are described therein with reference to the dominant psychopathological modes of functioning: typical autistic modalities (notion of post-autistic recourse), symbiotic modalities, acute anxious exacerbations, depressive and manic functionings.ResultsPropose an elucidation of challenging behaviors (or problem behaviors) and make it possible to address them; demonstrate that their evolution during advancing age is rather favorable while insisting on the permanent vulnerability of certain subjects. Specify the main courses of action, insisting on spatial, temporal, and relational security; on the central place of care procedures (fundamental physiological needs, consideration of somatic pathologies, specific care with psychotropic drugs, psycho-corporal approaches); and on the attention paid to everyday life, a major therapeutic mediator, through maintaining a reasonable amount of activity.DiscussionThe approach proposed here confirms that the main problem facing adults diagnosed with ASD is that of associated disorders and psychiatric co-morbidities, more than that of the fundamental symptomatic particularities necessary for the diagnosis of ASD (the autistic tripod). This requires going beyond the notion of challenge behavior and adopting a functional perspective that ultimately reveals sometimes major psychic suffering and the adaptive attempts that these patients make to cope with it.ConclusionThe clinical work with this particular population confirms the need for structured institutional work, the only thing that can ensure the coherence of the approaches to working with this diverse patient population, one that is diverse, with generally favorable developments, but which still remains very vulnerable.     

Les transidentités de l’enfant et de l’adolescent : un héritage en mouvement

Nowadays, in France, specialized consultations for transgender youth are developed. In a context of societal, political and anthropological evolution of the concept of gender, the international experience of the Gender Clinics abroad and the Standards of Care produced by international professional associations are guiding the French experience for gender transition in children and adolescents.     

Le travail de l’exil à l’adolescence. Dispositif d’étayage groupal et de médiation par la bande dessinée

ObjectiveThe exile is particularly traumatic for adolescents who, in the host country, live the post-migration experience in uncertainty. In order to enhance the continuous sense of being and the imaginary of a group of young unaccompanied minors, and to promote the narrative of their exile, we have set up a group mediated by comics. We strive to understand how and by which processes a comic mediation group could enable the support of the continuous sense of being as well as the imagination in a group of unaccompanied minors.MethodSix (n = 6) adolescents aged 15 to 17 were invited to design a group comic strip. Participants were invited to create a comic in group. The study was divided in three specific times: (1) the first was to invent a story, (2) the second was to do a storyboard and (3) the third and last one consisted in the creation of a comic. The group proceeded in X session and each session ended with a speaking time. We chose to create a comic as a medium because of its formal qualities: the specificity and complexity of its codes seemed appropriate to work on the time and space. Therefore, the breaks and discontinuities as essential parts of the comic structure allowed the participants to work out their temporal and special experiences of exile. As working in group enables to enhance the creative processes, we have designed and set up a comic mediation group.ResultsWe observed that the creation of the comic facilitates the updating of break and loss experiences, because of its formal structure. This sometimes made the group envelope porous and fragile, and damaged the group associative chain. The mediation group allowed participants to express and transform their primary affects through images and words, which led them to go from a fixed time to a historicized time. The comic became an object that represents the individual psychic reality work, the group work but also refers to the common societal reality that concerns those adolescents. Through the comic, they question the adults, the institutions and the environments that are supposed to protect them. The structure of the comic and the group setting helped participants to restore a sense of security. Moreover, the secure and containing space created by the setting allowed the group to enhance its imagination.DiscussionThe setting permitted participants to be in an active position, which supported them in the process of identity reconstruction. They used comics to transform and make sense of a painful part of their story in order to appropriate it. It is necessary to keep doing research on this subject to improve the support given for this young people. Moreover, it is essential to offer them places where they can be accompanied in the crossing of their exile experience.     

Prises en charge médicales et psychologiques de la vie sexuelle des femmes trans : revue de la littérature internationale

ObjectivesTo understand the place of, and the evolutions in, medical and psychological treatment for trans women's sexual health, within the framework of gender transition/affirmation processes.MethodA narrative review of the medical, psychiatric, and psychological literature. After selection, 19 articles were analyzed inductively using grounded theory and classical methods of thematic content analysis.ResultsMost of the articles reviewed establish a relative lack of research on the topic of sexual health and well-being. Sex reassignment surgical treatments significantly increase the quality of sex life for trans women, except when a “neovagina” is constructed. Changes in sexual orientation are not always linked to elements of treatment, but appear to be linked to other psychosocial factors.DiscussionCategories of sexual orientation are as fluid as sexual practices and gender and change over the course of a subject's lifetime. The discursive construction of gender and sexual orientation is located within the singular discourse of a particular individual at a given moment of her evolution.ConclusionsAfter having long been considered a central element in the diagnosis of “transsexualism”, the issues of sexuality and, in particular, of sexual orientation currently appear to be little taken into account by those professionals who accompany trans people on their medical pathway. This absence is strongly criticized by the authors of the main literature reviews that have already been published. They suggest a more serious clinical consideration of trans women's singular sex lives. It is also observed that the practice of genital reassignment surgery no longer occupies the central place it did until recently, and that the question of sexuality is posed independently of anatomical modifications of the genitals.