Les maladies chroniques chez les étudiants en médecine au Maroc : quelles interactions avec le stress psychosocial ?

ObjectivesTo evaluate the prevalence and factors associated with Chronic psychiatric and somatic illness among medical students in Morocco.MethodsA multicentric cross-sectional study during a period of four weeks in February 2019 involving 605 students of 1st, 2nd and 3rd cycle of medical studies of the faculties of medicine in Morocco.Results41.5% (251) of students confirmed having a chronic disease, among which 80% were under treatment. Psychiatric conditions represented the most frequent chronic illnesses among medical students (28%), followed by dermatological (16%), allergic and respiratory (12.2%), and gastroenterological (11%) conditions. Chronic illnesses among medical students were significantly associated with female gender (P: 0.0000000037), level of education (P: 0.0000), personal history of suicide attempts (P: 0.0000259), and a consumption of psychoactive substances (P: 0.0000029046).ConclusionChronic illnesses are frequent, underestimated and undertreated among medical students in Morocco. The link with stress has been suggested as the value of establishing a program to train medical students in stress management.     

Perceptions des externes en médecine lors de leur stage en pédopsychiatrie : étude qualitative

ObjectiveA part of medical students complete their psychiatric traineeship in adolescent psychiatry. They have to face with patients close in age. Furthermore, a few medical students are themselves still in an adolescent stage: cerebral changes of pubertal development occur until 24 years old; while medical studies length prevent from earlier empowerment. This study seeks to understand medical students’ personal experience during their adolescent psychiatric clerkship to enhance mentoring.Patients and methodsA multicentric qualitative study was conducted using Interpretative Phenomenological Analysis methodology. Data were collected through semi-structured face-to-face interviews among eight medical students from 18 to 25 years old after completing their clinical clerkship. In-depth analysis were performed using Nvivo software program.ResultsData analysis found three major themes; 1) loss of usual clinical work references and confusion regarding their previous experiences (absence of white coat, fewer traditional medical hierarchy, adjustment of appropriate relationship with patient, difference between normal and pathology); 2) discovery of psychiatric care supports both moving beyond first stigmatization attitude toward patient with psychiatric disorders and increasing empathy toward patients’ stories; 3) strength of psychoaffective involvement and identification, including confusion between patients and their own family stories.ConclusionAdolescent psychiatry clinical clerkship means a particular involvement for undergraduate medical students. It suggests a need to enhance mentoring.     

Burnout chez les résidents en médecine tunisiens : à propos de 149 cas

Background

Burnout is a professional psychological chronic stress-induced syndrome defined by three dimensions: emotional exhaustion, depersonalization, and low personal accomplishment. This syndrome concerns all professions but especially healthcare staff. Numerous studies have attempted to document the impact of work activities on the doctor's mental health. According to the literature, junior doctors are more vulnerable to develop this syndrome.

Freins à l’abord des troubles du comportement alimentaire en médecine générale

IntroductionGeneral practitioners (GP) are the most suitable candidates to screen for eating disorders (ED), which affect 0.6 to 4.5% of the population over their lifetime. 13% of adolescents are concerned if we consider sub-syndromic form. The outcome of ED improves with early detection but 50% of patients are still not identified in primary care.AimTo explore GP's representations of ED and the barriers they face while broaching the subject in practice and to understand this under-screening of ED.MethodIt was a qualitative study by focus groups. The five focus-group need for data saturation were transcribed and the verbatim was double coded and analyzed by the grounded theory.ResultsThe focus on anorexia nervosa, a BED remaining unrecognized and the misidentification of obesity as an ED were the main representations of the asked GPs. They considered ED as being bound to the intimacy of patients, just as sexuality would be, they feared to be too intrusive while approaching them and to compromise the patient-doctor relationship. The time-consuming part of such consults, the unknown assessment tools, a perceived lack of communication and psychological skills, the feeling of helplessness and lack of a psychiatric support stood in the way of approaching ED in general practice.ConclusionTraining for time-saving communication techniques, organizing a dedicated screening consult, a well identified psychiatric network or free psychotherapy sessions are ways to improve screening of ED. To study how psychiatry can be more positively perceived would be a first step to overcome its induced mistrust.     

L’empathie en médecine

ObjectivesEmpathy is everywhere. It has become a major topic of interest in many disciplines and professions. Cultivating empathy has been prescribed as a solution to numerous social ailments and political problems. One reason for such a proliferation of attention is the lack of a clear conceptual taxonomy and the use of empathy as an umbrella under which definitions vary enormously. It is widely acknowledged that empathy plays a critical role in the physician-patient relationship and has a positive impact in clinical practice. However, the medical profession is struggling to achieve an appropriate balance between clinical distance and empathy. Too much sensitivity to negative affect expressed by patients, without proper emotion regulation, may lead to anxiety and personal distress, which is detrimental to efficient cognitive functioning and can take a toll on the well-being of physicians. Too little empathy may lead to an underestimation of the pain of others and poor rapport with patients. As the field of empathy expands, the lack of conceptual coherence challenges advances in medicine. Moreover, in some cases there is little added theoretical or clinical value in applying the broad/all-encompassing term of empathy, which is by nature multidimensional and interpersonal.MethodsThe number of competing conceptualizations of empathy circulating the literature has created a serious problem by making it difficult to keep track of which process or mental state this neologism refers to in any given discussion. Multiple definitions limit progress in the role of empathy in medicine, and which instruments are appropriate to assess its function and utility. Keeping track is important because the different conceptualizations refer to distinct psychological processes that vary, sometimes widely, in their function, phenomenology, biological mechanisms, and effects on interpersonal relationships. In this article, after considering the polysemic nature of empathy, I briefly review the functions attributed to empathy in medicine. Then I explain how theoretical clarity may be improved by examining knowledge from empirical investigations in psychology and social neuroscience which has led to better define the different components of empathy as well as their neurological mechanisms. One section critically reviews the functional neuroimaging studies that have been specifically designed to examine patterns of brain response in physicians and health professionals. A separate section addresses how social and relational factors, particularly group membership, may impact the expression and effect of empathy in medical care. This new perspective, based on advances in scientific psychology and social neuroscience, has the potential to reduce confusion and ambiguity. This critical and informed analysis of empirical studies in functional neuroimaging with health professionals calls for a nuanced assessment of empathy's functions, that are not necessarily a panacea as some seem to think.ConclusionA provocative and more sober view on the value and the very interest in the notion of empathy in medicine is proposed. Ultimately, cultivating empathic concern (sympathy or compassion in today's medicine) seems more important than other aspects, particularly affect sharing or putting oneself in the patient's shoes.     

Impact de la formation théorique et clinique sur les attitudes de stigmatisation des étudiants en médecine envers la psychiatrie et la pathologie psychiatrique

Objective

The aim of the study was to explore whether a medical student education program and clinical posting in psychiatry had an impact on medical students’ stigmatizing attitudes towards psychiatry and psychiatric disorders.

Étude des tempéraments affectifs chez des patients épileptiques en Tunisie

Purpose

Epilepsy is a chronic neurological disorder that is associated with an increased risk for psychopathology. Depression is the most common comorbid psychiatric condition in epilepsy, with often atypical clinical manifestations, including symptoms of irritability and anxiety. Temperament refers to biologically based characteristic patterns of emotional reactivity and self-regulation. In early studies, specific temperamental factors have been shown to be risk factors for depression symptoms in adult epilepsy patients. Thus, determining the affective temperament profile of epilepsy patients has important clinical implications especially in identifying those patients most at risk of developing mood disorders. However, very few studies of temperament in epilepsy patients have yet been published. The purpose of this study was to measure depression symptoms and severity, and to assess temperament in adult epilepsy patients, in comparison with control subjects; and to evaluate among the group of epilepsy patients the relationships between affective temperament types, sociodemographic profiles, clinical characteristics, and symptoms of depression.

Humour : quels regards portés par les professionnels et étudiants manipulateurs en électroradiologie médicale ?

Objectives

Although many scientific studies have focused on humour in the care relationship, we thought it would be a good idea to interview radiographers, whose role illustrates the dichotomy between humanity and sophisticated healthcare techniques. We intended to highlight the need to introduce humour – an essential part of communication with the patient – in the technical environment of this profession. We collected data on how practitioners perceive humour in their day-to-day practice, and then compared the results with the abstract opinions the radiographer students have on using humour in their future practice. This study thus reports on the comparison between the students’ expectations and the reality of radiographers in the field, dealing with the extent to which it is relevant to introduce a more personal approach in healthcare through humour and laugher.

Quelles interventions pour améliorer le bien-être des étudiants en médecine ? Une revue de la littérature

Physician's psychological distress has been known for more than a century. A meta-analysis found an increase in the suicide rate among physicians, compared to the general population, with a relative risk of 1.41 for men and 2.27 for women. Among interns, the prevalence of depression or depressive symptoms is estimated at 28.8% (IC 95% = 25.3%–32.5%). The suffering of medical students prior to internship has been recognized more recently. But now there are many studies, and a few meta-analyses, which have evaluated the prevalence of anxiety, depression, burnout and, more generally, the lack of well-being. Among medical students, the prevalence of depression or depressive symptoms is estimated at 27.2% (IC 95% = 24.7–29.9) and that of suicidal ideation of 11.2% (CI at 95% = 9.0–13.7). Another meta-analysis found a prevalence of burnout of 44.2 % (IC 95% = 33.4–55.0). Since the problem has been known researchers have tested interventions to improve the well-being of students. Our work aims to review interventions to help medical students and use validated scales. A review was published in 2016 about interventions on the learning environment, and the well-being of medical students was published; 28 studies were identified. But they did not systematically use validated questionnaires allowing a quantitative approach. Interventions included: pass/fail scoring systems (n = 3), mental health programs (n = 4), psycho-corporal skills programs (n = 7), curriculum structure (n = 3), multi-component program reform (n = 5), wellness programs (n = 4), and counseling/mentoring programs (n = 3). We chose to focus only on studies using validated questionnaires. A search was performed in the MEDLINE biomedical electronic database until July 31, 2018. The inclusion criteria were: original study, in French or English, concerning medical students prior to internship involving an intervention to improve the well-being of medical students by measuring at least one criterion of psychological distress (anxiety, burnout, depression…) using a validated scale. Thirty-six studies were included in this review. The quality of the studies is very heterogeneous. We can distinguish three types of intervention: institutional (modification of the system of notation, classification…), in-group (management of the stress, therapy full of conscience, relaxation, psychoeducation…) or individual (screening and support custom). These interventions encompass all levels of prevention (primary, secondary and tertiary). There is limited effectiveness of group interventions. This effectiveness disappeared after SIX months with the exception of institutional interventions. The data set encourages us not to favor a single type of intervention but to promote a global intervention acting at all levels. In particular, researchers can draw on studies of doctors and interns. France is late to come to the issue with few published studies on interventions to improve the well-being of students, but recent awareness seems to have taken place. Our study has some limitations: restriction to French and English, the choice to select only comparative studies using validated scales which limited the number of studies selected but also the type of interventions not all of which allow a quantitative evaluation. In the interventions not taken into account in this review, several seem promising. They mainly involve secondary prevention: improving the training of staff and students in the detection of symptoms of depression, burnout and psychological stress, screening at-risk populations, and communication campaigns to combat the stigma of psychiatric disorders and encourage students to consult. But tertiary prevention is also of interest: have psychologists and psychiatrists in the faculties accessible to students who feel the need and can also accommodate. Finally, a certain number of faculties have set up vocational guidance and selection aids that are appreciated by students but have not been evaluated for their impact on students’ health. Recent studies and meta-analyses indicate a significant prevalence of outstanding medical students, however, there is reason to be optimistic. Many health professionals and researchers are interested in the problem as well as the means to remedy it. Most studies are effective in the short term. However, the methodological limitations (low number of subjects, limited follow-up time…) and the heterogeneity of studies concerning interventions (mindfulness, psychoeducation…) on students do not allow us to conclude that they are effective in the long term. It should therefore rather move towards comprehensive care acting on the three levels of prevention: primary (institutional interventions/speech groups/psycho education), secondary (screening of subjects at risk, speech groups/psycho education/others) and tertiary (individual interventions).     

Évaluation des états mentaux à risque de transition psychotique dans un échantillon de jeunes détenus de sexe masculin en Tunisie

BackgroundPrevalence of psychotic disorders in a prison population is higher than in the general population. Recent research has shown that early intervention is feasible in prison settings, and that approximately 5% of screened prisoners have met ultra-high-risk (UHR) for psychosis criteria. We aimed to identify the prevalence of the UHR states for developing psychosis in a group of newly incarcerated men in the Jendouba Civil Prison and to analyze the association between UHR states and socio-demographic data and substance use.MethodWe carried-out a cross-sectional study among 120 prisoners. Every prisoner was interviewed using the Comprehensive Assessment of At-Risk Mental States (CAARMS). The Social and Occupational Functioning Assessment Scale (SOFAS) was used to assess the participant's level of functioning.ResultsWe found a prevalence of subjects meeting the UHR criteria of 21.3%. UHR subjects had significantly more psychiatric family history (P = 0.035), personal history of suicide attempt(s) (0.035) and self-injury (P = 0.013) compared to non-UHR subjects. Clinical self-evaluation found significantly more depression and anxiety in the UHR group (P = 0.020 and P = 0.035, respectively). In addition, social and occupational functioning was significantly more impaired in the UHR group (P = 0.007). UHR subjects used significantly more cannabis in lifetime (P = 0.015) as well as in the past year (P = 0.022) and had a significantly higher frequency of cannabis use (P = 0.01) compared to non-UHRs.ConclusionPrison mental health teams face the challenge of identifying prisoners who need mental health services and providing early care to this vulnerable group; this challenge may offer a unique opportunity for intervention among a population that might not otherwise have had access to it.     

Efficacité de la médecine thermale en psychiatrie

Objectives

Relatively little known in psychiatry, spa psychiatric medicine is an original approach, which has started to form the subject of thorough assessments. It concerns 3 week spa therapy stays in practice, the patient being totally free and self-sufficient, though having to go to 3 to 4 prescribed daily bathing sessions and to the medical and psychotherapy follow-up provided within the scope of their medical care. Since the beginning of the years 2000, Spa Medicine has been subject to studies that have better shown the outline and its potential application areas. We present you here, through a review of the literature from these past 30 years, the main elements of scientific proof of its therapeutic activity and as a result, its best documented indications in psychiatry. Therefore, the article is stated by chapter, indication by indication.

Distorsion des consensus scientifiques dans les thèses de médecine dédiées à l’hyperactivité/TDAH en France

Attention Deficit and Hyperactivity Disorder has first been defined in the third version of the DSM published in 1980. Though it still lacks a consensual biological etiology, ADHD is the most common mental disorder among school-age children nowadays. Several recent studies have however highlighted considerable distorsions between international scientific consensus and information provided to the general public. Those distorsions always favor biomedical approaches of ADHD and support the use of psychostimulant medication. They hence overshadow the psychosocial factors contributing to the disorder and leave no room for other therapeutic approaches like psychodynamic psychotherapies. We therefore deemed it necessary to investigate the content of medical theses focusing on this particular disorder. In this article, we examine the representations of hyperactivity in medical theses dedicated to ADHD in France, based on the systematic analysis of a corpus of 45 theses defended between 1990 and 2018. Our corpus was analyzed using the following questions: 1) does the thesis support a biomedical or psychoanalytical approach to ADHD? We used the term “combined approach” when both points of view were argued; 2) for each thesis, is the biological etiology of ADHD – genetic, neurological or neurodevelopmental – mentioned and discussed?; 3) are the environmental and social factors of hyperactivity also discussed?; 4) do medical theses present the risks associated with ADHD: academic failure, delinquency, substance abuse?; 5) what treatment do medical theses recommend in the care and support of children diagnosed with hyperactivity: drug treatment, psychotherapy or a combination of both?; 6) does the use of a psychostimulant treatment protect against the risk of school failure: yes/no/both opinions?; 7) is it possible to diagnose ADHD hyperactivity by brain imaging?; 8) finally, we sought references to scientific work or experts involved in conflicts of interest with the pharmaceutical industry – references in the text body or bibliography. We also looked for critical indications for the risks of over-medication of ADHD. The results we obtained indicate major distortions (94.5 %) in scientific knowledge concerning the etiology of ADHD, the approved methods for diagnosis or the benefits of psychostimulant medication on academic performances. Indeed, though hundreds of studies using MRI imaging have failed to show any neurological lesion associated with ADHD, 91 % of our corpus supported a neurological etiology of this disorder. Similarly, 87 % of our corpus wrongly described ADHD as a genetic disorder, and more than 50 % still affirmed MRI could be used to diagnose ADHD, despite the scientific consensus claiming the opposite. Psychostimulant medication was also the most mentioned form of treatment, despite it theoretically being a « last resort » treatment. Our results suggest there might be a biomedical ideology determining physicians’ representations of ADHD. This ideology could have an impact on physicians’ care pratices with children suffering from ADHD and their families, thus possibly increasing the risk of over-medication. It could also lead future practitioners to underestimate the importance of their diagnostic skills and the therapeutic work they engage into.