Familles et patient souffrant de schizophrénie : questions liées à l’avancée en âge ?

The management of elderly schizophrenic patients is a medical and a political issue with regard to life expectation. There is a paucity of global research. This matter concerns patients, sanitary and social workers, family, care teams, and also decision makers and elective representatives as they all have to work together. A psychiatric patient remains a psychiatric patient throughout his/her life, he/she does not become a geriatric patient. Assuring a continuity of care, of housing, of financial autonomy and of support in a social network is indispensable. Family and care teams are of capital importance (as in all long-lasting diseases). Training in the management of care is essential. One question: can a schizophrenic patient also be an elderly person?     

Prise en charge somatique des patients en accueil familial thérapeutique. Une dimension de la réhabilitation

Foster care is a therapeutic specificity of Ainay-le-Chateau Hospital (Allier, France). The goal of foster care is to promote the rehabilitation and reintegration of the patient. It combines support by a care giver and institutional care. It offers to patients who cannot live alone, but do not justify in-patient care, a therapeutic care in a stable family environment. An initial treatment plan determines the duration of the stay, more or less long term. In addition to psychiatric care, a somatic treatment of patients is organized by qualified practitioners in general medicine. These practitioners provide medical monitoring of patients. Every patient benefits from a treatment plan including monitoring of medication side effects, medical comorbidities and prevention. General practitioners work in collaboration with the nearby General Hospital when an admission is needed for any medical or surgical condition. They can also admit patients in a 10 beds unit within our institution. The hospital specializes Ainay-le-Chateau has adopted a medical organization that provides follow-up for major comorbidities according to present recommendations in this field, thus adding an important element of rehabilitation. Medical consultation assesses vital parameters of patients, monitoring of side effects, nutritional evaluation, and prevention of malnutrition (in partnership with a dietician), assessment of pain, psychiatric comorbidities. Screening protocols are organized for cancer. These protocols are established in accordance with the recommendations of the High Authority of Health. In addition to general medical activity, two consultations have been implemented and validated by the decision-making bodies of the hospital, a follow-up consultation for chronic pain and a specific evaluation of daily autonomy. Pain in psychiatry is often difficult to assess in-patients with mental illness and the usual scales of assessment may be difficult to implement. This consultation provides weekly monitoring of chronic pain patients and the adaptation of analgesics, in partnership with psychiatrists to avoid drug interactions with psychotropic drugs. This consultation also allows anticipating possible hospitalizations and allowing patients to take maximum advantage of the rehabilitation project of foster care. Considering the relatively high proportion of elderly patients, a specific consultation has been established to evaluate daily autonomy in this age group, in order to prepare admissions in institutions for old age patients whenever necessary. During this consultation are evaluated cognitive abilities of the patient, the risk of fall, nutritional parameters, independence from the grid resource AGGIR iso 2 and occupational activities. Care givers provide information to complete this assessment.     

Les évolutions institutionnelles et théoriques de la psychiatrie française entre 1838 et 1914

The text of 1838, “law of philanthropy and general police”, results of compromises between the “Doctrinaire” philosophy of the monarchy of July (Royer-Collard), the political management of social problems and the obligations of public security. It is marked by preeminence of isolation from judicial interdiction (Esquirol, Falret), administrative centralization (general inspector Ferrus), care of financial gestion, prevention of the arbitrary sequestrations, recognition of the asylum physicians and suspicion on the private asylums, often religious. But the departmental establishments destined to the insane are been generally built in the second half of the 19th century, at the time of the industrial Revolution, without consideration to social mutations that operate then, from which results the development of the asylum chronicity. Several French alienists play a political part in the parliaments of the 2nd (Trélat) and of the 3rd Republic (Bourneville). Most do not establish correlations between the increase of the insane and the revolutions of the 19th century. They do not also generally give psychiatric diagnosis about the insurgents of Paris 1848 and 1871 Revolutions. During the 1860 decade, several lawsuits of presumed arbitrary sequestrations (Sandon, Garsonnet) come to the first political criticisms of the 1838 law. About ten projects of reform of this law are elaborated between 1870 and 1912 (Gambetta, Roussel, Bourneville, Dubief, Strauss). They emphasize on the intervention of the justice in the psychiatric internments and on the suppression of private asylums, but do not end in. Ambulatory consultations (Magnan) and “opened” departments are however organized, either in asylums (Marandon de Montyel), or in general hospitals (Régis, Ballet). The concepts of heredity (Lucas, 1847) and of degeneracy (Morel, 1857) spread from psychiatry to general medicine. The forensic psychiatry expands with the increasing roll of medical experts (Chaumié circular, 1905) and the social implication of the alienists develops during the same time (Bourneville, Toulouse).     

Je suis malade, donc je suis: Douze monographies de patients à forte consommation de soins

Context. - Some patients, although they present no severe diseases, consult frequently, either for somatoform disorders, or for mild chronic diseases. A “Caisse Nationale d'Assurance Maladie” [National Health Insurance Fund] survey, built on care consumption criteria, has evaluated this sort of patient as constituting 3,6% of a vast sample of members of the national insurance scheme. They represent 8% of general practice acts and 14% of the whole care expenses. The aim of this survey is to describe, in general practice, the clinical reality of this category of patients recognised as high care consumers.Method. - Four urban or rural General Practitioners selected non-psychotic adult patients, consulting more than six times a year for more than two years, for at least two minor motives. Twelve of them accepted to meet the investigator for a detailed interview inspired by the method of “récit de vie” (life story) used in sociology. Interviews lasted between one and three hours, and were directed toward biography, complaints, pathologies, and care.Results. - The patients, ten women and two men, between 29 and 70-years-old, belonged to rather disadvantaged social categories. They had consulted their General Practitioner an average of 20.8 times over a period of a year. Pains, digestive or ORL disorders were the main motives for consultation. Objective diseases were rare and minor. Seven of them consumed psychotropic drugs in the absence of any well-argued psychiatric diagnosis as we found out afterwards in the files. Only one of them presented HARD scale depression criteria. Specialist consultations were rare; only three patients had consulted a psychiatrist. No actual addiction to alcohol or to illicit products was noted. They were all faithful to their General Practitioner; the link, solid in each case, could be of a submissive or aggressive nature. They all had known situations of lasting affective frustrations from childhood, such as abandonment or parental unavailability. Seven of them were also concerned by parental failures when they entered adulthood when, furthermore, they were already weakened by disease or pregnancy. For five patients, it was a complicated mourning which began the period of high care consumption. Nine patients had witnessed one parent's serious disease during childhood. And six insisted on their own childhood diseases. The identification of a sick relative and the need for the support of a medical person were retained as an explanatory hypothesis for adopting the status of patient. Narcissistic weakness and the central role of an analytic relation with their General Practitioner, without any other psychological trouble, revealed a borderline condition.Conclusion. - High care consumption studied, as a “life situation” via these twelve stories seems to be characterized by an experience of past affective frustrations and more recent traumatisms of the patients. The survey permits, in the absence of located psychiatric pathologies, to assume as possible meaning a behaviour that is not socially adapted. It also put forward the modest but central role of the General Practitioner in receiving complaints.     

R4P – Un réseau régional de professionnels dédié à l’enfant en situation de handicap

A regional health network for children and teenagers with disabilities (R4P) was created in Rhône-Alpes region (France) in 2007 with the aim to improve the quality of care provided to those patients. The main projects of the R4P concern training, harmonization of care and communication. R4P is a very special regional health network in France because of two particularities. First, it concerns all types of disabilities; secondly, it includes each kind of professionals concerned by children with disabilities: health care professionals of hospital and ambulatory care, social workers, administrations and education professionals. Decompartmentalization and collaboration between all kinds of professionals is necessary to improve global care of children and teenagers with disabilities. Today, 750 professionals are participating in the R4P network.     

Étude de l’influence des troubles mentaux sur les difficultés de réinsertion sociale

The psychiatric problems of the “homeless” population are now recognized. The aim of this article is to focus the study on a sample of this population (n = 999) asking for help in their social insertion. The results on clinical disorders (Axis I of the DSM-IV) and personality disorders (Axis II of the DSM-IV) are compared to estimations on general population and to other studies on “homeless” in France. These comparisons show the prevalences of some disorders whose symptoms involve problems in social rehabilitation. At last, measures of interaction and impact (multiplicative interactions, odd ratio, etiologic fractions) shows that these morbid associations increase the problems in the attempts to social rehabilitation.     

Mesurer la sévérité des problèmes des patients et leur évolution dans un secteur psychiatrique : une étude sur le terrain du Health of Nation Outcome Scales en français (HoNOS-F)

The Health of Nation Outcome Scales (HoNOS-F) are designed to measure severity of a large range of problems of psychiatric patients and their evolution. Behaviour, handicap, symptoms and social problems are considered. The aim of this field study is to examine the ability of the HoNOS-F to predict access to psychiatric care, use of services and mental health outcomes. 533 patients were evaluated in Lausanne in- and outpatient services. Results show a good acceptation of scales by clinicians ; grouping of problem profiles that suppose specific needs for some populations of patients ; differentiation of access to care through the number and severity of problems ; sensitivity to problems outcomes for inpatient care. Limitations of HoNOS are low tolerance to measurement errors, with only one scale for each dimension, and low progression margin when measuring change of moderate problems, particularly in outpatient psychiatric care.     

Séjours de répit dans un service de médecine physique et réadaptation pédiatrique : intérêt pour les patients polyhandicapés

Introduction

The respite care meets a real need for families of children with multiple disabilities. The service of Physical Medicine and Paediatric Rehabilitation of the University Hospital of Saint-Etienne offers to accommodate a patient with multiple disabilities already known by the service for short periods to provide respite for his families. The objective of this study is to assess the value for patients.

Method

It is a retrospective qualitative study, starting from an exhaustive review of medical records of 19 patients who were admitted in the department since the opening of beds in December 2004. The parents of these children answered to a telephone questionnaire and physicians and senior health care providers of the department were interviewed.

Results

The vast majority of stays went well. Irrespective of the relief expected, they sometimes induced medical and paramedical acts such as changes in the treatment or equipment, the use of expert advice, requirements of additional tests… All children underwent a clinical examination for admission. There was also a secondary benefit with parents relaxed and reassured by the hospital.

Conclusion/Discussion

This survey confirms the importance of these respite stays for children with multiple disabilities in this department but raises another question: is the role of the hospital there to compensate for the lack of temporary shelter bed? It also highlights the total lack of knowledge of these hospital admission opportunities from general practitioners and the public.     

Comment mesurer la charge des aidants naturels de personnes souffrant de schizophrénie ?

Since psychiatric institutions began discharging mentally ill patients into the community, families of patients suffering from schizophrenia were more and more involved in the therapeutic process. During the last decade psychoeducational programs were proposed to families, in order to help them having a better knowledge about the disease, more efficient coping strategies or less expressed emotional level. The adverse consequences of having at home a patient suffering from schizophrenia have been studied by a number of authors, and some of them published standardized questionnaires for evaluating “caregiver burden”. Very few of these questionnaires were elaborated from the caregiver’s point of view, only five of them have well documented psychometric properties and none of them has shown a good sensitivity to change. In this work we present an overview of the literature about caregiver burden questionnaires. Among the 30 questionnaires found in the literature, 16 only have been validated in caregivers of patients suffering from schizophrenia. The validation work is often partial: generally an evaluation of internal consistency. Only eight instruments have been validated with a factorial analysis, and in three of them a study of external validity study has been conducted. Sensitivity to change is described for none of the published questionnaires. These questionnaires may contain three great domains: a caregiver’s evaluation patient’s behavior or social functioning when considered as a burden, the consequences of care giving on caregiver’s life, the subjective perception of care giving by the caregiver. Some instruments evaluate only one domain, others two or three of them. The best validated instruments are the Experience of Caregiving Inventory (Szmuckler et al.), the Involvement Evaluation Questionnaire (Schene et al.), the Questionnaire of Family Attitude and Burden (Morosini et al.). The Social Behavior Assessment Scale (Platt et al.) is the most detailed and complex instrument, and many questionnaires derived from it. No international consensus has been found about the dimensions of such an instrument, the evidence about the usefulness of these instruments for evaluating psychoeducational or therapeutic programs is weak, the lack of information about sensitivity to change is a major problem. In addition to the analysis of the literature, we performed 33 interviews of relatives of French patients suffering from schizophrenia. The results of the qualitative analysis of the verbatim are presented in detail: a global evaluation, some items about patient’s behaviors mentioned as burdensome, items about relationships with patients, family and social relations, daily family routine, physical and mental health, satisfaction with psychiatric care, prospects and philosophy of life. As in the ECI and and the QFAB, some positive dimensions are found together with negative ones. A computer text data analysis has been further performed. The results show four great domains: (1) family routine and daily activities, (2) family and social relations, relationships with the patients, (3) satisfaction with psychiatric care, relationships with the patient, (4) a miscellaneous about the future for the patient as well as the caregiver, hope, fears… Items about mental health and psychological consequences of care giving are found in all dimensions. The comparison of experimental results and data from the literature shows the interest of a quality of life approach in caregivers. We further propose the development of a French language self-administered questionnaire for caregivers of patients suffering from schizophrenia.     

Facteurs associés aux réadmissions psychiatriques des patients hospitalisés pour la première fois à Bingerville en 2001 (Cote d’Ivoire)

Objective

To ascertain the factors related to patients’ psychiatric readmissions at Bingerville.

Patients and method

It was a case-control study built on 436 files of patients who had been hospitalized for the first time in 2001 at Bingerville's psychiatric hospital. We called readmission all rehospitalization arisen 15 days after the end of the previous hospital stay. Sociodemographic and clinical characteristics of the patients who had been readmitted for at least a fold within 1st January 2001 and 31st December 2006 were compared to those who had not been readmitted during this period, by using the Chi-square test.

Results

Patients admitted for the first time at Bingerville psychiatric hospital were in majority less than 44 years old (87.8%) with mean age at 31.1 ± 10.9 years. More than half of them, had male gender (61.9%), was single or widowed or separated (70.6%), without a kid (55.5%). Numerous of them were not educated above secondary school (95.4%). In these first admitted patients, 50.9% did not earn a wage, 68.8% lived in Abidjan. Those who had both their mother and father alive represented 53.9% of the study sample. About two-third of the patients were younger in their siblings, as well in father's children as in mother's. Regarding the clinical features, schizophrenia and other psychotic disorders (59.2%) were the most frequent diagnosis, followed by mood disorders (19.0%). These mental disorders started during the month before first psychiatric hospitalization at Bingerville (47.2%). The majority (74.5%) of these patients were hospitalized 30 days at most. They were discharged with medical advice (85.8%) and less than two drugs prescribed (66.3%). The aftercare treatment did not last more than 26 weeks for most of the patients (79.6%). Readmission occurred at least a fold in 22.5% of the subjects, in majority during the first 2 years after being discharged in 2001 (68.4%). Patients characteristics related to readmission during the 6 years of study period were: being less than 21 years old (p = 9 × 10⁻⁴), younger in the siblings of mother's children (p = 10⁻³), having both mother and father alive (p = 3 × 10⁻³), a mood disorder diagnosis (p = 0.046) and a length of aftercare treatment exceeding 26 weeks (p = 4 × 10⁻³).

Conclusion

When they are repeated and closer, readmissions can worsen patients’ social reinsertion. The knowledge of factors related to these rehospitalizations is useful to prevent this consequence.     

Insertion sociale et professionnelle des jeunes adultes IMC. Intérêt de facteurs prédictifs dès l’enfance pour ajuster leur projet de vie

Introduction

The aim of this study was to compare the real vocational and social outcome of a young adult CP population that was treated for 2 years at the Kerpape rehabilitation unit, with a retrospective insertion prognosis, taken from the analysis of their clinic record.

Material and method

Investigators first evaluated functional independence, social autonomy, years of education, and vocational status through a phone survey. A second group of investigators (independent from the first one), studied the medical clinic record assessment in order to determine the clinical type of cerebral palsy (CP). The prediction was based on their clinical judgment, using information about the diagnosis, type of involvement, functional status. Out of 120 selected patients, 43 were eventually included in this study.

Results

Type of CP: 36; 4% quadriplegia; 24.2, diplegia, 9.1% hemiplegia, 30.3% dyskinesia. Walking ability: 45.5 walking, 54.5% wheelchair. Complete independence: 36.4% for personal care, 18.2% for domestic life. Vocational assessment: 6.1% competitive employment, 6.1% sheltered, 78.8% unemployed, 3% studying. Social autonomy and vocational prediction was right in 72.7% of the cases.

Discussion

The Intellectual Quotient is the most reliable predictive factor for social and vocational outcomes. On the other hand, the functional independence and walking ability are less predictive for social autonomy prediction. Thus, a greater number of CP adults who are dependent in their everyday life could reach social autonomy. A shortfall in social ability darkens social insertion prognostic, and reduces their quality of life. For CP children, it should be useful to develop specific programs to improve their social ability, in addition to motor rehabilitation, and specific education.     

À propos de l’intégration des soins psychiatriques dans la ville, évaluation d’une structure d’hospitalisation à domicile sur un secteur de psychiatrie adulte

Home care tries to restore the patients into their social life. It points up the questioning about the place given by our societies to the patients suffering from mental diseases, as well as the questioning about the pertinence of the transfer of the care setting out of the hospital institutions. Home care is indeed integrated in the mental health district practice, as it has been developed in France during the seventy’s. Its practice is focused on the therapeutic relation and on the continuity of the care relation. In this way, it considers the patients within their progressive reality. Home care is recent in French psychiatry and exists in the psychiatric district 59G32 (Valenciennes, France) since June 2004. It constitutes a tool out of the hospital, completing the therapeutic units already existing on the district. After two years of existence, this study tries to evaluate the interests of home care and its contributions to the therapeutic possibilities in psychiatric district. With five places available, this structure can be seen as an alternative to full time hospitalisation. Home care offers indeed a graduated and individualized care within patient’s usual environment; and this is done, when it’s possible, with the participation of the patient’s relatives. This unit integrates a pluridisciplinary working team. The interventions take place several times weekly in the patient’s home, during a minimum period of one month, and with an average period initially planned to last three months. Home cares intervene before the moment when full time hospitalisation appears unavoidable, and also after hospitalisation in order to help the patients to come back to their usual environment. The aim is to maintain or to develop the autonomy of the patients, to promote or restore their social integration, to improve therapeutic alliance and treatment’s follow-up. It is a retrospective study, evaluating the interests of home care and its contributions into the psychiatric district 59G32. This study is realised after two years running, during the period of February and March 2006. It interviews the medical and paramedical team, as well as the patients and their relatives about their point of view concerning home care. Population studied: the patients entering into the selection’s criteria were those living on the 59G32 psychiatric district and who had home care before and during the study period. 1) All of the 21 patients of the population studied have been interviewed. Comparing men and women, the distribution was equivalent; 2) looking at the age’s distribution, two groups of patients were over represented: from 30 to 39, and from 50 to 59 years old, with each time 1/3 of the population studied. Those results are linked with the necessity to help those patients to develop a certain autonomy during the first years following their disease’s discovery, and when the needs are majorated for elder patients, at least until their admission into old people’s home; 3) the diagnosis found during this evaluation were, in majority (2/3 of the answers), psychotic disorders; 4) the evaluation has shown an amelioration about, on one hand: the therapeutic alliance, the information given about the diagnosis, and the treatment’s follow-up, and on the other hand: the patient’s integration and autonomy on the district, when this was possible. Finally, even if this kind of care is still not really developed within French adult psychiatric districts, such structures, complementing a full time hospitalisation offer, permit a better quality of life for the patients, and the development of actions of prevention as well as a better information about psychiatric disorders.     

Adhésion au traitement prescrit et traits de personnalité dans une population de patients atteints de schizophrénie

Schizophrenia is one of the most important public health problems. It is a common, tragic and devastating mental illness that typically strikes young people when they are maturing into adulthood. Among schizophrenic out-patients, 24-63% of patients are non compliant as they failed to take the correct drug in the correct dosage. Clinical experience had demonstrated the existence of several groups of patients, some who comply with the medical regimen and others who do not adhere to treatment. Some of the factors that had been linked to poor compliance included low socio-economic status, unstable lifestyle, general negative attitudes towards one’s predicament, cognitive strategies and patient’s personal and psychological characteristics. As such, several studies have shown that three personality dimensions are particularly important for understanding schizophrenia which are extraversion, neuroticism and peculiarity. The aim of this study is to search for the possible association between personality traits or cognitive strategies and compliance to treatment in a sample of adult patients with schizophrenia. Eighty-three patients were screened for suitability for inclusion into the study. Patients who fulfilled the following criteria were recruited: aged 18 and more, who received a diagnosis of schizophrenia (Axis I DSM-IV), without severe cognitive impairment, without a diagnosis of personality disorder (Axis II DSM-IV), consulting their psychiatrist for a period of one year after dismissal of their psychiatric ward and having given their written informed consent. The final study sample consisted of 50 out-patients adults, 35 males and 15 females, age 19-59 years. After inclusion, patients were divided into two groups (Compliant-C and Non Compliant-NC) on the basis of their compliance to treatment. Mean age for the two groups is, respectively, 34.59 ± 9.62 and 27.29 ± 7.93. Compliance to treatment was measured by indirect methods such as the impression of the treating psychiatrist, interviewing patients, therapeutic outcome, counting the number of tablets remaining in a patient’s supply and objective criteria such as presence to medical and staff appointments or ending the follow-up. Personality traits were measured by the Rorschach Test, scored and interpreted according to Exner’s Comprehensive System. This psychological measure was selected for its ability to differentiate state and trait personality variables and its sound validity when used in the manner for which it was designed and intended. The selected trait variables in the Rorschach are: P < a + 1, which identifies tendencies to be passive and deferential in social situations; HVI index, which indicates a cautious, distant and mistrustful orientation to people ; EB which shows a cognitive style of decision making; Lambda > 0.99 which identifies a lack of adequate openness to experience and tendencies to view one’s world with an overly narrow focus of attention; and Fr + rF, associated with narcissistic marked tendencies to overvalue personal worth. The selected defense mechanisms in the Rorschach are: the intellectualization index (2AB + Art + Ay) used to keep emotion at a distance and minimize their impact. Denial (MP > MA) defines a predilection for escapist fantasy and prevents the impact of an unpleasant reality. Patients were contacted during their hospitalization period by the medical chief of staff who described the study in details. After they had consented, participants received the Rorschach test, before leaving the hospital. The Rorschach protocols have been scored by two Senior Rorschach practitioners. On the selected variables their scoring agreement percentage was 100%. Rorschach protocols were assigned to the C and NC groups by the end of the scoring process and once the medical team had finished the inclusion into the two groups (C and NC). The two Rorschach practitioners had worked single-blind on the set of Rorschach protocols. Group differences in Rorschach variables at the end of one year of medical follow-up were examined by using the χ² test. The significance level was set at P < 0.05. Results have shown that the C and NC groups differ significantly on the basis of schizophrenia subtypes. The Paranoid type (295.30) is more frequent in the C group whether the Disorganized type (295.10) is more frequent in the NC group (χ²= 12.16, P < 0.001). Compliant schizophrenic patients use significantly, more frequently the intellectualization defense mechanism (χ² = 6.17, P < 0.012). Non compliant patients appear to have significantly more marked narcissistic traits and tendencies to overvalue personal worth (χ² = 8.79, P < 0,003). These observations support the idea that paranoid delusions, even if persecutory, do not alter pervasively the ability of maintaining genuine relationships with some others, such as the treating psychiatrist, for instance. In Disorganized type patients, the orientation to people is overall disturbed, the interest in the therapeutic alliance more superficial and fragile. Due to narcissistic traits and tendencies to overvalue personal worth, non compliant patients display a sense of grandiosity and entitlement which distort the genuine perception of personal needs and that of their psychological states. Intellectualization acts as cognitive coping strategy aiming to mute the intensity of emotions and safeguard against distress. Shifting emotional experience to a cognitive level allows the schizophrenic patient to acknowledge his needs for medical therapy even if he does not recognize himself as being ill. The research presented here comprises a 1-year prospective study designed to test some associations between personality factors and compliance to treatment. The degree to which schizophrenic patients comply with the advice of health workers depends, among other factors, on their stable personality traits and coping mechanisms. Continued study of the links between personality traits and compliance to treatment in this population as well as regular psychological assessment of these patients may identify which therapeutic approaches are best for which patients. There is increasing interest in the role of psychological mechanisms in compliance behavior formation after the onset of illness and these models may also be useful in thinking about events before onset.     

Quand le vieillissement se mêle au handicap : un exemple de prise en charge en médecine générale

We will present the example of the general medical care for a 52-year-old man with cerebral palsy (CP), living in a medicalised care home. Following his medical and social background, we retain the following main antecedents : a mitral insufficiency (Barlow's disease), a neurogenic bladder, a restrictive pulmonary syndrome and a dislocated left hip. Following the observations of the healthcare team concerning episodes of hyperthermia, weight loss, and coxalgia, two problems arise. How to prevent the risk of infectious endocarditis ? How to optimize the functions of swallowing ? We will describe the different vicious circles linking pain, contraction, infections, and nutrition. We will see how the advancing in age of this man with CP complicates his medical care. The general practitioner's role is to identify the main areas of the man's suggested care project using clinical examination, paraclinical data and specialized assessments. It is thus a question of reviewing and treating the outbreaks, of managing the pain by analgesics and installation, of using relaxation techniques at mealtimes in order to maintain adequate nutrition. The main objectives are to safeguard his psychical autonomy and his everyday comfort. Ethical reflection within the multidisciplinary team must be undertaken in order to make the therapeutic decisions that have the best risk benefit profile for patient.     

La perspective du travail comme média thérapeutique en psychiatrie : étude psychodynamique de trois patientes schizophrènes en soins de réadaptation

Patients often solicit the psychiatry services about their future especially concerning their social integration and their job. This question is as a problem as a help for care especially when it comes from schizophrenic patients. The psychiatric response is the psychosocial rehabilitation. In a psychodynamic conception, the author studies the evolution of three schizophrenic women in treatment in a care service of rehabilitation psychosocial. The author outlines the importance of the work project as a therapeutic medium. Some important characteristics are pointed out: the signification of the “job” for each patient and his family; the familial context; the effects of the job project’s on their psychopathology, the effects on their psychical organization of the reality of job and the importance of the protection in their social rehabilitation. These elements imply a multidimensional approach for the psychologist working in a psychosocial rehabilitation care service.     

Les résultats de l’accréditation ANAES en psychiatrie

In the year 1996, accreditation process started in France by the mean of a special law, which creates for any health structure an obligation to be assessed within 5 years and a specific organism to set up the assessment process and train a network of assessors which have to be professionals still in exercise (medical, nursing and administrative staff). Since the process has to be started from scratch it was decided to set up a unique accreditation manual, which has to be applied to any setting and speciality. In this context psychiatric resources fear to be penalised because of their specificities specially their extramural activities. This paper is using the first 120 accreditation processes completed by ANAES (the French accreditation organisation) in order to compare psychiatric and no psychiatric resource results to accreditation. The process was based on assessment on how the diverse quality criteria described in the manual were completed; they were 10 main chapters concerning patients rights and information, patients charts, care organisation, management, logistic, risk management and quality control. Each of the chapter has been divided into up to 10 criteria, which set up rules for quality and propose references which have to be first self assessed by the team; the assessors will then start from this self assessment to make their own and propose a note. The notes are compiled to decide if the reference has been fully completed, partially completed or not completed at all resulting in recommendations or reserve. At the end of the process all chapter results allow to pronounce the accreditation status of the structure: no reserve no recommendation, recommendation, reserve, major reserve. This last result means no accreditation and is attributed when a major risk has been assessed; in this case the structure will be given a short delay to modify the problem and is reassessed. This paper is based on analyses of 65 no psychiatric and 41 psychiatric hospitals private or public; the 14 hospitals, which include psychiatric units, were excluded since it was impossible to attribute results to a specific unit. In comparing the global accreditation results, the psychiatric one have better results: no one got a major reserve and 22% vs. 46.6% for the no psychiatric got reserve, on the other hand the psychiatric got more recommendation 58.5% vs. 35.4% but more no reserve no recommendation 19.5% vs. 13.8%. The comparison of the average number of either reserve or recommendation is also in the favour of the psychiatric ones. In order to look at the diverse domain we compare percentages of no psychiatric and psychiatric having at least a reserve or recommendation in one of the diverse domain covered by the manual: no psychiatric have better results in all domain especially patients charts, care organisation which were significantly worse in the no psychiatric. However, when the profiles are compared (relative percentage of either reserve or recommendation) psychiatric got lower results for patient’s rights and information and better results concerning patients charts and care organisation. Since this quantitative comparison was back up by a qualitative evaluation based on interview on diverse professionals, which participated to the accreditation process, some specific theme emerged which could be check by looking in detail to the corresponding criteria. The first theme is dealing with infectious risks: sanitarians risk controls and prevention mechanisms assessments were more frequently deficient in the psychiatric hospitals than in the control group, however they were not difference for setting up these controls and mechanisms. The second theme concerns patient’s rights and information: when results are looked at globally no difference appears however this theme appears higher if the psychiatric accreditation profiles; when looking at the specific reference concerning the intimacy and dignity patient’s respect psychiatric results seem lower: 9.4% of the psychiatric hospitals reserve or recommendation are concerned by this reference vs. 2.5% in the no psychiatric. Some limitation of these comparisons should be mentioned; size effects was controlled for and no difference was found but all results presented here concern the first accreditation procedures where the most concerned and performing structures were candidates. We assume that this obvious bias affects both type of structure at a similar degree, which may be wrong. To conclude the accreditation process could be applied to psychiatric as well as no psychiatric structures and it appears that psychiatric resources obtain globally better results than no psychiatric; however two conflicting areas appear for the psychiatric resources: risk control procedures and intimacy and freedom patients rights completion.     

Conséquences psychopathologiques de l'épilepsie. À partir de l'analyse de 10 observations

From the analysis of clinical data and the viewpoint of the bibliographic data, bringing out the comorbidity epilepsy/mental health, frequency of personality disorders during epilepsy and constancy of behavioural troubles are outlined. However, results of works, dealing with behavioural disorders, are often contradictory. Association with mental retardation shows a problem of imputability. Depressive mood, often concomitant with anxiety disorders, represent the psychiatric comorbidity frequently associated with epilepsy; recent works assess the factors of seriousness of depression. As for the relationship between psychosis and epilepsy, the term ”epileptic psychosis” indicates today specific entity. Psychotic patients who suffer from epilepsy are not in that concept frame. Alcoholism does not seem more frequent in people suffering from epilepsy than in general population. The social disqualification assessed by the scales of quality of life is frequent with people suffering from epilepsy.     

Accueil familial thérapeutique. Historique et évolutions récentes

The aim of foster care is to treat patients in a stable environment provided by foster home caregivers paid by a hospital. This mode of treatment has its distant origin in the legend of Saint Dymphna, Irish princess. This princess, exposed to the incestuous ardours of her father the king, decided to flee with her confessor, Gerebene. They landed in Flanders Geel, where she was eventually found by her father and beheaded in the public square. At the same moment an insane recovered his health. Since then, Geel became a pilgrimage for the mentally ill, who stayed there in a family for a fee. In France, the first mental health Act dates back to June 30, 1938. It required that each “department” or district has a psychiatric hospital. At the end of the xixth century, these institutions were overcrowded with chronic patients, incapable of returning to normal life. The psychiatrist August Marie created institutions then called “Family colony” to accommodate these patients. These institutions located in the Centre of France, treated as many as 1345 patients (Dun-sur-Auron) and 1145 patients (Ainay-le-Château). A new act codified this practice in 1989, defining a recruitment procedure for caregivers, specifying the facilities they should offer and the continuity of care they had to insure. Various mental hospitals then created Foster Care units. The hospitals ensuring foster care have to comply to quality controls by the High Health Authority. They offer hospitalization units for the treatment of acute psychiatric of medical episodes. Foster care thus includes these partners: a patient, a caregiver, a mental health and medical team. According to a report in 2011, 3800 patients were treated by foster care that year. The cost is estimated at the rate of 240 € per day, much lower than traditional hospital treatment, but with a better quality of life for beneficiaries.     

Place des unités de soins intensifs psychiatriques (USIP) dans le dispositif de soins

Psychiatric Intensive Care Units (PICU) are a recent creation in France. These facilities propose a secure setting for patients with acute behavioural disturbances difficult to manage in psychiatric general wards. Physical violence against other patients or hospital staff, substance abuse, non-compliance with care and treatment, intensity of symptoms or absconding are common motives for admission. Patients are admitted from psychiatric facilities of a health-care area or by agreement between hospitals. Care and treatment must be centred on the patient, be multidisciplinary, intensive, and comprehensive with an immediacy of response to critical situations. Interface and liaison with original services of patients are important issues as the length of stay should not exceed two months. In France, PICU exist at Cadillac, Lyon, Paris, Montpellier, Nice, Pau, Prémontré and Eygurande. They are a missing link between psychiatric general wards and maximum security hospitals in the mental health care system. The report emphasizes the creation of an association, foreign experience and existence of national minimum standards.