What belgian neurologists and neuropsychiatrists tell their patients with Alzheimer disease and why: a national survey

To check their opinions concerning the disclosure of the diagnosis of Alzheimer disease (AD), a questionnaire was sent to all neurologists and neuropsychiatrists currently active in Belgium, excluding neuropediatricians. Of 573 questionnaires, 44% were returned. Sixty-eight percent of the responders always announce the diagnosis to their patients, 24% prefer to reveal the diagnosis only to patients with mild dementia. Doctors who announce the diagnosis to all their patients and who believe that its a benefit for the patient (67%) were more likely to be younger, to be neurologists, and to speak Dutch. The most important arguments in favor of announcing the diagnosis were the patient's right to know and the reinforcement of the doctor-patient relationship. The main arguments against revealing the diagnosis were the patient's right not to know and fear of provoking a depression. Two-third of the participants informed the patients about the prognosis and natural evolution of AD. These doctors tended to be younger, to be neurologists, and to speak Dutch. Young doctors tend to be more "open" toward their patients concerning the diagnosis of AD, consistent with the current guidelines. The differences between Dutch and French speaking doctors might be partially due to the fact that in French, "démence" has a psychiatric connotation.     

Qu’en est-il de l’annonce du diagnostic de schizophrénie aujourd’hui en France ?

Introduction

The progressive shifts in the legal and social contexts, along with major changes in information seeking habits with the development of the Internet, have placed patients’ information at the core of medical practice. This has to be applied to the psychiatric fields as well, and to questions about how schizophrenic patients are being told their diagnosis nowadays in France.

L’annonce du diagnostic de schizophrénie. Analyse textuelle d’entretiens cliniques

The issue of announcing a schizophrenia diagnosis induced a great controversy among practitioners, some of whom being reluctant to inform patients. This taboo seems to be disappearing. In France, on the one hand the March 4, 2002 patients’ rights law requires doctors to inform patients of the diagnosis and of the appropriate treatment and on the other hand research has thrown light on the positive impact of announcing a schizophrenia diagnosis. Considering that qualitative patient studies should be developed to gain a better understanding of the way in which patients receive the news of their diagnosis, we have conducted semi-directive interviews recorded with 20 schizophrenic subjects who were informed of their diagnosis and gave their consent for this study. Data were processed using the Alceste Method, a computer program of discourse analysis. Results show that schizophrenic patients can experiment relief in being informed of the diagnosis and that they are active in searching for information about the disease. The therapeutic alliance appears to be heightened by announcing the diagnosis.     

Schizophrénie et génétique : concepts et évidences

The relationship between the field of genetics and the social sciences has been fraught with difficulties. The philosophers were the first to predict that it would not be an easy matter, and genetics was used in psychiatry not as an aid to persons recognized as being vulnerable, but with the aim of putting a term to degeneration within the population (the theory of Morel). The hesitancy shown by psychiatrists toward this area of research can thus be well understood. However, genetics is first of all a powerful and original means of investigating psychic suffering. A certain number of misunderstandings explain why psychiatrists (French psychiatrists in particular, and to a greater degree than the patients themselves) show some reserve regarding genetic research into mental illnesses. Three concepts that are often poorly understood have been detailed in this article (genetic determinism, heritability, familial aggregation), then illustrated for schizophrenia through a review of familial studies and several candidate genes. The implications and limits of genetics as applied to schizophrenia should thus be better defined.     

Adherence to guidelines by French psychiatrists in their real world of clinical practice

The treatment modalities of bipolar disorder and adherence to international guidelines recommendations in France were investigated. We conducted an observational survey among 210 French psychiatrists concerning their prescribing practice in bipolar disorder, and whether they use guidelines or not. Simple mania is mainly treated with valproate, whereas second-generation antipsychotics are preferred for delusional mania. Lithium is mostly used as second-line treatment by "young psychiatrists." Personal experience appears in the foreground (41% of psychiatrists) in the choice of therapy. Young psychiatrists refer more to guidelines (32% of responders) as compared with other psychiatrists. The main reason for the lack of use of guidelines is because they refer mostly to an Anglo-Saxon medical practice, which is considered different from the French practice. Guidelines for treatment of bipolar disorder are not frequently used. French psychiatrists' age and practice type are the most important variables correlated to the level of use of guidelines.     

Attitudes of psychiatrists toward patients with schizophrenia

A questionnaire was distributed to psychiatrists to investigate their attitudes toward patients with schizophrenia. A total of 42.7% of 60 respondents never informed patients of the diagnosis of schizophrenia and 40.7% informed on a case-by-case basis. The reason that psychiatrists gave for avoiding informing the patients/family members of the diagnosis was the idea that they would not understand the meaning (32.6%) and that they would drop-out from treatment (28.3%). A total of 88.4% of respondents thought the term 'schizophrenia' was used in a pejorative manner in public. The findings revealed that stigmatizing attitudes of society are also shared by some psychiatrists.     

Disclosure of diagnosis of Alzheimer's disease in French general practice

Most practitioners find disclosing the diagnosis of Alzheimer s disease (AD) to an individual with dementia very difficult. Literature results show a wide variability in attitudes and clinicalpractice, and diagnosis seems to be more often disclosed to caregivers than to patients. The objective of this study was to examine whether and how diagnosis of AD is disclosed in French general practice and which issues are addressed with the patient. A questionnaire was sent via mail to 1,629 general practitioners (GPs), 1,105 belonging to the Sentinel's network and 524 specially recruited doctors practicing in the Rh?ne-Alpes region. A total of 631 questionnaires were returned (response rate, 39 percent), of which 616 were eligible for analysis. Twenty-eight percent of GPs reported having disclosed diagnosis to the patient (25 percent mentioned "Alzheimer's disease"), whereas 88 percent considered it their role to announce the diagnosis to the patient. Regarding the type of information provided to the patient, only 25 percent discussed the nature of the illness, 23 percent behavioral problems, and 47 percent depression, mainly for psychological reasons (63 percent). Stress was discussed with 79 percent of the caregivers. We concluded that GPs do not discuss the consquences of AD and symptoms (e.g., behavioral disorders) with patients, mainly for psychological reasons, whereas they have a less-reluctant attitude toward caregivers. As the GP has the weighty task of providing ropriate community care and psychological support to the patient, it is of utmost importance to reflect on how disclosure of diagnosis can be facilitated.     

Schizophrenia: Is it time to replace the term?

The attitudes of Japanese psychiatrists toward their patients who suffer from schizophrenia were investigated. We were concerned specifically with whether the psychiatrists inform their patients of the suspected diagnosis. We discuss how the term 'schizophrenia' may influence a psychiatrist's decision to inform his patients of the diagnosis. A self-reported questionnaire was distributed to 150 executive board members of the Japanese Society of Psychiatry and Neurology and analysis of the data obtained from 110 respondents was carried out. The results showed that the concepts that psychiatrists use when they give a diagnosis of schizophrenia vary considerably. Fifty-nine per cent of the respondents informed their patients of a diagnosis of schizophrenia on a case-by-case basis, while 37% informed only the patients' families. A tree analysis showed that the most important predictors for informing the patients of the diagnosis were assumptions about the public image of schizophrenia and a negative impression of the term schizophrenia, translated as 'Seishin Bunretsu Byou' in Japanese. The results revealed that the Japanese term for schizophrenia influences a psychiatrist's decision to inform patients of the diagnosis and that, by changing the term to a less stigmatized one, the disclosure of information about schizophrenia to patients would be promoted.     

The therapy of families of patients suffering from schizophrenia

The development of pharmacotherapy, social psychiatry and the new patterns of comprehensive treatment of patients suffering from schizophrenia make most of psychiatrists believe that hospitalisations should be reduced to minimum. There has been a change in the roles and tasks of parents and spouses of the patients during their ambulatory therapy. Apart from outpatient clinics, daily wards, and hostels, there is a significant role of the therapy of families of the patients in the posthospital treatment. The patterns of schizophrenia as a disease and the relating indications concerning basic therapeutic management are of significant importance. The work presented here discusses two basic therapies of the families of patients suffering from schizophrenia, namely psychoeducation and systemic family therapy. The work draws attention to aims, forms and concepts of these therapies. However, an appropriate pharmacotherapy of patients suffering from schizophrenia is necessary regardless of their positive response to the families.     

Oversight of constipation in inpatients with schizophrenia: a cross-sectional study

Objective

Constipation is often overlooked in patients with schizophrenia. We examined their awareness of constipation and whether they reported it to their psychiatrists.

Method

Five hundred three inpatients with schizophrenia (International Classification of Diseases, 10th Revision) were interviewed about their recent bowel movements and evaluated for the diagnostic criteria for functional constipation. If constipation was present, patients were asked if they were aware of it and had reported it to their psychiatrists in charge. Additionally, their global psychopathology and functioning were assessed using the Clinical Global Impression-Schizophrenia (CGI-SCH) and the Global Assessment of Functioning (GAF), respectively.

Results

The criteria for constipation were met by 184 patients (36.6%); of these patients, only 56.0% (103/184) were aware of it. Moreover, only 34 of the constipated patients (18.5%) reported its presence to their psychiatrists. No significant differences were found in the CGI-SCH overall severity or subscale scores or in the GAF scores between those patients who reported and those who failed to report constipation.

Conclusions

The present study demonstrated that constipation was neither recognized nor reported to psychiatrists by a significant percentage of the patients. These findings underscore the importance of greater vigilance and active evaluation of constipation in patients with schizophrenia for appropriate clinical management.     

Research on schizophrenia in Southern European countries

The research on schizophrenia during the last 50 years in the Latin language countries of Southern Europe is briefly surveyed. Particular emphasis is given to the contributions of French authors to the diagnostic concept of schizophrenia, as well as to the phenomenological studies concerning the "essence" of schizoidia/schizophrenia, and some initial schizophrenic "Erlebnisse." The development of biological, psychological, and sociological theories concerning the etiology of schizophrenia is outlined, and contributions such as the "aminotoxic theory" of V. M. Buscaino and the theoretical principles of "alternative psychiatry" are examined in detail. Lastly, the role of French, Italian, Spanish, and Portuguese psychiatrists in the introduction and improvement of somatic treatments is described.     

Sémiologie motrice oubliée : les crises non épileptiques psychogènes

Psychogenic Non Epileptic Seizure (PNES) are defined as paroxysmal and transient behavioral manifestations, suggestive of epileptic seizures, but without the concomitant electro physiological activity linked to an epileptic seizure. There is a net female predominance (75 %). The beginning of illness is typically in the second or third decade. About 80 % patients have antecedents of traumatisms. The understanding of PNES requires the analysis of three types of factors (3P): predisposing, precipitating, and perpetuating factors. These factors all are not always found. There would be a correlation between the dysfunction of some cerebral networks and the dissociation for patients suffering from PNES. There would be a complex emotional dysfunction for some patients suffering from PNES. The semiological analysis in video-EEG allows to identify characteristic associations of signs during seizure allowing to differentiate five clinical subcategories which linked to the semiological analysis of 3 P allow to diagnose PNES. The diagnostic announcement of PNES is a delicate stage, but important to start a first therapeutic stage: it conditions the forecast of the patients suffering from PNES. The diagnostic announcement and the taking care require a close collaboration between neurologists and psychiatrists.     

Smoking Cessation and Electronic Cigarettes in Community Mental Health Centers: Patient and Provider Perspectives

Little is known about patients’ electronic cigarette use, interest in and use of smoking cessation treatments, and providers’ attitude towards such treatment. We assessed patients (N?=?231) and providers (45 psychiatrists, 97 case workers) in four Community Mental Health Centers. Interestingly, 50% of smokers reported interest in using electronic cigarettes to quit smoking, and 22% reported current use. While 82% of smokers reported wanting to quit or reduce smoking, 91% of psychiatrists and 84% of case workers reported that patients were not interested in quitting as the lead barrier, limiting the provision of cessation interventions. Providers’ assumption of low patient interest in treatment may account for the low rate of smoking cessation treatment. In contrast, patients report interest and active use of electronic cigarettes to quit smoking. This study highlights the need for interventions targeting different phases of smoking cessation in these patients suffering disproportionately from tobacco dependence.     

Comorbidity patterns in routine psychiatric practice: is there evidence of underdetection and underdiagnosis?

OBJECTIVE: The purpose of this study is to present data on the rates of diagnosis and patterns of Axis I comorbidity treated by psychiatrists in routine psychiatric practice, ascertained by practicing psychiatrists, and compare them with those ascertained through structured interview in a national sample of individuals treated in the specialty mental health sector for evidence of underdetection or underdiagnosis of comorbid disorders in routine psychiatric practice. METHODS: Data on 2117 psychiatric patients gathered by 754 psychiatrists participating in the 1997 and 1999 American Psychiatric Institute for Research and Education's Practice Research Network's Study of Psychiatric Patients and Treatments (SPPT) were analyzed, assessing psychiatrist-reported rates of Axis I disorders and comorbidities. SPPT data on patients treated by psychiatrists were compared with a clinical subset of patients in the National Comorbidity Survey who had been treated in the specialty mental health sector (SMA). RESULTS: Rates of comorbidity were higher in the SMA (53.9%) than in the SPPT (31.5%). The prevalence of schizophrenia diagnoses was more than twice as prevalent in the SPPT as in the SMA sample; anxiety disorders were 2 to 22 times more prevalent in the SMA sample. In the SPPT, 4 of the 10 most prevalent comorbid pairs included schizophrenia or bipolar disorder; only one pair in the SMA sample included either diagnoses. Of the 10 most prevalent comorbidity pairings in the SMA sample, 6 included a phobia diagnosis. CONCLUSIONS: Results of these analyses suggest greater differences in the patterns and rates of comorbidities than one might expect between these 2 samples. Possible reasons for these disparities, including methodological differences in diagnostic ascertainment and underdiagnosis of anxiety disorders, are discussed.     

Middle-ear disease and schizophrenia: case-control study

BACKGROUND: One hundred years ago psychiatrists thought that ear disease could cause insanity by irritation of the brain. Current understanding of the role of the temporal lobes in schizophrenia and their proximity to the middle ear supports this hypothesis. AIMS: To establish the rate of middle-ear disease pre-dating the onset of schizophrenia. METHOD: Eighty-four patients with schizophrenia were each matched to four non-psychiatric controls by age, gender and season of birth. History of ear disease was obtained from general practice records. Additional information on symptoms was collected for participants in the case group, who also had audiometry. RESULTS: The odds ratio of recorded middle-ear disease pre-dating schizophrenia was 3.68 (95% CI 1.86-7.28). This excess was particularly marked on the left (OR=4.15, 95% CI 2.08-8.29). Auditory hallucinations were associated with middle-ear disease but not with hearing loss. CONCLUSIONS: There is an association between middle-ear disease and schizophrenia which may have aetiological significance.     

A survey of private practice psychiatrist's training and activity in activity in Aquitaine, France, in 1993

This study was conducted to gather information regarding the current professional activities of French private practice psychiatrists. METHOD: A mail survey was carried out in an attempt to find more about the characteristics of the 380 private practice psychiatrists in Aquitaine (south west France) in 1993. Data are reported in terms of psychiatrist's characteristics (demographics, training and practice activities), patient characteristics and trends in treatment modalities. RESULTS: There was a good response rate (55%), and this enabled us to statistically analyze the data to determine profiles of activities. For the respondents in this survey, the median age is 45 years and 30.7% of respondents are women. The portion of responders reporting a qualification in Neuropsychiatry versus Psychiatry, is low (1/7). The patients seen in private practice are generally young females with anxiety and affective disorders. An important feature was the trend for psychotherapy training and practice. Psychoanalytically oriented and individual psychotherapy were predominant over other forms of psychotherapy. Half of the psychiatrists reported using pharmacotherapy in combination with psychotherapy. There are only little differences in the practice of young and female psychiatrists. CONCLUSION: The impact of psychodynamic theories on the training of French private practice psychiatrists is still very important. Interestingly, these same psychiatrists seem to use an eclectic approach to their practice of psychiatry; about half of the respondents report using pharmacological treatments in combination with psychoanalytically oriented psychotherapy.     

The role of psychotropic drugs in the insidious deconstruction of the Kraepelinian dichotomy

62 patients suffering from mood disorders or schizophrenia diagnosed retrospectively according to DSM-4 as 295.xx or 296.xx were followed up by the author personally for 20 years. The DSM-IV diagnosis of schizophrenia (295.xx) was changed to a diagnosis of a mood disorder in 13 patients (26%). If schizoaffective disorder is classified as a mood disorder to form a group of periodic disorders, 41% of patients diagnosed as "pure" schizophrenia (295.xx without 295.70) at the start of the observation period were re-diagnosed as periodic disorder over 20 years. This "retrogression" of schizophrenia is seen as a result of the treatment with psychotropic drugs. The Kraepelian dichotomy is based on the relationship between the symptomatic pattern (syndrome) and the course of the illness. This relationship is disrupted by long-term treatment with psychotropic drugs.     

Has the informed consent for people with schizophrenia prevailed among Japanese psychiatrists by changing the name? The outcome of 3-year study]

"Togo-shiccho-sho"--the integration ataxic disorder--which has been recommended as the alternative Japanese translation of schizophrenia rather than "Seishin-bunretsu-byo", had the approval of the Japanese Society of Psychiatry and Neurology (JSPN) at the 98h annual meeting in August, 2002. OBJECTIVE: This study aims to know the prevalence of the informed consent for people with schizophrenia and to find out the factors related to the informed consent among the Japanese psychiatrists. METHODS: Subjects of this study were all psychiatric members of JSPN. They received the self-report questionnaire entitled "The Actual State of Informed Consent" by the return cards and sent it back by the return at around mid November every year between 2002 (right after the change) and 2004 (after 2 years). Author took 3 months for recovery. RESULTS: Rates of the psychiatrists who informed the patient himself have been relatively increasing for 3 years (37%, 2002; 65%, 2003; 70%, 2004), while the rates of the one who didn't have been decreasing (44%, 2002; 21%, 2003; 15%, 2004). The users of Togo-shiccho-sho for the informed consent have been increasing (68%, 2002; 86%, 2003; 90%, 2004), while the non-users have been decreasing (19%, 2002; 9%, 2004). The non-users of Seishin-bunretsu-byo increased from 63% in 2003 to 71% in 2004 and the other-name-users also increased from 18% in 2003 to 42% in 2004. DISCUSSION: The prevalence of togo-shiccho-sho became about 90% among the Japanese psychiatrists and they seem to use it not accompanied with Seishin-bunretsu-byo or any other names. Moreover, 70% of psychiatrists informed their patients himself of their diagnosis, especially eagerly among younger generation. As well as the disease condition of patients and doctor-patient relationship, whether patient and his/her family could understand or not affected to the decision of informed consent. There were also differences among districts on informed consent, especially negative at Kinki district.