Santé mentale et Santé bucco-dentaire : de l’intérêt de faire tomber le masque

The mouth is at the heart of our daily life. However, oral health is often overlooked, especially in people with mental illness. The objectives of this review were to identify the factors that can increase their vulnerability toward oral diseases, to describe the consequences in terms of health and quality of life, and to explore solutions for preventing and managing oral diseases in this population.Why are patients with mental illnesses more at risk of poor oral health?The mental illnesses themselves, which can alter one's self-image and perception of the body, may decrease motor skills or disorganize daily life, contribute to a decrease in the practice of daily oral hygiene or in seeking healthcare services. The presence of vomit or gastroesophageal reflux stimulates the demineralization of dental surfaces. Addictive substances, the consumption of which is frequent in this population, particularly tobacco, have a direct impact on the oral mucosa and contribute to poor oral health as well as to a reduction of the effects of pharmacological treatments used to treat psychiatric pathologies. By stimulating the appetite, they promote snacking. By inhibiting the production of saliva, they prevent it from playing its role as a natural oral lubricant. It has a negative effect on self-cleaning dental surfaces, the neutralization of oral acidity and defensive power but also on food pre-digestion, chewing, swallowing and speaking. Finally, by inducing abnormal movements of the lips, tongue or jaw, problems of lip incompetence, breathing through the mouth or bruxism may develop. Difficulties in accessing oral care can also contribute to patients’ poor oral health. They may be related to mental pathology: the failure to keep appointments, refusal of care, anxiety, to the lack of information and understanding of their rights for health insurance and transportation to a dental office. They can also be linked to a stigmatizing or critical attitude or a rush to provide care from some dentists that can discourage the patient from continuing his/her oral follow-up.What are the consequences?Xerostomia has several consequences: difficulty in chewing, swallowing, speaking, wearing removable dentures and altered taste, bad breath, cracked lips, and burning mouth. The patient will then modify his/her diet and increase their consumption of soft drinks and soft foods, which adhere more to dental surfaces. Patients have an increased risk of carious lesions, erosion of the teeth, and periodontal lesions accentuated by smoking. People with substance addiction are roughly three times more likely to have periodontal pockets than control groups. People with eating disorders are five times more likely to have dental erosion, responsible for sensitive teeth than control groups due to vomiting or gastroesophageal reflux. Finally, the problem of dental caries is more severe in people suffering from mental illness: People with schizophrenia seem to be the most affected with 7.7 more tooth decay, missing and filled teeth on average than do control participants. Oral afflictions are responsible for acute and chronic pain and infection. Patients with severe mental illness are 2.8 times more likely to lose all their teeth than those in control groups. Edentulism has many repercussions for the patient's health and quality of life, (eating disorders, speech impediments, and deformed smiles, all of which can lead to low self-esteem and social isolation).What are the solutions?A set of measures can be proposed against xerostomia: frequent intake of unsweetened, non-acidic drinks, chewing sugar-free chewing gum with xylitol, salivary substitutes or salivary stimulants. Support measures to encourage patients to quit smoking, when possible and compatible with the patient's clinical condition, should be offered during psychiatric follow-up. Patients could be encouraged, as soon as their mental pathology has stabilized, to select a dentist and to consult him/her at least once a year for dental care and preventative measures and to become accustomed to receiving dental care. The continuum between psychiatric care and oral care is important, as is the training of medical teams. The number of dental treatments and/or the mental pathology of some patients can cause them to be uncooperative and may necessitate the use of a general anaesthesia during oral care, but this procedure has many limitations. For long-term health improvement and to avoid the accumulation of comorbidities, therapeutic patient education seems to be an appropriate complementary approach. Integrating oral health with psychiatric care would make it possible to encourage patients to develop habits of healthy eating and good oral hygiene, to seek dental care, and to acquire improved social behaviours.     

L’enseignement du syndrome catatonique en France : enquête nationale et état des lieux

ObjectivesCatatonia is a transnosographic syndrome described by K. Kahlbaum in 1874. Catatonia can be life-threatening due to its complications and in case of malignant catatonia. Safe and effective treatments have been identified (benzodiazepines and electro-convulsive-therapy). The prevalence of this syndrome is important and represents about 10% of inpatients in an acute psychiatric ward. However, this syndrome appears to remain under-diagnosed and poorly known. We were, therefore, interested in the current knowledge of French psychiatry residents and young psychiatrists as well as the education they had received about catatonia.MethodsA questionnaire was submitted to French psychiatry residents and young psychiatrists with fewer than 5 years of experience. It included questions about knowledge of the symptoms, complications, causes and treatments of catatonia. Participants were also asked about their confidence in the management of a patient with catatonia and about the number of catatonic patients they had already met. The type of lecture and teaching about catatonia was also assessed.ResultsAmong the 376 psychiatrists that completed the questionnaire, 37.5% never had received any specific teaching about catatonia. Concerning the 62.5% who benefited from a specific lecture, this was mainly delivered as part of psychiatry DES. Heterogeneity in the education delivery on the French territory had been highlighted. In addition, participants’ knowledge of catatonic syndrome seems incomplete. However, knowledge of catatonic symptoms and first intention treatments was significantly better among respondents who were part of the “with education” group. The confidence in catatonia recognition and management, as well as the number of catatonic patients they met, are also significantly higher in the group “with education”.ConclusionSpecific education seems to improve the knowledge of young doctors and their ability to diagnose and treat catatonic patients. This education remains poorly provided and heterogeneous on the French territory. Catatonia deserves a place in the teaching program of the psychiatry DES, thus to become systematic.     

L’enquête en psychodynamique du travail : un dispositif de recherche-action

ObjectiveThis article examines the investigation in the psychodynamics of work as an intervention methodology. It presents theoretical presuppositions and practical modalities of the intervention framework that characterize this feature.MethodBy specifying the reasons why the investigative model is situated in the field of research-action, the authors comment on the characteristics of the methodology of the investigation in the psychodynamics of work. Deployed in the field, within companies and institutions, the survey is first of all a feature oriented towards the research on transforming the organization of work, but it also constitutes a specific method mobilized in the service of the production of knowledge and thus of research.ResultsFaced with new workplace organizations and the transformations of the social relations of work, the methodology of the survey is subject to adjustments, the main ones of which are enumerated by the authors.DiscussionThe epistemological discussion allows us to present the status of subjectivity and the modalities of its objectification by the investigative model. This search for objectification is based on the analysis of suffering/pleasure at work from the identification of individual and collective defense strategies.ConclusionThe investigation in the psychodynamics of work is considered as a situated practice with the aim of elucidating intrapsychic and intersubjective conditions related to action.     

Santé mentale et Covid : toutes et tous concernés. Une revue narrative

The COVID-19 pandemic (caused by the Sars-CoV-2 coronavirus) led to unprecedented challenges to public health, the healthcare system, and our daily lives (including work and education), particularly during the first wave in early 2020. In order to control infection of the virus, many countries have imposed restrictive measures to promote social distancing, ranging from curfews and school closures to widespread lockdown. At the beginning of 2022, there were 135,000 deaths from Sars-CoV-2 in France (nearly 6 million worldwide). Beyond the possible impact of Sars-CoV-2 on the brain, the pandemic has created complex human situations, with a possible impact on the mental health of populations. In this narrative review, we summarize current data on the impact of the pandemic on mental health in the general population and identify the most vulnerable groups. The goal is to provide more targeted prevention for these populations. Our review has identified several subgroups of subjects at higher risk of disorder in the context of the COVID-19 pandemic: those bereaved by COVID-19, adolescents, students, people with COVID (with potentially direct brain damages), and finally, health care workers. Gender disparities were accentuated, leading to more mental disorders in women. Longitudinal follow-up studies are needed to better identify the effects of the pandemic on the mental health of different populations, and also to define personalized prevention strategies. Screening and prevention measures must be taken to limit the impact of this pandemic on mental health. More generally, the “one health” approach, which places human health at the interface of environmental and animal health, seems essential to avoid the occurrence of this type of pandemic and its consequences in the future.     

Soins psychiatriques sans consentement : une enquête auprès des juges des libertés et de la détention

The procedure of involuntary hospitalization in France has been recently modified by the law of 5 July 2011. Since that time, a liberty and custody judge has been appointed to guarantee the rights of psychiatric inpatients and to prevent abusive hospitalizations. Currently, for one involuntary hospitalization in ten a release is decided by the liberty and custody judge although psychiatrists consider that psychiatric care is necessary. In order to improve our understanding of the role of liberty and custody judges, and how they make their decisions, we conducted a qualitative survey of liberty and custody judges in the Tribunal de Grande Instance of Lille. Three judges were questioned, based on a semi-structured interview. Judges’ responses have highlighted the need for psychiatrists to strictly respect the legal procedures and to accurately describe the clinical signs and symptoms that justify the procedure of involuntary hospitalization in the medical certificates. The intervention of liberty and custody judges for patients with psychiatric disorders represents a breakthrough for patients’ rights in France, reflecting that they are considered as citizens, with the same rights as others. Nonetheless, this new mission needs a progressive learning, based on mutual exchanges with doctors and caregivers.     

Santé et éducation thérapeutique en psychiatrie : une place à renforcer ?

Health is a subjective concept whose definition may have evolved. Good health is essential for anyone living with a psychiatric disorder. Only through acquiring good health can they achieve recovery. Tools are used for recovery such as therapeutic education. One example is the program ``Acting for our health and developing our well-being'', targeting non psychiatric co-morbidities.     

Patient polyhandicapé et épisode d’insuffisance respiratoire aigu : prise en charge en milieu hospitalier

Acute respiratory failure in severe disabled people is a frequent and serious complication with a high morbidity and mortality rate. Common management relies on antibiotic therapy combined with clearance of airway secretions. Several manual and instrumental airway clearance techniques can be used to improve patients and tend to avoid mechanical ventilation, which is a controversial ethical issue. Postural changes should be associated with these techniques to decrease muscular contraction and enhance alveolar recruitment. This article is an overview of the most useful airway clearance techniques in disabled patients.     

Trouble de la personnalité borderline: état des connaissances et des représentations auprès de praticiens francophones en santé mentale

ObjectivesPatients suffering from borderline personality disorder are very prevalent in various settings (emergency rooms, psychiatric and general hospitals, ambulatory consultations). However, it remains one of the most stigmatized and neglected mental health conditions, albeit being an area that is responsible for very interesting advances in psychotherapy. Today, the prognosis of patients with borderline personality disorder is rather favorable, provided that they follow a dedicated psychotherapy. Conceptions about this condition therefore deserve to be updated as it is sufficiently described in the literature that negative attitudes towards these patients diminish the quality of care they receive as well as their prognosis, and that these attitudes change with training. We decided to study the state of knowledge and attitudes towards borderline personality disorder in a group of French-speaking caregivers interested in these patients.MethodsBetween 2019 and 2020, at the start of training sessions in psychotherapeutic approaches to borderline personality disorder, we provided two questionnaires to 126 caregivers from various professional backgrounds (psychiatrists or child psychiatrists, psychologists, mental health nurses, social workers). The first consisted of 13 questions with 3 choice answers aimed at testing knowledge about borderline personality disorder and the second of 11 questions in the form of a Likert scale aimed at evaluating attitudes towards these patients (e.g. degree of comfort, involvement, hope, avoidance with these patients) adapted frome a questionnaire of Blake and colleagues.ResultsThe sample consisted of 126 caregivers (69 psychiatrists/pedopsychiatrists; 19 mental health nurses; 23 psychologists; 14 social workers). Fifty three of them (42.06 %) worked in an outpatient setting (either in a state facility or in private practice), 50 (39.68 %) worked in an inpatient psychiatric unit, 13 (10.32%) in both care systems, and 10 (7.94 %) worked in other facilities such as sheltered homes or workshops for persons with psychiatric disabilities. The average number of years in postgraduate training was 7.73 (SD = 5.67; rank = 0 to 31), and 35 (27.78%) had received at least one training course on borderline disorder in the past. The mean age of the sample was 37.89 (SD = 10.08; rank = 20 to 64) and there were 76 women (60.32%) and 50 men (39.68%). Concerning the first questionnaire (knowledge), the rate of correct responses among caregivers was relatively low (54%) considering that the vast majority of those assessed were caregivers already trained in mental health who were working with patients suffering from borderline personality disorder. The results showed a significant knowledge gap among professionals, in particular in the nursing profession, illustrating an ever more flagrant shortfall in formations in this sub-population. Concerning the second questionnaire (attitudes), the answers showed that attitudes of caregivers towards patients with borderline personality disorder were still tinged with fear and lack of confidence in taking charge of them. Thus, one participant out of five would have liked to avoid these patients, more than 12% of caregivers did not appreciate them, and 23% thought that they were manipulative. In addition, nearly half of the caregivers surveyed had low confidence in their ability to make a positive difference in the lives of borderline patients. However, there was a recognition of their distress as well as a demand for dedicated training.ConclusionsStigmas and ignorance persist around patients with borderline personality disorder. Current training courses do not allow caregivers who are on the front lines (in particular nurses) and who wish to be trained to acquire sufficient knowledge and tools necessary for the care of patients suffering from this disorder. This calls for an improvement in training as well as a reflection on the most appropriate approaches possible to the various target audiences.     

Justice résolutive de problèmes : efficacité des tribunaux en santé mentale aux États-Unis et présentation du dispositif lyonnais

People with mental disorders are over-represented in the criminal justice system. Mental Heath Courts are problem-solving oriented courts developed as a means of providing treatment to individuals with mental illness involved in the criminal justice system in order to avoid recidivism and to improve access to community mental health care services. MHCs are an alternative to the incarceration and the innovation behind his model is the collaboration between the judiciary and mental health services. The first MHC was created in 1997 in Florida; there are now more than 300 such courts in the United States. In Lyon, France, thought work with Canadian team at the Montreal Mental Health court, a new program called Contrainte Pénale Justice Thérapeutique was created in 2016. CPJT is also based on the collaboration of legal, social and pre-existing mental health services in order to treat recidivist offenders suffering from psychiatric and/or addictive disorder. The aim of this interview with Constance Baheux and Dr Sabine Mouchet–Mages is to present the results of American mental health court in terms of effectiveness and to introduce the French program Contrainte Pénale Justice Thérapeutique in Lyon according to French law.     

L’électroconvulsivothérapie en période périnatale : représentations des professionnels de santé mentale

IntroductionPsychiatric disorders are common in peripartum and are associated with adverse outcomes for mother and fetus. Electroconvulsive therapy (ECT) is one of the most effective and safe options to treat severe mental illness, including during the perinatal period. Nevertheless, it remains underutilized during this period, possibly due to negative representations. Research has been carried out on the representations and attitudes of caregivers towards ECT, but the specificities of these attitudes during peripartum have not been explored.ObjectivesWe aimed to assess the attitudes towards ECT during the peripartum among psychiatrists, nurses, social workers and psychologists. The primary objective was to compare the score of favorability for ECT during peripartum according to the profession. The secondary objective was to highlight other factors involved in the favorability for ECT in peripartum.MethodsWe investigated mental health professionals’ attitudes sending by e-mail an anonymous questionnaire in five hospitals in France. The questionnaire was composed of demographic details, one scale about the attitudes towards ECT (the Questionnaire on Attitudes and Knowledge of ECT (QuAKE)) used in several studies; in this questionnaire, a specific part for perinatal period has been added for our study, both using a Likert scale. The completion time for this online questionnaire was approximately 5 to 7 minutes. A score of favorability for ECT in general and in peripartum was established for each participant. These scores represented the percentage of positive responses to favorable items and of negative responses to unfavorable items towards ECT. Comparison of the QuAKE answers with a sample of English caregivers in 2001 has been determined with χ² tests. A Bonferroni correction was applied due to the large number of tests performed. Factors involved in the favorability for ECT have been studied with Pearson correlation, Kruskall-Wallis and Wilcoxon tests.ResultsTwo hundred and twenty one professionals (80 psychiatrists, 78 nurses, 19 social workers and 44 psychologists) were included in the study. Their answers to the QuAKE questionnaire were comparable or more favorable to ECT than the English sample answered in 2001. The perinatal part of questionnaire had a good internal consistency (Cronbach coefficient: 0,91). Participants were less favorable to ECT in perinatal period (favorability score: 44.2) than in general (63.6). They more often responded « uncertain » to the perinatal questionnaire (44,9 % against 18.4 % for the ECT in general; W = 19931,5; P < 0,001). The favorability for ECT in general and during peripartum were statistically associated with profession (psychiatrists were more favorable), specific training and experience in ECT. Gender, perinatal specialization, age, and the number of years in professional service were not associated with favorability for ECT in general and during peripartum in this study.ConclusionsIn this study, we have found that profession, training and experience in ECT are linked to the attitudes towards ECT, including in the perinatal period. It is necessary to inform professionals about the possibility of prescribing ECT in the perinatal period by training them in the specificities of pregnancy.     

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.