Administering brief motivational interventions to young men: Results from a pilot census transmissible study among 19 year-old francophone Swiss men.

AIMS - To pilot the implementation of brief motivational intervention (BMI) among conscripts, and to test the effectiveness of BMI in young men voluntarily showing up for a single face-to-face alcohol BMI session. Participants were conscripts attending the army recruitment process in Lausanne. This process is mandatory for all Swiss males at age 19 and Lausanne serves all francophone Swiss men. METHODS - Of 3'227 young men that were seen during the army recruitment procedures, 445 voluntarily showed up for a BMI and 367 were included in the study (exclusions were random and unsystematic and related to organizational aspects in the recruitment center). After an initial assessment, subjects were randomized into two groups: an immediate BMI and a 6-month delayed BMI (waiting list design). A 6-month follow-up assessment was conducted in both groups. BMI was a face-to-face 20 minutes counseling session with a psychologist trained in motivational interviewing at baseline and a telephone session for the control group at follow-up. Strategies of BMI included the exploration and evocation of a possible behavior change, importance of future change, readiness to change, and commitment to change. A filmed example of such an intervention is available in French at www.alcoologie.ch. RESULTS - All procedures are now fully implemented and working and the provision of preventive efforts found general approval by the army. 3'227 were eligible for BMI and 445 of them (13.8%) showed up for receiving a BMI. 367 were included in the study, 181 in the BMI group and 186 in the control group. More than 86% of those included were reached at follow-up. With one exception all findings on alcohol use went in the expected direction, i.e. a stronger decrease in alcohol use (or a smaller increase as for usual weekly drinking amount) in the BMI group. The risk for risky single occasion drinking (RSOD) decreased from 57% at-risk users at baseline to 50.6%, i.e. a 6.4% point decrease in the BMI group, while there was only a 0.6% point decrease (from 57.5% to 56.9%) in the control group. Moreover, the study showed that there was a likelihood of crossover effects for other substances like tobacco smoking and cannabis use. Despite these encouraging and consistent positive findings, none reached significance at conventional levels (p < 0.05). DISCUSSION - Data suggest a beneficial impact of BMI on alcohol use outcomes and potential effect on other substance use in 19-year old men attending the army recruitment and showing up voluntarily for BMI. As the main aim was to implement and test feasibility of conducting BMI in this setting none of our findings reached statistical significance. The consistency of findings across measures and substances, however, raises hope that non-significance in the present study does not mean no effect, but mainly insufficient power of this pilot study. [Authors]

Spirituality and religious practices among outpatients with schizophrenia and their clinicians

OBJECTIVES: Religious issues may be neglected by clinicians who are treating psychotic patients, even when religion constitutes an important means of coping. This study examined the spirituality and religious practices of outpatients with schizophrenia compared with their clinicians. Clinicians' knowledge of patients' religious involvement and spirituality was investigated. METHODS: The study sample included 100 patients of public psychiatric outpatient facilities in Geneva, Switzerland, with a diagnosis of nonaffective psychosis. Audiotaped interviews were conducted with use of a semistructured interview about spirituality and religious coping. The patients' clinicians (N=34) were asked about their own beliefs and religious activities as well as their patients' religious and clinical characteristics. RESULTS: Sixteen patients (16 percent) had positive psychotic symptoms reflecting aspects of their religious beliefs. A majority of the patients reported that religion was an important aspect of their lives, but only 36 percent of them had raised this issue with their clinicians. Fewer clinicians were religiously involved, and, in half the cases, their perceptions of patients' religious involvement were inaccurate. A few patients considered religious practice to be incompatible with treatment, and clinicians were seldom aware of such a conflict. CONCLUSIONS: Religion is an important issue for patients with schizophrenia, and it is often not related to the content of their delusions. Clinicians were commonly not aware of their patients' religious involvement, even if they reported feeling comfortable with such an issue.

Pneumothorax sur prise de cocaïne [Cocaine use and pneumothorax].

Cocaine use, often not recognized, is a frequent cause of consultation in the emergency room or by primary care physicians. The use of cocaine causes numerous cardiovascular and pulmonary side effects. In this context, the occurrence of a pneumothorax represents a specific complication, often misunderstood by primary care physicians. We describe here three cases of patients who suffered from subcutaneous emphysema and pneumothorax after taking cocaine and emphasize the importance of always keeping in mind the possibility of illicit substance use in such cases, especially among young and healthy patients.

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Evidence of altered antioxidant systems and signs of elevated oxidative stress are reported in peripheral tissue and brain of schizophrenic patients, including low levels of glutathione (GSH), a major thiol antioxidant and redox buffer. Functional and genetic data indicate that an impaired regulation of GSH synthesis is a vulnerability factor for the disease. Impaired GSH synthesis from a genetic origin combined with environmental risk factors generating oxidative stress (e.g., malnutrition, exposure to toxins, maternai infection and diabetes, obstetrical complications, and psychological stress) could lead to redox dysregulation. This could subsequently perturb normal brain development and maturation with delayed functional consequences emerging in early adulthood. Depending on the nature and the time of occurrence of the environmental insults, the structural and functional delayed consequences could vary, giving rise to various endophenotypes. The use of animal models of GSH deficit represents a valuable approach to investigate how interactions between genetic and environmental factors lead to the emergence of pathologies found in the disease. Moreover, these models of GSH can be useful to investigate links between schizophrenia and comorbid somatic disorders, as dysregulation of the GSH system and elevated oxidative stress are also found in cardiovascular diseases and diabetes. This chapter reviews pharmacological and genetic rodent models of GSH synthesis dysregulation used to address some of the aforementioned issues. Up to date, these models revealed that GSH deficits lead to morphological, physiological, and behavioral alterations that are quite analogous to pathologies observed in patients. This includes hypofunction of NMDA receptors, alteration of dopamine neurotransmission, anomalies in parvalbumin-immunoreactive fast-spiking interneurons, and reduced myelination. In addition, a GSH deficit affects the brain in a region-specific manner, the anterior cingulate cortex and the ventral hippocampus being the most vulnerable regions investigated. Interestingly, a GSH deficit during a limited period of postnatal development is sufficient to have long-lasting consequences on the integrity of PV-IR interneurons in the anterior cingulate cortex and impairs cognitive functions in adulthood. Finally, these animal models of GSH deficit display behavioral impairments that could be related to schizophrenia. Altogether, current data strongly support a contributing role of a redox dysregulation on the development of pathologies associated with the illness and demonstrate the usefulness of these models to better understand the biological mechanisms leading to schizophrenia.

DSM-5: a collection of psychiatrist views on the changes, controversies, and future directions.

The recent release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association has led to much debate. For this forum article, we asked BMC Medicine Editorial Board members who are experts in the field of psychiatry to discuss their personal views on how the changes in DSM-5 might affect clinical practice in their specific areas of psychiatric medicine. This article discusses the influence the DSM-5 may have on the diagnosis and treatment of autism, trauma-related and stressor-related disorders, obsessive-compulsive and related disorders, mood disorders (including major depression and bipolar disorders), and schizophrenia spectrum disorders.

When "enough" is not enough: new perspectives on optimal methadone maintenance dose.

Some methadone maintenance treatment (MMT) programs prescribe inadequate daily methadone doses. Patients complain of withdrawal symptoms and continue illicit opioid use, yet practitioners are reluctant to increase doses above certain arbitrary thresholds. Serum methadone levels (SMLs) may guide practitioners dosing decisions, especially for those patients who have low SMLs despite higher methadone doses. Such variation is due in part to the complexities of methadone metabolism. The medication itself is a racemic (50:50) mixture of 2 enantiomers: an active "R" form and an essentially inactive "S" form. Methadone is metabolized primarily in the liver, by up to five cytochrome P450 isoforms, and individual differences in enzyme activity help explain wide ranges of active R-enantiomer concentrations in patients given identical doses of racemic methadone. Most clinical research studies have used methadone doses of less than 100 mg/day [d] and have not reported corresponding SMLs. New research suggests that doses ranging from 120 mg/d to more than 700 mg/d, with correspondingly higher SMLs, may be optimal for many patients. Each patient presents a unique clinical challenge, and there is no way of prescribing a single best methadone dose to achieve a specific blood level as a "gold standard" for all patients. Clinical signs and patient-reported symptoms of abstinence syndrome, and continuing illicit opioid use, are effective indicators of dose inadequacy. There does not appear to be a maximum daily dose limit when determining what is adequately "enough" methadone in MMT.

Prevalence of methadone injection in three Swiss cities.

OBJECTIVE: Intravenous methadone is associated with increased risk of morbidity and mortality. A previous report from a methadone center in Fribourg, Switzerland, found a high prevalence (43%) of patients who injected oral methadone. We therefore wished to assess the prevalence of methadone injection among patients in oral methadone programs in 3 other Swiss cities--Lausanne, Geneva, and La Chaux-de-Fonds. METHOD: Subjects were randomly selected and interviewed by assistant psychologists who were not on the staff of the study centers. Participation was voluntary and anonymous. RESULTS: 164 patients participated in the study (n = 58 in Lausanne, 52 in Geneva, and 54 in La Chaux-de-Fonds). The prevalence of methadone injection was low (5%) and did not differ significantly between the cities. DISCUSSION: Less liberal policies cannot explain the lower prevalence of methadone injection in these three centers than in Fribourg. The high prevalence of methadone injection there is probably related to its separate methadone injection program: patients in oral methadone programs may be more likely to injection methadone when other patients authorized to do so. IN CONCLUSION: Although the 5% prevalence of methadone injection found in the 3 cities surveyed is low, it is not negligible. These results suggest that information on the risks associated with injection of methadone syrup should be provided to all methadone maintenance. This information is especially necessary when maintenance therapy is provided in the same center, or city as injectable methadone maintenance.

Visuo-spatial processing in a dynamic and a static working memory paradigm in schizophrenia.

Recent findings suggest that the visuo-spatial sketchpad (VSSP) may be divided into two sub-components processing dynamic or static visual information. This model may be useful to elucidate the confusion of data concerning the functioning of the VSSP in schizophrenia. The present study examined patients with schizophrenia and matched controls in a new working memory paradigm involving dynamic (the Ball Flight Task - BFT) or static (the Static Pattern Task - SPT) visual stimuli. In the BFT, the responses of the patients were apparently based on the retention of the last set of segments of the perceived trajectory, whereas control subjects relied on a more global strategy. We assume that the patients' performances are the result of a reduced capacity in chunking visual information since they relied mainly on the retention of the last set of segments. This assumption is confirmed by the poor performance of the patients in the static task (SPT), which requires a combination of stimulus components into object representations. We assume that the static/dynamic distinction may help us to understand the VSSP deficits in schizophrenia. This distinction also raises questions about the hypothesis that visuo-spatial working memory can simply be dissociated into visual and spatial sub-components.

Le sevrage ultra-rapide sous anesthésie générale: l'expérience de l'Hôpital de St-Loup [Ultrafast opiate detoxification under general anesthesia: the St. Loup Hospital experience]

Rapid antagonist induction under anesthesia is a method that has been increasingly used to detoxify opiate addicts. These procedures are useful to reduce the duration and the discomfort of withdrawal. However, the high risk and the cost of these methods require randomized clinical trial to evaluate safety and clinical effectiveness. The University Substance Abuse Division of Lausanne and the Intensive Care Unit of the St-Loup Hospital work on a randomized clinical trial comparing anesthesia-assisted versus traditional clonidine detoxification combined with an additional psychosocial week. This paper describes the technique of anesthesia used in our study. Our clinical experience suggests that, integrating this technique in a multidisciplinary network, with a strong emphasis on post-anesthetic follow-up, is a viable and safe option in the treatment of opiate dependence.

2013 Update in addiction medicine for the generalist.

Increasingly, patients with unhealthy alcohol and other drug use are being seen in primary care and other non-specialty addiction settings. Primary care providers are well positioned to screen, assess, and treat patients with alcohol and other drug use because this use, and substance use disorders, may contribute to a host of medical and mental health harms. We sought to identify and examine important recent advances in addiction medicine in the medical literature that have implications for the care of patients in primary care or other generalist settings. To accomplish this aim, we selected articles in the field of addiction medicine, critically appraised and summarized the manuscripts, and highlighted their implications for generalist practice. During an initial review, we identified articles through an electronic Medline search (limited to human studies and in English) using search terms for alcohol and other drugs of abuse published from January 2010 to January 2012. After this initial review, we searched for other literature in web-based or journal resources for potential articles of interest. From the list of articles identified in these initial reviews, each of the six authors independently selected articles for more intensive review and identified the ones they found to have a potential impact on generalist practice. The identified articles were then ranked by the number of authors who selected each article. Through a consensus process over 4 meetings, the authors reached agreement on the articles with implications for practice for generalist clinicians that warranted inclusion for discussion. The authors then grouped the articles into five categories: 1) screening and brief interventions in outpatient settings, 2) identification and management of substance use among inpatients, 3) medical complications of substance use, 4) use of pharmacotherapy for addiction treatment in primary care and its complications, and 5) integration of addiction treatment and medical care. The authors discuss each selected articles' merits, limitations, conclusions, and implication to advancing addiction screening, assessment, and treatment of addiction in generalist physician practice environments.

Psychopathologie chez les enfants de patients souffrant de troubles liés à une substance ou de troubles de l'humeur

L'objectif principal de cette thèse est d'exposer les résultats des premières évaluations psychopathologiques menées, dans le cadre d'une étude familiale, sur une cohorte d'enfants de patients souffrant de troubles liés à des substances ou de troubles de l'humeur. Plus précisément, nous avons examiné des enfants de patients souffrant de dépendance à l'alcool et à l'héroïne, de troubles bipolaires et unipolaires, ainsi qu'un groupe d'enfants témoins, dont les parents étaient des patients contrôles recrutés dans des départements d'orthopédie. Nous nous sommes ainsi proposé d'étudier de façon précise le risque de psychopathologie chez des enfants de parents malades en menant une étude longitudinale prospective au moyen d'évaluations standardisées. Ces enfants ainsi que leurs parents-patients (probands) sont actuellement évalués chaque trois ans. Nous avons aussi effectué une évaluation des co-parents biologiques de ces enfants afin de tenir compte également de l'impact de leurs éventuels troubles psychiatriques sur les manifestations psychopathologiques de leurs enfants. Le volet longitudinal-prospectif de ces familles est actuellement en cours, et les deux articles contenus dans cette thèse, publiés dans des revues à politique éditoriale, exposent les résultats obtenus lors de l'évaluation initiale de ces enfants et de leurs deux parents. Nous résultats montrent que les enfants de patients, pourtant encore très jeunes (moyenne d'âge d'environ 11 ans), présentent déjà de plus hauts taux de manifestations psychopathologiques que les enfants de parents contrôles. Nous avons également pu démontrer le rôle joué par le co-parent, en plus de celui du parent-patient, dans le développement de psychopathologie chez ces enfants. Ces résultats soulignent la nécessité d'une identification et d'une prise en charge très précoce de ces enfants, et indiquent également l'importance de porter un intérêt clinique non seulement au parent-patient, mais également au co-parent de ces enfants. - This thesis presents the baseline results of psychopathological assessments conducted in a prospective longitudinal cohort study of children whose parents have substance use disorders or mood disorders. More specifically, we examined children of alcohol- and heroin- dependent patients, children of patients with bipolar or unipolar disorders, and, as a control group, children whose parents were recruited in orthopedics departments. Using standardized assessments, we conducted this study to accurately assess the risk of psychopathology in children of parents with these substance use or mood disorders. The prospective longitudinal study of these families is currently ongoing, with the children and their parent-patients (probands) being followed up every three years. We also assessed the biological co-parent in order to determine the impact of their possible psychiatric disorders on the risk of mental disorders in offspring. The two articles of this thesis, which have been published in peer-reviewed journals, present the results of baseline assessments of the children and their two parents. Our results show that the children of patients who are still very young at baseline assessment (mean age about 11 years) already have higher rates of psychopathological manifestations compared with children of control parents. We also demonstrate the effect of the co-parents, in addition to that of the parent-patients, on the development of early psychiatric manifestations in these children. These results emphasize the importance of prompt identification and treatment of these children and highlight the need for clinical care not only of the patient, but also of the co- parent, in order to optimize the prevention of mental disorders in their offspring.

Planning sleep-related animal and translational research

With the aim of improving human health, scientists have been using an approach referred to as translational research, in which they aim to convey their laboratory discoveries into clinical applications to help prevent and cure disease. Such discoveries often arise from cellular, molecular, and physiological studies that progress to the clinical level. Most of the translational work is done using animal models that share common genes, molecular pathways, or phenotypes with humans. In this article, we discuss how translational work is carried out in various animal models and illustrate its relevance for human sleep research and sleep-related disorders.

Ultra-rapid opiate detoxification using deep sedation and prior oral buprenorphine preparation: long-term results.

BACKGROUND: New methods of ultra-rapid opiate detoxification (URD) under intravenous sedation have been criticized because of limited data on safety and long-term follow-up. Premedication with buprenorphine has been advocated to improve safety by decreasing vomiting. Prior research has not explored URD in socially impaired patients. METHOD: Sixteen patients were detoxified with URD and prospectively evaluated over at least 30 months. Data of this procedure were compared with those of our previous study without buprenorphine preparation (Drug Alcohol Depend. 52(3) (1998) 243). The 16 patients were followed up by a general practitioner (GP) before and after URD. The GPs also supervised the 7-day course of buprenorphine treatment prescribed for the 16 patients prior to URD. RESULTS: During the procedure, only one episode of vomiting occurred instead of 13 out of 20 in our previous study. Post-procedure, only two patients experienced moderate withdrawal symptoms, such as persistent nausea, abdominal cramps and vomiting lasting from 24 to 48 h, in comparison with most patients in the previous study without buprenorphine. After a period of at least 30 months (36.0+/-6.38), the 16 patients were still alive and were regularly monitored by their GP. Only two of the 16 never relapsed after URD and reported total opiate abstinence. Fourteen patients relapsed; 12 of these were prescribed a licensed methadone substitution program and two were still using heroin. CONCLUSION: In this small sample, the data indicated that URD with buprenorphine preparation was safe and that it markedly decreased post-procedure morbidity. No patient died over a minimum 30-month follow-up period. Furthermore, the procedure was employed with socially impaired patients. In the long term, a few patients were still free of opiates, while the majority opted for a methadone maintenance program, showing that URD can serve as one possible step in a long-term treatment program.

Autosomal dominant dopa-responsive parkinsonism in a multigenerational Swiss family.

AIM: To describe a large family with autosomal dominant parkinsonism. BACKGROUND: Seven genes are directly implicated in autosomally inherited parkinsonism. However, there are several multigenerational large families known with no identifiable mutation. MATERIAL AND METHODS: Family members were evaluated clinically, by history and chart review. Genetic investigation included SCA2, SCA3, UCHL1, SNCA, LRRK2, PINK1, PRKN, PGRN, FMR1 premutation, and MAPT. The proband underwent brain fluorodopa PET (FD-PET) scan, and one autopsy was available. RESULTS: Eleven patients had a diagnosis of Parkinson's disease (PD), nine women. Mean age of onset was 52 with tremor-predominant dopa-responsive parkinsonism. Disease progression was slow but severe motor fluctuations occurred. One patient required subthalamic nucleus deep-brain stimulation with a good motor outcome. One patient had mental retardation, schizophrenia and became demented, and another patient was demented. Three patients and also two unaffected subjects had mild learning difficulties. All genetic tests yielded negative results. FD-PET showed marked asymmetric striatal tracer uptake deficiency, consistent with PD. Pathological examination demonstrated no Lewy bodies and immunostaining was negative for alpha-synuclein. CONCLUSION: Apart from a younger age of onset and a female predominance, the phenotype was indistinguishable from sporadic tremor-predominant PD, including FD-PET scan results. As known genetic causes of autosomal dominant PD were excluded, this family harbors a novel genetic defect.

Thoracic aortic dissection associated with cocaine abuse.

Cardiovascular complications of cocaine abuse include myocardial ischemia and infarction, dysrhythmias, cardiomyopathies and aortic dissection. The case in point pertains to a 26-year-old, Caucasian male, substance abuser who suffered a thoracic aortic dissection following the use of crack cocaine. The autopsy and histological findings showed a connective tissue abnormality including a focal microcystic medial necrosis and a fragmentation of the elastic fibers in the arterial walls. Blood concentrations of cocaine and benzoylecgonine, taken individually, were considered to be within a potentially toxic range. Blood concentrations of methadone also indicated use of this drug at the same time. The small amounts of morphine found in the blood and urine were compatible with heroine or morphine use more than 24 h before death.