"INTERMED": a method to assess health service needs. I. Development and reliability.

The purpose of this paper is to describe the development and to test the reliability of a new method called INTERMED, for health service needs assessment. The INTERMED integrates the biopsychosocial aspects of disease and the relationship between patient and health care system in a comprehensive scheme and reflects an operationalized conceptual approach to case mix or case complexity. The method is developed to enhance interdisciplinary communication between (para-) medical specialists and to provide a method to describe case complexity for clinical, scientific, and educational purposes. First, a feasibility study (N = 21 patients) was conducted which included double scoring and discussion of the results. This led to a version of the instrument on which two interrater reliability studies were performed. In study 1, the INTERMED was double scored for 14 patients admitted to an internal ward by a psychiatrist and an internist on the basis of a joint interview conducted by both. In study 2, on the basis of medical charts, two clinicians separately double scored the INTERMED in 16 patients referred to the outpatient psychiatric consultation service. Averaged over both studies, in 94.2% of all ratings there was no important difference between the raters (more than 1 point difference). As a research interview, it takes about 20 minutes; as part of the whole process of history taking it takes about 15 minutes. In both studies, improvements were suggested by the results. Analyses of study 1 revealed that on most items there was considerable agreement; some items were improved. Also, the reference point for the prognoses was changed so that it reflected both short- and long-term prognoses. Analyses of study 2 showed that in this setting, less agreement between the raters was obtained due to the fact that the raters were less experienced and the scoring procedure was more susceptible to differences. Some improvements--mainly of the anchor points--were specified which may further enhance interrater reliability. The INTERMED proves to be a reliable method for classifying patients' care needs, especially when used by experienced raters scoring by patient interview. It can be a useful tool in assessing patients' care needs, as well as the level of needed adjustment between general and mental health service delivery. The INTERMED is easily applicable in the clinical setting at low time-costs.

Validation française d'un questionnaire de stress post-traumatique destiné aux parents d'enfants présentant un risque périnatal élevé = French validation of the "Perinatal PTSD Questionnaire" assessing parent's posttraumatic stress reactions following the birth of a high risk infant.

(from the journal abstract) Objectives: The birth of a high risk infant--such as a very or extremely premature infant--can represent an important traumatic experience for parents. R. DeMier, M. Hynan et al's "Perinatal PTSD Questionnaire" aims at exploring, retrospectively, parent's posttraumatic stress reactions following the birth of a high risk infant. This paper describes the French validation of this questionnaire. Methods: Fifty-two families with a very or extremely premature infant and 25 families with a full term infant responded to the "Perinatal PTSD Questionnaire" and the "Impact of Event Scale" when children were 18 months old. Results: Parents of high risk infants can present posttraumatic stress reactions such as intrusion, avoidance or arousal symptoms. The French version of the "Perinatal PTSD Questionnaire" has satisfactory psychometric properties. Conclusions: As posttraumatic reactions are not directly related to objective descriptions of the stressful event, it may be essential to the liaison child psychiatrist to consider individual posttraumatic reactions in order to optimise preventive intervention with the parents. A questionnaire should not replace a clinical interview, however it may represent a useful screening tool. Also, this questionnaire should be useful for research purposes. (PsycINFO Database Record (c) 2005 APA, all rights reserved)

Expérimentation et clinique électroencéphalographiques entre physiologie, neurologie et psychiatrie (Suisse, 1935-1965)

The electroencephalogram (EEG), invented by the German psychiatrist Hans Berger in 1924, reached the neurophysiological laboratories and several clinical contexts in the mid-30s. In Switzerland, some skeptical physiologists and enthusiastic psychiatrists paved the way for its integration, but it was only after the Second World War that an emerging field of epileptology became part of a process of technological and epistemological innovation which raised great expectations and produced a large body of research at the crossroads of physiology, neurology and psychiatry. An informal network was created, characterized by clinical, scientific and local institutional cultures. The EEG also made it possible to detect some clinical entities, not however without transforming them, as in the case of epilepsy. Some attempts to probe psychiatric diseases and subjects with the EEG are described as negotiated relationships between clinical observations, subjective manifestations or symptoms and inscriptions of a spontaneous or elicited electrical brain activity. These attempts shape a clinical and experimental cerebral subject, which is analyzed in this article from the point of view of its technical aspects and the concrete procedures on which it depends.

Le regard d'un psychiatre sur les écrits de la folie : la carrière de Hans Steck à l'Asile psychiatrique de Cery (1920-1960)

Quelles représentations de la schizophrénie les psychiatres vont-ils construire à travers l'étude des écrits asilaires des patients et des scientifiques dans la première moitié du XXème siècle? Le psychiatre helvétique Hans Steck (1891-1980), qui a travaillé à l'Asile psychiatrique de Cery de 1920 à 1960 et qui s'est fait connaître du public grâce à l'oeuvre d'Aloïse Corbaz, reconnue comme auteure d'art brut par Jean Dubuffet en 1945, constitue le fil rouge de la thèse. Dans le contexte des mouvements tels que Γ "art psychopathologique" et Γ "art brut", Steck étudie les théories de "la mentalité primitive et les peintures magiques des schizophrènes". En 1927, il se tourne vers les théories évolutionnistes de la régression et les premières études de Lévy-Bruhl pour avancer l'idée qu'il existe un "parallélisme schizo-primitif'. Puis il développe des explications de la pensée délirante, à partir des théories exposées lors du Premier Congrès International de Psychiatrie en 1950. Enfin, adoptant la perspective phénoménologique, il explique que "la fonction de l'art et la fonction du délire visent à reconstituer un monde viable pour le malade". En ce sens, l'expression artistique, bien que n'entrant pas dans le champ de la psychothérapie, fournit des indicateurs de l'état psychique du malade en même temps qu'elle contribue à son bien-être. Sont abordés les problèmes concernant la reconnaissance de Γ "auteur" interné, dont les oeuvres appartiennent soit aux archives médicales, soit au musée. La pérennité des critères qui définissent les oeuvres d'"art psychopathologique" ou d'"art brut" est également mise en question. Enfin, le rôle essentiel de l'écriture à l'hôpital, tant pour les patients que pour les soignants, fait l'objet de nombreux développements. - What representations of schizophrenia have psychiatrists been constructing when studying writings by patients and scientists in mental asylums in the first half of the 20th century? The Swiss psychiatrist Hans Steck (1891-1980) is the protagonist of this dissertation. From 1920 to 1960, he has been working at the "Asile psychiatrique de Cery" near Lausanne. Steck is known thanks to the paintings of Aloïse Corbaz, an artist recognized by Jean Dubuffet as belonging to the "art brut" movement in 1945. In the context of movements like "art psychopathologique" and "art brut," Steck studies theories of "primitive character and magic paintings of schizophrenics." In 1927, Steck engages with theories of regression and Lévy-Bruhl's early studies in order to push the idea of a "parallelism schizo-primitif." On the occasion of the First International Congress of psychiatry held in Paris in 1950, Steck develops explanations for the "pensée délirante." Finally, turning to a phenomenological point of view, he explains, "the function of art and the function of the delusion help the patient to reconstruct a viable environment for the sick person." In this way, artistic expression is not thought of as a psychotherapeutical means, but provides insight into the state of mind of a mentally sick person at the same time as contributing to his well-being. The dissertation discusses whether the "author's" work belongs in medical archives or museums. The continuity of "psychopathological art" and "art brut" criteria will be discussed. Finally, the essential role that writing played in the hospital for the patients as well as for the medical staff is presented.

A randomized trial of spiritual assessment of outpatients with schizophrenia: Patients' and clinicians' experience

Objective: Recovery-oriented care for patients with schizophrenia involves consideration of cultural issues, such as religion and spirituality. However, there is evidence that psychiatrists rarely address such topics. This study examined acceptance of a spiritual assessment by patients and clinicians, suggestions for treatment that arose from the assessment, and patient outcomes-in terms of treatment compliance and satisfaction with care (as measured by treatment alliance). Methods: Outpatients with psychosis were randomly assigned to two groups: an intervention group that received traditional treatment and a religious and spiritual assessment (N=40) and a control group that received only traditional treatment (N=38). Eight psychiatrists were trained to administer the assessment to their established and stable patients. After each administration, the psychiatrist attended a supervision session with a psychiatrist and a psychologist of religion. Baseline and three-month data were collected. Results: The spiritual assessment was well accepted by patients. During supervision, psychiatrists reported potential clinical uses for the assessment information for 67% of patients. No between-group differences in medication adherence and satisfaction with care were found at three months, although patients in the in- tervention group had significantly better appointment attendance dur- ing the follow-up period. Their interest in discussing religion and spirituality with their psychiatrists remained high. The process was not as well accepted by psychiatrists. Conclusions: Spiritual assessment can raise important clinical issues in the treatment of patients with chronic schizophrenia. Cultural factors, such as religion and spirituality, should be considered early in clinical training, because many clinicians are not at ease addressing such topics with patients.

Collaboration entre médecin de famille et psychiatre pour les problèmes de santé mentale [Family physicians and psychiatrists' collaborative care for mental health problems].

The burden of disease linked to mental disorders represents more than one-fifth of years lived with disability in the world. Less than half of people suffering from mental disorders are adequately treated. Three quarter of those who receive treatment are followed by primary care. Collaborative care aims to increase the efficiency of direct general practitioner's treatment. Main components are sustainable and individualized consultation-liaison relationship (1/2 day of psychiatrist by 15 days for 10-15 general practitioners), and support of a clinical case manager for complex situations. Collaboration is bidirectional: early or crisis access to specialist care and long-term followup by general practitioner. This model is a challenge for the doctor-patient dual relationship and requires incentives in a public health perspective.

The Beck Cognitive Insight Scale in outpatients with psychotic disorders: further evidence from a French-speaking sample.

OBJECTIVE: The Beck Cognitive Insight Scale (BCIS) evaluates patients' self-report of their ability to detect and correct misinterpretation. Our study aims to confirm the factor structure and the convergent validity of the original scale in a French-speaking environment. METHOD: Outpatients (n = 158) suffering from schizophrenia or schizoaffective disorders fulfilled the BCIS. The 51 patients in Montpellier were equally assessed with the Positive and Negative Syndrome Scale (PANSS) by a psychiatrist who was blind of the BCIS scores. RESULTS: The fit indices of the confirmatory factor analysis validated the 2-factor solution reported by the developers of the scale with inpatients, and in another study with middle-aged and older outpatients. The BCIS composite index was significantly negatively correlated with the clinical insight item of the PANSS. CONCLUSIONS: The French translation of the BCIS appears to have acceptable psychometric properties and gives additional support to the scale, as well as cross-cultural validity for its use with outpatients suffering from schizophrenia or schizoaffective disorders. The correlation between clinical and composite index of cognitive insight underlines the multidimensional nature of clinical insight. Cognitive insight does not recover clinical insight but is a potential target for developing psychological treatments that will improve clinical insight.

Predictors of physiotherapy and occupational therapy use two years after a vocational rehabilitation for orthopaedic trauma

Introduction.- Health care utilization is an important field of our economy. Nevertheless a minority of cases induce the majority of costs. For instance, in the setting of accident insurance, the most expensive 5% of all injured cases involve 80% of the health care costs. Although physiotherapy and occupational therapy consist of only a small proportion of these costs, it is nevertheless important to evaluate the factors that predict its use in order to improve services (i.e. allocation of resources to those who need them and benefit most).Patients and methods.- In this longitudinal prospective study, the cohort consisted of 2156 consecutively included patients with orthopaedic problems attending the clinique Romande de réadaptation (CRR) at Sion for inpatient rehabilitation after a work, traffic or leisure related injury. Two years after discharge, a questionnaire regarding the use of different health cares was send to the patients (1502 patients returned their questionnaires). The aim of this study was to calculate, with a logistic multivariate model, in-patient hospitalized for orthopaedic problems, the variables that mostly predict physiotherapy use 2 years after discharge.Results.- The full multivariate model contains 46 predictors. The use of physiotherapy and occupational therapy was significantly predicted in this multivariate model by the following predictors: Patients with a spinal problem (OR 1.51 versus lower-extremity problem, 95% CI 1.01 to 2.27), a disability pension (OR 1.69, 95% CI 1.09 to 2.60), patients with sports activities (OR 1.56, 95% CI 1.26 to 1.94), patients with longer stay at the rehabilitation clinic (OR 1.22 per week, 95% CI 1.05 to 1.41), women (OR 1.64, 95% CI 1.09 to 2.48) and those consulting a psychiatrist (OR 1.66, 95% CI 1.06 to 2.60).Discussion.- In this prospective study with a 2-year follow-up, different factors predicted the use of physiotherapy and occupational therapy after an injury. Further studies are needed to clarify the impact of these factors for the health care utilization and the strategies, which would allow to improve allocation of available resources.

Die Krankheit Depression kann jeden treffen [In Process Citation].

The survey "Datenerhebung zur Depression in der Allgemeinbevölkerung" was conducted from fall 2010 to spring 2011 on several online platforms. The results show that there is a considerable timespan between the appearance of initial symptoms of depression and the first diagnosis of a patient. Intervention at early stages of the disease can reduce a potentially long time of suffering and can lead to the successful treatment of depression. General practitioners play an important role as the link between patient and psychiatrist.

Assessment of the capacity to consent to treatment in patients admitted to acute medical wards.

BACKGROUND: Assessment of capacity to consent to treatment is an important legal and ethical issue in daily medical practice. In this study we carefully evaluated the capacity to consent to treatment in patients admitted to an acute medical ward using an assessment by members of the medical team, the specific Silberfeld's score, the MMSE and an assessment by a senior psychiatrist. METHODS: Over a 3 month period, 195 consecutive patients of an internal medicine ward in a university hospital were included and their capacity to consent was evaluated within 72 hours of admission. RESULTS: Among the 195 patients, 38 were incapable of consenting to treatment (unconscious patients or severe cognitive impairment) and 14 were considered as incapable of consenting by the psychiatrist (prevalence of incapacity to consent of 26.7%). Agreement between the psychiatrist's evaluation and the Silberfeld questionnaire was poor (sensitivity 35.7%, specificity 91.6%). Experienced clinicians showed a higher agreement (sensitivity 57.1%, specificity 96.5%). A decision shared by residents, chief residents and nurses was the best predictor for agreement with the psychiatric assessment (sensitivity 78.6%, specificity 94.3%). CONCLUSION: Prevalence of incapacity to consent to treatment in patients admitted to an acute internal medicine ward is high. While the standardized Silberfeld questionnaire and the MMSE are not appropriate for the evaluation of the capacity to consent in this setting, an assessment by the multidisciplinary medical team concurs with the evaluation by a senior psychiatrist.

Crohn's disease-associated polymorphism within the PTPN2 gene affects muramyl-dipeptide-induced cytokine secretion and autophagy.

BACKGROUND: The single nucleotide polymorphism (SNP) rs2542151 within the gene locus region encoding protein tyrosine phosphatase non-receptor type 2 (PTPN2) has been associated with Crohn's disease (CD), ulcerative colitis (UC), type-I diabetes, and rheumatoid arthritis. We have previously shown that PTPN2 regulates mitogen-activated protein kinase (MAPK) signaling and cytokine secretion in human THP-1 monocytes and intestinal epithelial cells (IEC). Here, we studied whether intronic PTPN2 SNP rs1893217 regulates immune responses to the nucleotide-oligomerization domain 2 (NOD2) ligand, muramyl-dipeptide (MDP). MATERIALS AND METHODS: Genomic DNA samples from 343 CD and 663 non-IBD control patients (male and female) from a combined German, Swiss, and Polish cohort were genotyped for the presence of the PTPN2 SNPs, rs2542151, and rs1893217. PTPN2-variant rs1893217 was introduced into T(84) IEC or THP-1 cells using a lentiviral vector. RESULTS: We identified a novel association between the genetic variant, rs1893217, located in intron 7 of the PTPN2 gene and CD. Human THP-1 monocytes carrying this variant revealed increased MAPK activation as well as elevated mRNA expression of T-bet transcription factor and secretion of interferon-γ in response to the bacterial wall component, MDP. In contrast, secretion of interleukin-8 and tumor necrosis factor were reduced. In both, T(84) IEC and THP-1 monocytes, autophagosome formation was impaired. CONCLUSIONS: We identified a novel CD-associated PTPN2 variant that modulates innate immune responses to bacterial antigens. These findings not only provide key insights into the effects of a functional mutation on a clinically relevant gene, but also reveal how such a mutation could contribute to the onset of disease.

Crises non épileptiques psychogènes: le défi des troubles fonctionnels en neurologie

Psychogenic non epileptic seizures (PNES) look like epilepsy, but are not accompanied by the electrophysiological alterations found in epilepsy. The diagnosis requires a complex process at the interface between neurology and psychiatry. Diagnostic restitution to the patient and treatment of the condition should be a collaboration between neurologist and psychiatrist including as much as possible a general practitioner. Vulnerability and triggering psycho-social factors, as well as frequent psychiatric co morbidity implicate that psychiatric-psychological care is needed in a majority of situations, however this cannot be done without a strong "somatic back-up" with rapid access to somatic facility for advice and care when needed. The neurological presentation of the disease, with psychiatric causes underlying the condition, bear the risk for the patient that neither neurological nor psychiatric care is offered. Current knowledge about the condition is still scarce, but the field is progressively enriched by studies with stronger methodologies. Recent neuroimaging studies open fascinating avenues on our understanding of the interplay between emotional regulation, representation of the self, and dissociative symptoms. These new avenues help our understanding of these disorders which challenge classical frontiers between neurology and psychiatry. In this paper we try to formulate a framework for the care of patient with dissociative disorders including NEPS.

Assistance au suicide en hôpital de soins aigus: sommes-nous prêts [Physician-assisted suicide in university hospital: are we ready?]

Assisting people to commit suicide has generated a passionate public debate. In exceptional situations, access to this support can be granted to the demanders in a hospital environment. So did the CHUV and the academic hospitals of Geneva draw up a procedure permitting, in principle, the access to an assistance to commit suicide. Two recent clinical situations experienced in the CHUV's Service of internal medicine have created a lot of discussions, doubts and revealed, sometimes, divergent positions. By the light of this clinical cases, we wished to share the perspective of the internist in charge of the ethician, of the chaplain, of the medical director, of the psychiatrist and of the palliative care responsible. Theses complex situations illustrate the deep ambivalence felt by the clinicians confronted to situations which require a multidisciplinary approach.