Thrombotic microangiopathic syndromes associated with drugs, HIV infection, hematopoietic stem cell transplantation and cancer

Thrombotic microangiopathy (TMA) has multiple etiologies. In the four disorders described in this review, the primary organ involved is the kidney. Drug-associated TMA can be an acute, immune-mediated disorder or the result of gradual, dose-dependent toxicity. TMA may occur in patients with advanced HIV infection, possibly mediated by angio-invasive infections. TMA following allogeneic hematopoietic stem cell transplantation may also be caused by drug toxicity; the pathogenesis may involve inhibition of vascular endothelial cell growth factor in renal podocytes. Malignancies of many types with systemic microvascular involvement may cause TMA. Recognition that these syndromes may mimic TTP is important to provide appropriate management and to avoid the inappropriate use of plasma exchange treatment.

Milk ejection disorders in Swiss dairy cows: a field study

A questionnaire was sent to 2099 dairy farms to investigate the occurrence of poor milkability. Based on that, the frequency of poor milkability in Swiss dairy cows was 4% and the percentage of cows treated with oxytocin (OT) was 2%. In addition, 270 dairy farms that had reported cases of animals with poor milkability were contacted for an interview to classify the disorders. Farmers suspected disturbed milk ejection in 52%, anatomical dysfunction of the teat and/or the udder in 16% and milk ejection disorder or impaired milkability caused by discernable environmental factors in 32% of the cases. Forty-eight animals from 18 farms with suspected milk ejection disorders were selected for an experimental field study which included milk flow recording and OT administration to induce milk ejection. After cessation of the spontaneous milk flow, a low dose of OT (0.2, 0.5 or 1 i.u.) was injected i.v. to test the responsiveness of the udder to OT at a physiological level. When milk flow ceased again, 10 i.u. OT was injected i.v. (supraphysiological) to ensure complete udder emptying and to determine the residual milk. Milk ejection disorder could be confirmed in 69% of the cases, i.e. if residual milk was >20% of the total milk. Because in 27% of the animals milk ejection disorder was not confirmed on the basis of elevated residual milk, an anatomical disorder of the teat and/or the udder was suspected. Milk ejection disorder could be confirmed in 69% of the cases whereas in 27% of the suspected cases an anatomical disorder of the teat and/or the udder was suspected. An increased cortisol production in cows with milk ejection disorder was not obvious because faecal concentrations of cortisol metabolites with a 5 beta-androstane-3 alpha,11 oxo-structure were not augmented in animals with disturbed milk ejection.

Status epilepticus and multiple organ system dysfunction

Recent reports have suggested the possible association of status epilepticus and multiple organ system failure. The purpose of this case control study was to investigate this association and to identify factors that predispose individuals with status epilepticus (SE) or aborted status epilepticus (ASE) to develop multiple organ system failure (MOSF) or multiple organ system dysfunction (MODS).^ For the purpose of the study, definitions of SE, ASE, MOSF, and MODS were operationalized as follows: SE was defined as any seizure lasting for a duration of $\ge$30 minutes or intermittent seizures lasting for $\ge$30 minutes from which the patient does not regain consciousness. ASE was defined as any seizure lasting for a duration of $\ge$10 minutes but $<$30 minutes and which was aborted as a result of a medical intervention. MOSF was defined as the failure of $\ge$2 organ systems in the same patient; organ system failure was said to be present whenever standard MOSF criteria were met. MODS was defined as the dysfunction of $\ge$2 organ systems in the same patient; organ system dysfunction was said to be present, whenever the monitor(s) of that organ's function exceeded the normal range for the physiological or laboratory parameters.^ Medical records of 686 individuals between the age of 5 and 44 years, with history of seizures needing hospitalization at the Texas Children's Hospital or Methodist Hospital, Houston, Texas, between 1991-95 were reviewed and 100 individuals with SE/ASE were identified. Of these 100 individuals with SE/ASE, 45 developed MOSF/MODS during their hospitalization and 9 of these individuals died. Using multivariate analyses, it was found that adult individuals who had an "acute" etiology of their seizure disorder (OR = 5.23; 95%CI: 0.41, 66.24) and children who had a "remote" etiology of their seizure disorder (OR = 3.92; 95%CI: 0.53, 29.22), were more likely to develop MOSF/MODS compared with those who had other etiologies of the seizure disorder. Individuals with SE lasting more than one hour were more likely to develop MOSF/MODS compared with individuals with SE lasting less than 1 hour (OR = 6.51; 95%CI: 1.63, 25.92). Individuals who presented with the SE/ASE episode as their first seizure episode were more likely to develop MOSF/MODS compared to those with a previous history of seizure episodes (OR = 1.78; 95%CI: 0.36, 8.82).^ The major limitations of this study includes the relatively small sample size and the study being performed in only two institutions. However, this is the first study of this kind and should therefore be viewed as largely exploratory in nature. Future studies should investigate the relationship of the risk factors identified in this study using a larger number of institutions and patients. ^

Efficacy of a dilemma-focused intervention for unipolar depression: study protocol for a multicenter randomized controlled trial

BACKGROUND: Depression is one of the more severe and serious health problems because of its morbidity, disabling effects and for its societal and economic burden. Despite the variety of existing pharmacological and psychological treatments, most of the cases evolve with only partial remission, relapse and recurrence.Cognitive models have contributed significantly to the understanding of unipolar depression and its psychological treatment. However, success is only partial and many authors affirm the need to improve those models and also the treatment programs derived from them. One of the issues that requires further elaboration is the difficulty these patients experience in responding to treatment and in maintaining therapeutic gains across time without relapse or recurrence. Our research group has been working on the notion of cognitive conflict viewed as personal dilemmas according to personal construct theory. We use a novel method for identifying those conflicts using the repertory grid technique (RGT). Preliminary results with depressive patients show that about 90% of them have one or more of those conflicts. This fact might explain the blockage and the difficult progress of these patients, especially the more severe and/or chronic. These results justify the need for specific interventions focused on the resolution of these internal conflicts. This study aims to empirically test the hypothesis that an intervention focused on the dilemma(s) specifically detected for each patient will enhance the efficacy of cognitive behavioral therapy (CBT) for depression. DESIGN: A therapy manual for a dilemma-focused intervention will be tested using a randomized clinical trial by comparing the outcome of two treatment conditions: combined group CBT (eight, 2-hour weekly sessions) plus individual dilemma-focused therapy (eight, 1-hour weekly sessions) and CBT alone (eight, 2-hour group weekly sessions plus eight, 1-hour individual weekly sessions). METHOD: Participants are patients aged over 18 years meeting diagnostic criteria for major depressive disorder or dysthymic disorder, with a score of 19 or above on the Beck depression inventory, second edition (BDI-II) and presenting at least one cognitive conflict (implicative dilemma or dilemmatic construct) as assessed using the RGT. The BDI-II is the primary outcome measure, collected at baseline, at the end of therapy, and at 3- and 12-month follow-up; other secondary measures are also used. DISCUSSION: We expect that adding a dilemma-focused intervention to CBT will increase the efficacy of one of the more prestigious therapies for depression, thus resulting in a significant contribution to the psychological treatment of depression. TRIAL REGISTRATION: ISRCTN92443999; ClinicalTrials.gov Identifier: NCT01542957.

Stimulant medication and psychotic symptoms in offspring of parents with mental illness

BACKGROUND: Stimulants, such as methylphenidate, are among the most commonly used medications in children and adolescents. Psychotic symptoms have been reported as rare adverse reactions to stimulants but have not been systematically inquired about in most previous studies. Family history of mental illness may increase the vulnerability to drug-induced psychotic symptoms. We examined the association between stimulant use and psychotic symptoms in sons and daughters of parents with major mood and psychotic disorders. METHODS: We assessed psychotic symptoms, psychotic-like experiences, and basic symptoms in 141 children and youth (mean ± SD age: 11.8 ± 4.0 years; range: 6–21 years), who had 1 or both parents with major depressive disorder, bipolar disorder, or schizophrenia, and of whom 24 (17.0%) had taken stimulant medication. RESULTS: Psychotic symptoms were present in 62.5% of youth who had taken stimulants compared with 27.4% of participants who had never taken stimulants. The association between stimulant use and psychotic experiences remained significant after adjustment for potential confounders (odds ratio: 4.41; 95% confidence interval: 1.82–10.69; P = .001) and was driven by hallucinations occurring during the use of stimulant medication. A temporal relationship between use of stimulants and psychotic symptoms was supported by an association between current stimulant use and current psychotic symptoms and co-occurrence in cases that were assessed on and off stimulants. CONCLUSIONS: Psychotic symptoms should be monitored during the use of stimulants in children and adolescents. Family history of mood and psychotic disorders may need to be taken into account when considering the prescription of stimulants.

An integrated molecular biology and computational approach to CYP1A1 expression in human brain

The cytochromes P450 comprise a superfamily of heme-containing mono-oxygenases. These enzymes metabolize numerous xenobiotics, but also play a role in metabolism of endogenous compounds. The P450 1A1 enzyme generally metabolizes polycyclic aromatic hydrocarbons, and its expression can be induced by aryl hydrocarbon receptor (AhR) activation. CYP1A1 is an exception to the generality that the majority of CYPs demonstrate highest expression in liver; CYP1Al is present in numerous extrahepatic tissues, including brain. This P450 has been observed in two forms, wildtype (WT) and brain variant (BV), arising from alternatively spliced mRNA transcripts. The CYP1A1 BV mRNA presented an exon deletion and was detected in human brain but not liver tissue of the same individuals. ^ Quantitative PCR analyses were performed to determine CYP1A1 WT and BV transcript expression levels in normal, bipolar disorder or schizophrenic groups. In our samples, we show that CYP1A1 BV mRNA, when present, is found alongside the full-length form. Furthermore, we demonstrate a significant decrease in expression of CYP1A1 in patients with bipolar disorder or schizophrenia. The expression level was not influenced by post-mortem interval, tissue pH, age, tobacco use, or lifetime antipsychotic medication load. ^ There is no indication of increased brain CYP1A1 expression in normal smokers versus non-smokers in these samples. We observed slightly increased CYP1A1 expression only in bipolar and schizophrenic smokers versus non-smokers. This may be indicative of complex interactions between neuronal chemical environments and AhR-mediated CYP1A1 induction in brain. ^ Structural homology modeling demonstrated that P450 1A1 BV has several alterations to positions/orientations of substrate recognition site residues compared to the WT isoform. Automated substrate docking was employed to investigate the potential binding of neurological signaling molecules and neurotropic drugs, as well as to differentiate specificities of the two P450 1A1 isoforms. We consistently observed that the BV isoform produced energetically favorable substrate dockings in orientations not observed for the same substrate in the WT isoform. These results demonstrated that structural differences, namely an expanded substrate access channel and active site, confer greater capacity for unique compound docking positions suggesting a metabolic profile distinct from the wildtype form for these test compounds. ^

Folate pathway polymorphisms and neuropsychological impairment after leukemia therapy

Neuropsychological impairment occurs in 20%-40% of childhood acute lymphoblastic leukemia (ALL) survivors, possibly mediated by folate depletion following methotrexate chemotherapy. We evaluated the relationship between two folate pathway polymorphisms and neuropsychological impairment after childhood ALL chemotherapy. Eighty-six childhood ALL survivors were recruited between 2004-2007 at Texas Children's Hospital after exclusion for central nervous system leukemia, cranial irradiation, and age<1 year at diagnosis. Neuropsychological evaluation at a median of 5.3 years off therapy included a parental questionnaire and the following child performance measures: Trail Making Tests A and B, Grooved Pegboard Test Dominant-Hand and Nondominant-Hand, and Digit Span subtest. We performed genotyping for polymorphisms in two folate pathway genes: reduced folate carrier (RFC1 80G>A, rs1051266) and dihydrofolate reductase (DHFR Intron-1 19bp deletion). Fisher exact test, logistic regression, Student's t-test, and ANOVA were used to compare neuropsychological test scores by genotype, using a dominant model to group genotypes. In univariate analysis, survivors with cumulative methotrexate exposure ≥9000 mg/m2 had an increased risk of attention disorder (OR=6.2, 95% CI 1.2 – 31.3), compared to survivors with methotrexate exposure <9000 mg/m2. On average, female survivors scored 8.5 points higher than males on the Digit Span subtest, a test of working memory (p=0.02). The RFC1 80G>A and DHFR Intron-1 deletion polymorphisms were not related to attention disorder or impairment on tests of attention, processing speed, fine motor speed, or memory. These data imply a strong relationship between methotrexate dose intensity and impairment in attention after childhood ALL therapy. We did not find an association between the RFC1 80G>A or DHFR Intron-1 deletion polymorphisms and long-term neuropsychological impairment in childhood ALL survivors.^

The role of workplace absence as an organizational mechanism in predicting employee alcohol and drug disorders

Background. EAP programs for airline pilots in companies with a well developed recovery management program are known to reduce pilot absenteeism following treatment. Given the costs and safety consequences to society, it is important to identify pilots who may be experiencing an AOD disorder to get them into treatment. ^ Hypotheses. This study investigated the predictive power of workplace absenteeism in identifying alcohol or drug disorders (AOD). The first hypothesis was that higher absenteeism in a 12-month period is associated with higher risk that an employee is experiencing AOD. The second hypothesis was that AOD treatment would reduce subsequent absence rates and the costs of replacing pilots on missed flights. ^ Methods. A case control design using eight years (time period) of monthly archival absence data (53,000 pay records) was conducted with a sample of (N = 76) employees having an AOD diagnosis (cases) matched 1:4 with (N = 304) non-diagnosed employees (controls) of the same profession and company (male commercial airline pilots). Cases and controls were matched on the variables age, rank and date of hire. Absence rate was defined as sick time hours used over the sum of the minimum guarantee pay hours annualized using the months the pilot worked for the year. Conditional logistic regression was used to determine if absence predicts employees experiencing an AOD disorder, starting 3 years prior to the cases receiving the AOD diagnosis. A repeated measures ANOVA, t tests and rate ratios (with 95% confidence intervals) were conducted to determine differences between cases and controls in absence usage for 3 years pre and 5 years post treatment. Mean replacement costs were calculated for sick leave usage 3 years pre and 5 years post treatment to estimate the cost of sick leave from the perspective of the company. ^ Results. Sick leave, as measured by absence rate, predicted the risk of being diagnosed with an AOD disorder (OR 1.10, 95% CI = 1.06, 1.15) during the 12 months prior to receiving the diagnosis. Mean absence rates for diagnosed employees increased over the three years before treatment, particularly in the year before treatment, whereas the controls’ did not (three years, x = 6.80 vs. 5.52; two years, x = 7.81 vs. 6.30, and one year, x = 11.00cases vs. 5.51controls. In the first year post treatment compared to the year prior to treatment, rate ratios indicated a significant (60%) post treatment reduction in absence rates (OR = 0.40, CI = 0.28, 0.57). Absence rates for cases remained lower than controls for the first three years after completion of treatment. Upon discharge from the FAA and company’s three year AOD monitoring program, case’s absence rates increased slightly during the fourth year (controls, x = 0.09, SD = 0.14, cases, x = 0.12, SD = 0.21). However, the following year, their mean absence rates were again below those of the controls (controls, x = 0.08, SD = 0.12, cases, x¯ = 0.06, SD = 0.07). Significant reductions in costs associated with replacing pilots calling in sick, were found to be 60% less, between the year of diagnosis for the cases and the first year after returning to work. A reduction in replacement costs continued over the next two years for the treated employees. ^ Conclusions. This research demonstrates the potential for workplace absences as an active organizational surveillance mechanism to assist managers and supervisors in identifying employees who may be experiencing or at risk of experiencing an alcohol/drug disorder. Currently, many workplaces use only performance problems and ignore the employee’s absence record. A referral to an EAP or alcohol/drug evaluation based on the employee’s absence/sick leave record as incorporated into company policy can provide another useful indicator that may also carry less stigma, thus reducing barriers to seeking help. This research also confirms two conclusions heretofore based only on cross-sectional studies: (1) higher absence rates are associated with employees experiencing an AOD disorder; (2) treatment is associated with lower costs for replacing absent pilots. Due to the uniqueness of the employee population studied (commercial airline pilots) and the organizational documentation of absence, the generalizability of this study to other professions and occupations should be considered limited. ^ Transition to Practice. The odds ratios for the relationship between absence rates and an AOD diagnosis are precise; the OR for year of diagnosis indicates the likelihood of being diagnosed increases 10% for every hour change in sick leave taken. In practice, however, a pilot uses approximately 20 hours of sick leave for one trip, because the replacement will have to be paid the guaranteed minimum of 20 hour. Thus, the rate based on hourly changes is precise but not practical. ^ To provide the organization with practical recommendations the yearly mean absence rates were used. A pilot flies on average, 90 hours a month, 1080 annually. Cases used almost twice the mean rate of sick time the year prior to diagnosis (T-1) compared to controls (cases, x = .11, controls, x = .06). Cases are expected to use on average 119 hours annually (total annual hours*mean annual absence rate), while controls will use 60 hours. The cases’ 60 hours could translate to 3 trips of 20 hours each. Management could use a standard of 80 hours or more of sick time claimed in a year as the threshold for unacceptable absence, a 25% increase over the controls (a cost to the company of approximately of $4000). At the 80-hour mark, the Chief Pilot would be able to call the pilot in for a routine check as to the nature of the pilot’s excessive absence. This management action would be based on a company standard, rather than a behavioral or performance issue. Using absence data in this fashion would make it an active surveillance mechanism. ^

DESEMPENHO EM TESTES DE ATENÇÃO VISUAL E INTERFERÊNCIA DE ESTÍMULOS AUDITIVOS DE MOVIMENTO EM INDIVÍDUOS COM E SEM MEDO DE ALTURA

Desordens da ansiedade, especialmente a agorafobia e a desordem do pânico foram associadas a anormalidades das funções vestibulares. Evidências de que o controle do equilíbrio pode exigir habilidades atencionais também foram relatadas. Utilizando o medo de altura como modelo clínico onde sintomas ansiosos coexistem com anormalidades com a percepção espacial e controle do equilíbrio, este estudo investigou o desempenho em testes de atenção visual em voluntários normais com altos e baixos escores obtidos do Questionário de Acrofobia. O teste de rastreio visual foi realizado em 30 indivíduos (15 em cada grupo) enquanto ouviam dois tipos diferentes de estímulos auditivos. Na condição volume um som de 900 Hz era apresentado em ambos ouvidos durante 2 segundos seguidos de mais 2 segundos de silêncio. Na condição balanço , o mesmo som era apresentado durante 2 segundos ao ouvido direito seguido por 2 segundos ao ouvido esquerdo. Estímulos auditivos de movimento provocaram maior desconforto em ambos os grupos, mas nos indivíduos com maiores escores de acrofobia estes estímulos foram associados a um pior desempenho no teste visual. Embora muito limitado pela amostra experimental, este estudo sugere que o medo de altura pode estar associado à dependência visual para manutenção do equilíbrio e que poderia piorar o desempenho nos testes visuais devido à competição dos recursos neuro-cognitivos. Implicações experimentais e clínicas destes achados preliminares exigem outras pesquisas.

DESEMPENHO EM TESTES DE ATENÇÃO VISUAL E INTERFERÊNCIA DE ESTÍMULOS AUDITIVOS DE MOVIMENTO EM INDIVÍDUOS COM E SEM MEDO DE ALTURA

Desordens da ansiedade, especialmente a agorafobia e a desordem do pânico foram associadas a anormalidades das funções vestibulares. Evidências de que o controle do equilíbrio pode exigir habilidades atencionais também foram relatadas. Utilizando o medo de altura como modelo clínico onde sintomas ansiosos coexistem com anormalidades com a percepção espacial e controle do equilíbrio, este estudo investigou o desempenho em testes de atenção visual em voluntários normais com altos e baixos escores obtidos do Questionário de Acrofobia. O teste de rastreio visual foi realizado em 30 indivíduos (15 em cada grupo) enquanto ouviam dois tipos diferentes de estímulos auditivos. Na condição volume um som de 900 Hz era apresentado em ambos ouvidos durante 2 segundos seguidos de mais 2 segundos de silêncio. Na condição balanço , o mesmo som era apresentado durante 2 segundos ao ouvido direito seguido por 2 segundos ao ouvido esquerdo. Estímulos auditivos de movimento provocaram maior desconforto em ambos os grupos, mas nos indivíduos com maiores escores de acrofobia estes estímulos foram associados a um pior desempenho no teste visual. Embora muito limitado pela amostra experimental, este estudo sugere que o medo de altura pode estar associado à dependência visual para manutenção do equilíbrio e que poderia piorar o desempenho nos testes visuais devido à competição dos recursos neuro-cognitivos. Implicações experimentais e clínicas destes achados preliminares exigem outras pesquisas.

Using the R-PAS' Aggressive Content Score For the Evaluation of Aggressive Behaviors in Children

The Rorschach Performance Assessment System (R-PAS) was developed in 2011 as analternative to the previous Comprehensive System. The goal was to improve the psychometrics,and particularly the validity, of this assessment method. The norms for children werequestionable in the Comprehensive system (e.g., outdated, low numbers of subjects) and validitystudies for children were sparse. One of the indicators included in the R-PAS system, theaggressive content indicator (AgC), is intended to reflect aggressive behavior, but few studieshave examined the validity of this indicator. This study examined the validity of AgC in asample of 32 children and adolescents receiving services at a residential treatment center.Subjects' AgC scores were analyzed in relation to demographics and diagnosis, as well as ratingsof aggression and conduct problems from the Behavioral Assessment System for Children-2(BASC-2) Parent and Teacher Reports. Correlations between the AgC score and BASC-2aggression and conduct problems scores were not statistically significant. None of thecorrelations between AgC score and a diagnosis of Conduct Disorder, Oppositional DefiantDisorder, Posttraumatic Stress Disorder, or Mood Disorders were significant either. Given thesmall sample size, null results may be a result of power concerns. The lack of significantcorrelations may however, indicate that operational definitions of aggression used in variousforms of measurement reflect different constructs.

Revisión bibliométrica en Síndrome de Asperger: impacto en el ámbito de la psicología y educación

La productividad científica en Síndrome de Asperger (SA) se ha incrementado considerablemente en los últimos años desde distintos campos de la Educación y la Psicología. Incluido dentro de los Trastornos del Espectro del Autismo según el DSM-5, el SA se caracteriza por una alteración en las capacidades de relación social, comunicación y flexibilidad mental. Es objeto del presente estudio ofrecer una revisión del estado actual de la investigación en dicho ámbito e identificar las principales aportaciones científicas. La unidad de análisis se compuso por 1741 documentos extraídos de la Social Science Citation Index y revisados minuciosamente. Los resultados evidenciaron un incremento de la productividad temporal y el interés científico en las áreas de caracterización del SA, comorbilidad y tratamiento. Además, se observó una tendencia a realizar los trabajos en colaboración y un número considerable de autores clasificados como grandes productores por sus niveles de productividad superiores a los diez trabajos. La funcionalidad de esta revisión se encuentra en su valor como material de referencia para futuras líneas de investigación en tanto que abarca la identificación y análisis de los principales campos de estudio en este ámbito.

Guérir avec l'EMDR : preuves et controverses

L'EMDR est une thérapie qui a été développée pour traiter les souvenirs traumatiques, puis proposée pour traiter une variété de troubles psychologiques. Ce texte est le premier à recenser en français les études qui ont évalué l'efficacité de cette forme de thérapie. L'efficacité de l'EMDR est d'abord démontrée à l'aide d'études de cas qui comportent des limites importantes. Les études de cas basées sur un protocole expérimental donnent des résultats plus mitigés. Les études contrôlées qui examinent l'efficacité de l'EMDR sont ensuite décrites en fonction du type de contrôle exercé et du type de trouble traité. L'EMDR est aussi efficace que la thérapie cognitivocomportementale pour traiter le trouble de stress posttraumatique, mais pas pour le traitement de la phobie spécifique ni du trouble panique. De plus, les études montrent de façon répétée que l'absence des mouvements oculaires ne modifie pas l'efficacité de l'EMDR. Une analyse des différences et des similitudes entre l'EMDR et l'approche cognitivo-comportementale est présentée. Les caractéristiques pseudo-scientifiques qui ont marquées le développement et la diffusion de l'EMDR sont aussi abordées.

Guérir avec l'EMDR : preuves et controverses

L'EMDR est une thérapie qui a été développée pour traiter les souvenirs traumatiques, puis proposée pour traiter une variété de troubles psychologiques. Ce texte est le premier à recenser en français les études qui ont évalué l'efficacité de cette forme de thérapie. L'efficacité de l'EMDR est d'abord démontrée à l'aide d'études de cas qui comportent des limites importantes. Les études de cas basées sur un protocole expérimental donnent des résultats plus mitigés. Les études contrôlées qui examinent l'efficacité de l'EMDR sont ensuite décrites en fonction du type de contrôle exercé et du type de trouble traité. L'EMDR est aussi efficace que la thérapie cognitivocomportementale pour traiter le trouble de stress posttraumatique, mais pas pour le traitement de la phobie spécifique ni du trouble panique. De plus, les études montrent de façon répétée que l'absence des mouvements oculaires ne modifie pas l'efficacité de l'EMDR. Une analyse des différences et des similitudes entre l'EMDR et l'approche cognitivo-comportementale est présentée. Les caractéristiques pseudo-scientifiques qui ont marquées le développement et la diffusion de l'EMDR sont aussi abordées.

Modelling the population cost-effectiveness of current and evidence-based optimal treatment for anxiety disorders

Background. The present paper describes a component of a large Population cost-effectiveness study that aimed to identify the averted burden and economic efficiency of current and optimal treatment for the major mental disorders. This paper reports on the findings for the anxiety disorders (panic disorder/agoraphobia, social phobia, generalized anxiety disorder, post-traumatic stress disorder and obsessive-compulsive disorder). Method. Outcome was calculated as averted 'years lived with disability' (YLD), a population summary measure of disability burden. Costs were the direct health care costs in 1997-8 Australian dollars. The cost per YLD averted (efficiency) was calculated for those already in contact with the health system for a mental health problem (current care) and for a hypothetical optimal care package of evidence-based treatment for this same group. Data sources included the Australian National Survey of Mental Health and Well-being and published treatment effects and unit costs. Results. Current coverage was around 40% for most disorders with the exception of social phobia at 21%. Receipt of interventions consistent with evidence-based care ranged from 32% of those in contact with services for social phobia to 64% for post-traumatic stress disorder. The cost of this care was estimated at $400 million, resulting in a cost per YLD averted ranging from $7761 for generalized anxiety disorder to $34 389 for panic/agoraphobia. Under optimal care, costs remained similar but health gains were increased substantially, reducing the cost per YLD to < $20 000 for all disorders. Conclusions. Evidence-based care for anxiety disorders would produce greater population health gain at a similar cost to that of current care, resulting in a substantial increase in the cost-effectiveness of treatment.