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ABSTRACT: Short periods of hospitalization for first episode psychosis are generally considered preferable, although research evidence is inconsistent. Clinical and social determinants of length of hospital stay (LOS) were examined in 121 admissions for first episode psychosis using standardized assessment measures, in five clinical units of a French psychiatric hospital. LOS varied from 4 to 371 days, and considerably between units. LOS was examined both as a continuous variable and dichotomized comparing short (<31 days) to long (>31 days) stays. In the multivariate analyses, change in antipsychotic medication and the unit head psychiatrist's preference for longer stays were associated with both measures of LOS (for dichotomized LOS: OR=7.01; 95% CI: 1.9-26.2; p=0.004 and OR=6.4; 95% CI: 1.4-30.7; p=0.007, respectively), indicating effects on LOS per SE and not only with respect to a threshold duration of stay. Of the clinical factors at admission the only borderline significant association found was between the severity of negative symptoms and LOS on a continuum (beta(SE)=0.32 (0.17); p=0.05). Despite some justification for longer stays with respect to discharge conditions, the persisting association with the head psychiatrist's preference for long or short stays strongly suggest a need for greater evidence-based rationalization of practice.
Psychiatry research. 01/2013;
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ABSTRACT: Frequent attenders in family practice are known to have higher rates of mental disorder. However little is known about specific psychiatric disorders and whether this behavior extends to specialist services, in an open access fee-for-service health care system.
1060 patients from 46 family practices completed the Patient Health Questionnaire and the Client Service Receipt Inventory. During the consultation, family practitioners blind to the questionnaire responses rated the severity of mental health and physical disorders. The 10% of patients with the highest number of 6-month consultations in six age and sex stratified groups were defined as frequent attenders.
After adjustments for sociodemographic variables, physical health and other psychiatric diagnoses, patients with a somatoform disorder were more likely to be frequent attenders, with an odds ratio of 2.3 (95% CI: 1.3-3.8, p=.002).
When adjusting for confounders, among the four psychiatric diagnoses investigated only somatoform disorders remain significantly associated with frequent attendance. Physical health and chronic disease were no longer associated with frequent attendance which does not support the hypothesis that in an open access fee-for-service system, patients will consult for a wider range of health problems. Greater investigation into unexplained somatic symptoms could help reduce the frequency of attendance in both primary and secondary care, as this behaviour appears to be a general health-seeking drive than extends beyond family practice.
Journal of psychosomatic research 06/2012; 72(6):413-8. · 2.91 Impact Factor
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ABSTRACT: In the elderly, little attention has been paid to anxiety both on a symptom dimension and as a disorder, as an independent risk factor for the incidence of activity limitations.
In a community-dwelling cohort of 1581 persons aged 65+, the association between trait anxiety symptoms (Spielberger Trait, third highest tertile) and baseline DSM-IV anxiety disorder, and 7-year incident activity limitations was determined using mixed logistic regression models. Repeated measures of activity limitations included, by increased severity level: social restriction (neighbourhood and house confined), mobility (Rosow and Breslau scale) and limitations in instrumental activities of daily living (IADL).
Of the sample, 14.2% had an anxiety disorder at baseline. Adjusting for baseline socio-demographic and health variables, depression (past and current), antidepressant and anxiolytic drugs, baseline anxiety disorder was associated with an increased risk of incident IADL limitation (OR (95% CI): 1.84 (1.01-3.39), p=0.048) and trait anxiety with increased incidence of social restriction (OR (95% CI): 2.41 (1.42-4.09), p=0.001). Associations remained significant in participants free of depressive symptoms at baseline (OR (95% CI): 2.92 (1.41-6.05), p=0.004; OR (95% CI): 3.21 (1.31-7.89), p=0.011, respectively).
Activity limitations were self-reported and may have been over-reported in participants with anxiety.
Both trait anxiety symptomatology and anxiety disorder were independently associated with increased incidence of activity limitations with a gradient of severity: trait anxiety associated with incident social restriction and anxiety disorder with more severe IADL limitations, suggesting that anxiety is a predictor of activity limitations in the elderly independently of depression comorbidity.
Journal of affective disorders 05/2012; 141(2-3):276-85. · 3.76 Impact Factor
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ABSTRACT: A history of trauma is associated with poor mental and physical health, but the specific impact of posttraumatic stress disorder (PTSD) symptoms on physical health using objective indicators of health status has rarely been evaluated in elderly civilians. This study investigates the long-term consequences of a lifetime exposure to trauma on health in a French elderly general population.
Data from this retrospective study were derived from a longitudinal study (the Enquête de Santé Psychologique-Risques, Incidence et Traitement [ESPRIT]) of community-dwelling participants. Psychiatric health, medical history, and clinical examination (ICD-10 criteria) were assessed in 1,662 subjects (mean [SD] age = 72.5 [5.2] years). Lifetime traumatic exposure, PTSD, and psychiatric diagnoses were obtained using the Watson PTSD Inventory and the Mini-International Neuropsychiatric Interview. The outcome measures used were the Mini-International Neuropsychiatric Interview, Center for Epidemiologic Studies Depression Scale, Mini-Mental State Examination, and measures of physical health.
We observed an increase in the number and severity of health-related outcomes between groups, with nontraumatized subjects having the lowest risk and those with trauma leading to recurrent reexperiencing of events (nonresilient subjects) having the highest risk. Traumatized persons who did not report reexperiencing symptoms (resilient subjects) showed better current mental health than traumatized subjects who did and nontraumatized subjects. Nonresilient subjects were more likely to have current depressive symptoms (P = .003), current major depression (P < .0001), current anxiety disorder (P = .032), and psychiatric comorbidity (P = .002) than nontraumatized subjects. Resilient subjects differed from nontraumatized subjects in having significantly less current suicidal ideation (P = .054) and psychiatric comorbidity (P = .035). Both groups of traumatized subjects showed a higher rate of cardio-ischemic diseases, notably current angina pectoris (multivariate, adjusted OR = 2.27; 95% CI, 1.31-3.91; and OR = 2.34; 95% CI, 1.22-4.49; for resilient and nonresilient groups, respectively). Traumatized persons, specifically those nonresilient, showed a higher waist-hip ratio, higher triglyceride levels, and a greater frequency of hypertension.
Our findings suggest that trauma could be associated with cardio-ischemic diseases independently of PTSD symptoms expression. However, the presence of these symptoms appears associated with additional metabolic risk factors.
The Journal of Clinical Psychiatry 07/2011; 72(7):929-35. · 5.80 Impact Factor
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ABSTRACT: Doctor-shopping may reflect unmet patient needs and places a significant burden on health resources; however little is known about its underlying reasons and how it relates to mental illness and its recognition in an open access fee-for-service setting.
In 2003-2004, consecutive patients of 46 French general practitioners (GPs), completed in the waiting room the self-report Patient Health Questionnaire and reported on service use in the past six months. During the consultation, GPs rated the severity of any physical and psychiatric disorders.
Of 1079 patients, those rated by the GP as having a common mental disorder were significantly more likely to be doctor-shoppers but only if visiting another GP because of dissatisfaction with previous care (OR=2.3, 95% CI: 1.4-3.7). A similar trend is observed for those identified as having a common mental disorder by the Patient Health Questionnaire. Among patients with a common mental disorder, 'dissatisfied' doctor-shoppers were significantly more likely to be recognised as cases by the GP, adjusting for covariates (OR=6, 95% CI: 2.1-17.2). This was not the case for those doctor-shopping for practical reasons alone.
Doctor-shopping behaviour is associated with higher rates of mental illness and, among cases, an increased likelihood of recognition by the GP, only however for doctor-shoppers dissatisfied with previous care. This suggests a benefit to letting patients choose their GP as is the case in France and change if not satisfied.
Journal of affective disorders 01/2011; 131(1-3):428-32. · 3.76 Impact Factor
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ABSTRACT: Cortisol hypersecretion is characteristic of acute clinical depression, but little is known in fully recovered, non-treated elderly persons with a lifetime history of depression. This study was designed to examine patterns of diurnal cycle of cortisol in an elderly cohort without current depression or treatment for depression according to whether the person has or has not experienced a previous episode of depression or co-morbid depression with anxiety.
Cortisol secretion was evaluated in 162 community-dwelling elderly on a stressful and a non-stressful day (basal level). Past depression and anxiety disorders were assessed using a standardized psychiatric examination based on DSM-IV criteria (the Mini International Neuropsychiatric Interview).
Antidepressant-free persons with a history of non-co-morbid major depression (6.8% of the sample) showed basal cortisol hypersecretion compared to those with depression and anxiety (8.6%) or controls. Several hours after exposure to a stressful situation, controls showed a sustained increase in cortisol secretion, which was not observed in persons with a history of depression. Persons with a history of depression with anxiety showed a similar cortisol secretion at baseline to controls but a heightened response to stressful situation; a pattern comparable to that observed in subjects with pure anxiety disorders (16.7%).
An abnormal HPA response persists even after effective treatment for depression. A history of co-morbid depression and anxiety gives rise to changes characteristic of anxiety alone. Our findings suggest that cortisol abnormalities may be trait markers for vulnerability to depression and for the differentiation of depression and depression with co-morbid anxiety.
Journal of psychiatric research 01/2009; 43(8):777-83. · 3.72 Impact Factor
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ABSTRACT: Cortisol secretion in elderly persons with anxiety disorders exposed to common stressful situations has not been evaluated.
Salivary-free cortisol levels were evaluated at 8, 15, and 22 h, in 201 elderly subjects during stressful and non-stressful days. Psychiatric symptomatology was assessed by a standardized psychiatric examination (MINI).
Elderly subjects without psychiatric disorder showed a sustained increase in cortisol secretion several hours after the exposure to a stressful situation. In comparison, subjects with anxiety disorders showed a greater increase in cortisol secretion in the stressful situation, with lowered recuperation capacity. This effect was dose-dependent as a function of anxiety co-morbidity. Persons reporting lifetime major trauma with intrusions exhibited lowered continuous basal cortisol associated with efficient recuperation capacity. Independently of psychopathology, women appeared more reactive to stressful environmental conditions.
Exclusion of institutionalized persons and benzodiazepine users may have led to sampling of less severe anxiety symptoms.
Dysregulation of the hypothalamic-pituitary-adrenal axis was observed in elderly persons with anxiety disorders experiencing environmental stress. A common pattern of up-regulated diurnal cortisol secretion was observed in anxious subjects with lifetime and current anxiety disorder irrespective of sub-type (generalized anxiety, phobias) suggesting a stable trait and a common "core" across disorders. Elderly persons who had experienced trauma with subsequent intrusions showed a distinct pattern with down-regulated activity.
Journal of Affective Disorders 04/2008; 106(3):307-13. · 3.52 Impact Factor
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Marie-Laure Ancelin,
Sylvaine Artero,
Isabelle Beluche,
Alain Besset,
Jean-Philippe Boulenger,
Isabelle Carrière,
Isabelle Chaudieu,
Philippe Courtet,
Anne-Marie Dupuy,
Isabelle Jaussent,
Alain Malafosse, Joanna Norton,
Guilhem De Roquefeuil,
Joanne Ryan,
Jacqueline Scali,
Jacques Touchon,
Karen Ritchie
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ABSTRACT: Introduction – Les troubles neuro-psychiatriques constituent une des principales causes de morbidité et d'incapacités liées au vieillissement. Le projet Esprit a pour but d'étudier l'étiologie complexe des troubles psychiatriques chez le sujet âgé pour une meilleure prise en charge. Objectifs – 1) déterminer la prévalence (en actuel et au cours de la vie) et l'incidence des troubles psychiatriques en population générale âgée ; 2) évaluer les facteurs de risque de ces troubles, leur poids relatif et leurs interactions ; 3) étudier l'hétérogénéité clinique ; 4) estimer les probabilités de transition vers un état subsyndromique ou vers la maladie ; 5) construire des modèles étiologiques prédictifs. Méthode - L'étude longitudinale Esprit porte sur 1863 personnes non institutionnalisées de 65 ans et plus, recrutées par tirage au sort sur listes électorales. Depuis l'inclusion en 1999, ces sujets ont déjà été revus deux fois à 2 ans d'intervalle. Ils ont été soumis à différents questionnaires (socio-démographiques, antécédents médicaux, incapacités, expositions, survenue d'événements traumatiques), examens neurologiques ainsi qu'à un enregistrement polysomnographique à domicile. Une DNAthèque et une sérothèque ont été constituées et certains paramètres biochimiques dosés (lipides, cortisol...). La pathologie psychiatrique a été évaluée au cours d'un entretien structuré, le MINI (fondé sur les critères diagnostiques du DSM IV), la symptomatologie dépressive par la CES-D et le niveau d'anxiété via l'échelle de Spielberger. D'autres questionnaires ont été utilisés afin d'évaluer la personnalité colérique (Spielberger-anger), l'impulsivité (Barratt), l'agressivité (Buss-Durkee) et la survenue de traumatismes dans l'enfance. Résultats - Les troubles psychiatriques sont fréquents chez les sujets âgés et au cours de leur vie ils ont touché près d'une personne sur deux. La prévalence des troubles actuels est élevée notamment pour les phobies (10,7%), l'anxiété généralisée (4,6%) et les idéations suicidaires (9,8%). Pour la plupart des troubles psychiatriques, les prévalences sont près de 2 fois plus élevées chez la femme. Nos premières analyses montrent l'importance de certains facteurs de risque jusque-là peu explorés, facteurs environnementaux comme les événements de vie traumatiques ou facteurs biologiques comme le statut hormonal au cours de la vie reproductive ou le rôle des systèmes de régulation du stress (e.g. activité secrétoire de l'axe HPA). L'insomnie est également un facteur de risque de troubles dépressifs ou anxieux. Conclusion - L'étude longitudinale Esprit constitue une base de données relativement exhaustive sur les troubles psychiatriques en population générale française âgée. L'approche multifactorielle (prenant en compte facteurs environnementaux, psychosociaux, biologiques, génétiques, pharmacologiques ou cliniques et leurs interactions) devrait permettre la construction de modèles étiologiques complexes susceptibles d'être validés au sein d'études cliniques et ouvrir de nouvelles perspectives dans le champ de la santé mentale du sujet âgé.
L Encéphale 10/2006; · 0.63 Impact Factor
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ABSTRACT: Theory-based approaches are advocated to improve our understanding of prescription behaviour. This study is an application of the theory of planned behaviour (TPB) with additional variables. It was designed to assess which variables were associated with the intention to prescribe hormone therapy (HT). In addition, variations in the measures across medical specialities (GPs and gynaecologists) and across countries (France and Quebec) were investigated.
A survey among 2,000 doctors from France and 1,044 doctors from Quebec was conducted. Data were collected by means of a self-administered questionnaire. A clinical vignette was used to elicit doctors' opinions. The following TPB variables were assessed: attitude, subjective norm, perceived behavioural control, attitudinal beliefs, normative beliefs and power of control beliefs. Additional variables (role belief, moral norm and practice pattern-related factors) were also assessed. A stepwise logistic regression was used to assess which variables were associated with the intention to prescribe HT. GPs and gynaecologists were compared to each other within countries and the two countries were compared within the specialties.
Overall, 1,085 doctors from France returned their questionnaire and 516 doctors from Quebec (response rate = 54% and 49%, respectively). In the overall regression model, power of control beliefs, moral norm and role belief were significantly associated with intention (all at p < 0.0001). The models by specialty and country were: for GPs in Quebec, power of control beliefs (p < 0.0001), moral norm (p < 0.01) and cytology and hormonal dosage (both at p < 0.05); for GPs in France, power of control beliefs and role belief (both at p < 0.0001) and perception of behavioural control (p < 0.05) and cessation of menses (p < 0.01); for gynaecologists in Quebec, moral norm and power of control beliefs (both at p = 0.01); and for gynaecologists in France, power of control beliefs (p < 0.0001), and moral norm, role belief and lipid profile (all at p < 0.05).
In both countries, compared with GPs, intention to prescribe HT was higher for gynaecologists. Psychosocial determinants of doctors' intention to prescribe HT varied according to the specialty and the country thus, suggesting an influence of contextual factors on these determinants.
BMC Medical Informatics and Decision Making 02/2005; 5:31. · 1.48 Impact Factor
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ABSTRACT: The objectives of this study were to establish provisional psychiatric diagnoses using the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PHQ) and to describe family practitioner (FP) case recognition, survey-day prescription of anxiolytic and antidepressant medications and overall consumption rates (medication use).
Between October 2003 and April 2004, 1151 consecutive patients (> or = 18 years old) of 46 FPs practicing in and around the city of Montpellier, France, completed the PHQ. During the consultation, FPs rated the severity of any psychiatric disorder.
PHQ prevalence rates (FP case recognition percentages are given in parentheses) were as follows: 10.9% (36%) for probable alcohol abuse/dependence; 11.3% (40%) for somatoform disorder; 9.1% (75%) for major depression; 7.4% (42%) for other depressive disorders; 7.5% (69%) for panic disorder; and 6% (69%) for other anxiety disorders. The prescription rate for all study patients was 11.3%, ranging from 6.2% for those without a PHQ disorder to 30.3% for those with a PHQ diagnosis of anxiety or depression to 48.2% for FP-recognized cases. The estimated survey-day consumption rate for these medications was 19.4%.
High consumption of anxiolytic and antidepressant medications in France is confirmed but not explained either by higher prevalence rates of psychiatric disorders as compared with other locations or by unusually high survey-day prescription rates. A possible explanation would be the organization of the French health care system, which has multiple sources for obtaining medication.
General Hospital Psychiatry 29(4):285-93. · 2.74 Impact Factor
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ABSTRACT: Our objective was to compare physician characteristics associated with high-frequency hormone therapy (HT) prescription between gynecologists and general practitioners (GPs) within and between France and Quebec, Canada.
A self-administered mail survey was sent to a representative sample of 2,000 physicians in France and 1,000 physicians in Quebec. High-frequency prescribers were those who reported prescribing HT to more than 70% of their postmenopausal patients. The following characteristics were included in the analysis: country, specialty, age, gender, characteristics of the practice (solo or group, private or public, rural or urban, number of patients seen daily, duration of practice, percentage of women 45 years or older), teaching or research activities, participation in education course on HT, and practice patterns relating to menopausal women (having patient education materials available, providing materials to patients, and discussing the possibility of HT).
The analysis covered 974 physicians in France (389 GPs and 585 gynecologists) and 452 physicians in Quebec, Canada (318 GPs and 134 gynecologists). Despite differences in health care, in both countries gynecologists were more likely to be high-frequency prescribers than were GPs, although this difference was smaller in Quebec. Canadian physicians were more likely to prescribe HT. The difference between countries was greatest among GPs. Except for nationality and practice patterns designed to provide women with information, none of the physician characteristics was associated with high-frequency prescription among GPs. Among gynecologists, only the number of patients per day and the provision of information were associated with high-frequency prescription.
Notwithstanding a common language, differences in the prescription pattern of HT between countries were greatest at the level of primary care than secondary care. In both countries, specialists were more likely to prescribe HT than were GPs. Implementation of clinical practice guidelines to set baseline standards in the field of menopausal health remains a challenge but will need to take into account cultural characteristics as well as level of medical care.
Menopause 11(1):89-97. · 3.76 Impact Factor
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ABSTRACT: INTRODUCTION: Psychiatric disorders, mainly depression and anxiety, are frequently encountered in primary care and are a major cause of distress and disability. Nearly half of cases go unnoticed and among those that are recognised, many do not receive adequate treatment. In France, there is limited research concerning the prevalence, detection and management of these conditions in primary care. OBJECTIVES: To estimate the prevalence of psychiatric disorders, overall and for the main psychiatric diagnostic categories, encountered in primary care; to describe general practitioners' (GPs') case identification rate; to examine psychotropic medication prescription according to diagnosis, in a regionally representative sample of GP attenders. METHODS: GP practicing standard general practice in an urban area of the city of Montpellier and a nearby semi-rural region were recruited to participate. The response rate was 32.8% (n=41). Five additional GP almost exclusively offering homeopathy and acupuncture were recruited nonrandomly for convenience purposes. In each GP surgery, consecutive patients entering the waiting room were invited by a research assistant to participate until 25 patients per GP were recruited. Each participant completed self-report questionnaires in the waiting time, including the patient health questionnaire (PHQ), which yields provisional DSM-IV diagnoses. The GP completed a brief questionnaire during the consultation, giving his/her rating of the severity of any psychiatric disorder present and action taken. RESULTS: The patient response rate was 89.8%. In all, 14.9% of patients reached DSM-IV criteria for major depression or anxiety disorder on the PHQ (9.1% for major depression, 7.5% for panic disorder; 6% for other anxiety disorders). For the subthreshold categories, 7.4% met criteria for other depressive disorders, 11.8% for somatoform disorders and 10.9% for probable alcohol abuse or dependence. 66.3% of patients with DSM-IV diagnoses of major depression or anxiety disorder were identified by the GP as having a psychiatric disorder. The identification rate was 51% for all depressive disorders, anxiety and somatoform disorders. Of patients receiving a prescription for anxiolytic or antidepressant medication on the survey day, 80% were classified as cases of psychiatric disorder by the GP. Only 48.8% met criteria for major depression or anxiety disorder on the PHQ. CONCLUSION: This study highlights the frequency of psychiatric disorders in a regional study of French general practice. Overall, prevalence rates were similar to those found elsewhere, except for probable alcohol abuse and dependence, which was considerably higher than in the USA PHQ validation study. As in other countries, GP identified roughly half of psychiatric cases. Furthermore, half of patients treated by anxiolytic or antidepressant medication did not meet the diagnostic criteria on the survey day for which these medications have mainly shown their efficacy. This confirms the French paradox of one of the highest psychotropic medication consumption rates in Europe despite many cases of depression remaining untreated. The PHQ could be a rapid and acceptable diagnostic aid tool for French general practice but first needs to be validated against the diagnosis of mental health professionals in this setting.
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ABSTRACT: Introduction: In France, general practice is playing an increasing role in the management of common mental disorders. This is due to a variety of factors, among which the way general practice and specialised mental health services have evolved over time. Methods: A description of the status quo in France, with a comparison between France, the UK and the Netherlands. A review of reasons for the present position. Results: the general practitioner (GP) is often the only medical carer to be contated in cases of psychological distress and over 80% of psychotropic medications are prescribed in this setting. Although most common forms of mental disorder can be managed at the primary care level, GPs need to be able to refer patients rapidly to specialised mental health services. Yet there are delays for consultations with both private and public psychiatrists along with difficulties in finding beds for full-time hospitalisation. The situation is predicted to get worse with the reduction in the number of psychiatrists and GPs forecasted for the coming years. ‘Psychiatric sectorisation' has led to a substantial development of community mental health care services, yet this has not compensated fully for the reduction in full-time hospital beds. Furthermore, community mental health care services remain relatively isolated from other community health services with very limited exchanges with general practice. Conclusions: GPs report an urgent need for training in mental health. Along with improving their ability to accurately detect and treat mental disorders, it is crucial also to improve communication between GPs and psychiatrists and increase shared case-management. Structural changes are also necessary to ensure a quicker and easier access to specialised mental health care services.
The European journal of psychiatry.
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ABSTRACT: BACKGROUND: Cortisol hypersecretion is characteristic of acute clinical depression, but little is known in fully recovered, non-treated elderly persons with a lifetime history of depression. This study was designed to examine patterns of diurnal cycle of cortisol in an elderly cohort without current depression or treatment for depression according to whether the person has or has not experienced a previous episode of depression or co-morbid depression with anxiety. METHODS: Cortisol secretion was evaluated in 162 community-dwelling elderly on a stressful and a non-stressful day (basal level). Past depression and anxiety disorders were assessed using a standardized psychiatric examination based on DSM-IV criteria (the Mini International Neuropsychiatric Interview). RESULTS: Antidepressant-free persons with a history of non-co-morbid major depression (6.8% of the sample) showed basal cortisol hypersecretion compared to those with depression and anxiety (8.6%) or controls. Several hours after exposure to a stressful situation, controls showed a sustained increase in cortisol secretion, which was not observed in persons with a history of depression. Persons with a history of depression with anxiety showed a similar cortisol secretion at baseline to controls but a heightened response to stressful situation; a pattern comparable to that observed in subjects with pure anxiety disorders (16.7%). CONCLUSION: An abnormal HPA response persists even after effective treatment for depression. A history of co-morbid depression and anxiety gives rise to changes characteristic of anxiety alone. Our findings suggest that cortisol abnormalities may be trait markers for vulnerability to depression and for the differentiation of depression and depression with co-morbid anxiety.
