Encephale
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Comparative Study
[Prescribing ritalin in combined modality management of hyperactivity with attention deficit].
Attention Deficit Hyperactivity Disorder (ADHD) is a relatively frequent affection that can generate severe problems (school, social, professional) if no take in charge is done. Treatment of ADHD is generally multifactorial; it can associate medical treatment, comportemental and analytical psychotherapies, reeducation of associated disorders (orthophony, psychomotor reeducation) and educative approach. Methylphenidate, considered as therapeutic reference, is a central nervous system stimulant. ⋯ It's very important to instaurate an educative strategy in order to contend inattention and hyperactivity. Regular conservations with parents and child are necessary. The whole american literature shows better efficiency of multimodal treatment of ADHD in child, as opposed to single stimulant treatment.
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During the two last decades, several epidemiological studies have been conducted on bulimia nervosa. According to recent studies, prevalence rates were estimated to be 1%. There are a very few studies on eating behaviour conducted in Arab countries. ⋯ The review of the literature identified at least 5 domains associated to bulimic disorder: parental problems (lower parental contact or separation, disruptive events), vulnerability to obesity, parental psychiatric disorder (alcoholism, depression), sexual or physical abuse and a premorbid psychiatric disorder. With the enormous media coverage and the globalisation of the media, cultural differences are disappearing. In order to estimate the prevalence of bulimia nervosa in the Moroccan population and to identify the risk factors, further epidemiological community-based studies using structured psychiatric interviews are required.
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The interferon alpha stands as a reference both in oncology and virology. But its efficiency is limited by frequent somatic as well as neuropsychic side effects. As a matter of fact, the reduction or the ending of a chemotherapy treatment come chiefly from the psychiatric complications caused by the use of interferon. For about 30% of patients, various psychic disorders are noticed: personality disorders, mood disorders, anxiety states, suicidal tendencies, manic and psychotic symptoms. We thus propose a review which shall be completed by a discussion on wether the interferon is responsible or not of the appearance of the described mental disorders. We shall conclude with a synthesis of the proposed practical management when confronted with such disorders. Psychiatric complications under interferon-Alpha. The appearance of psychiatric complications caused by interferon has been the subject of many publications. They have also raised the question of the toxicity mechanism which is still misunderstood today. This toxicity appears to be dose-dependent with variations depending on the daily dose given, the mode of administration, the combination with other chemotherapy treatments, the concomitance with a cerebral radiotherapy or a medical history of psychiatric disorders. Most of these effects occur after three weeks of treatment but non specific neuropsychic symptoms can be observed earlier. Non specific symptoms. They appear early but are difficult to detect, though they bring together a whole lot of clinical signs: asthenia, irritability, psychomotor slowdown, depressive mood or even a real "subsyndromic" depressive syndrome, anorexia, decline of the libido, concentration and attention problems, dizzy spells and headaches. Some authors have described intense and fluctuating of personality, mixing anxiety, irritability and disorder of drive control. Depression. Depression is the most frequently found psychiatric pathology in studies but the real frequency of clear cases of depressive problems is difficult to determine through lack of serious studies. So the incidence of depressive disorders usually varies from 5 to 15%. The depressive syndrome can settle as soon as the first week treatment, with a peak in the frequency during the first and third months. The seriousness and the incidence of this syndrome seem to be dose-dependent. The gravity of this complication lies in the suicidal risk, a risk all the more dreadful since there is not any identified risk factor. Suicides and suicidal behaviours. Serious complications, because they act directly on the vital prognosis. However fortunately, suicidal behaviours only represent a minority within all the side effects attributed to the interferon-alpha. These actions fit into three main clinical dimensions: complication of a severe depressive syndrome, confusional context and disorder of the impulses control. In practical terms, prevention proves to be difficult without identified predictive factors. Nevertheless, some authors point out the importance of aggravating comorbid disorders like alcoholism or the coinfection by the HIV. Manic syndrome. The appearance of a manic state under a chemotherapy treatment seems to be rare, given that there have been only a dozen cases published around the world. But these observations are interesting as far as both the study of imputability and the understanding of the toxicity mechanisms are concerned. Most of the cases deal with patients without a family or personal history of psychiatric disorders, and whose symptomatology disappears with the end of the treatment, which is an argument in favour of the imputation of the interferon in the appearance of manic disorders. In addition, some authors introduce the notion of tertiary mania: the appearance of an autoimmune hypothyroidism in relation with interferon and leading to athymic elation. Eventually, the appearance of manic problems at the end of the treatment makes it possible to speculate about the physiopathological mechanisms that are at issue. Anxiety disorders. These disorders are not much described: they generally are already existing disorders (like phobic or obsessive compulsive disorders), reactivated or aggravated by the interferon-alpha molecule. Adaptation disorders. It deals with adaptation disorders along with anxious temper coming at the beginning of the treatment. These problems are more concerned with the announcement of the diagnosis and its seriousness than with the toxicity of the interferon-alpha molecule. Psychotic states. There are less papers on the prevalence of psychotic disorders during the treatment, or at the end of it. But they can be found in both viral and malignant pathologies. A large retrospective study has shown ten cases of psychotic disorders and that in the absence of history of psychiatry or of a HIV co-infection. In every case the psychiatric aspect is stopped by the ending of the treatment or by an appropriated treatment. Usually, the few cases of paranoïd delusion described in papers seem to appear between one and three months of treatment, with patients having a history of psychiatric disorders. Aggravation of pre-existing mental disorders. Numerous authors have reported the recurrence of addictive behaviours (alcohol or other psychoactive matter) by weaned patients. Imputability to interferon-alpha in psychiatric disorders. It is difficult to draw the relationship between the chemotherapy with the interferon-alpha treatment and neuropsychiatric complications because there is a lack in specific studies. Nevertheless, it seems to be causal relations between the prescription of interferon and the appearance of psychic disorders. As a matter of fact, even if there is neither predictive criterion nor diagnosis of clinical type (set apart a dose effect), it is clear that there are diagnostic criteria of chronological kind: delay of appearance and disappearance of side effects compatible with the kinetics of the molecule and test of positive reintroduction. The imputability is thus most likely towards, given the reported clinical observations and signs of direct cerebral toxicity described for interferon: induction of neurophysiological changes among healthy volunteers, reversible EEG impairments the second week of treatment, direct vascular and neurological toxicity. Eventually, authors have shown that the psychiatric morbidity could be more important among patients under treatment than in a control group. In conclusion, the imputability of interferon appears to be very likely, more particularly in the appearance of mood disorders, mainly depressive ones, of manic syndromes and of certain psychotic episodes. ⋯ The appearance of neuropsychiatric side effects during a chemotherapy using the interferon-alpha molecule is a frequent complication, the consequences of which can prove tragic: involvement of the vital prognosis, family and professional relation disturbances, compliance problems, risks of psychiatric morbidity at short and middle terms.... In spite of the absence of rigorous controlled studies, the imputability to the interferon of the appearance of psychological disorders appears very likely. So the role of the psychiatrist seems to be determining in the follow-up care of these patients who must be considered at high risk to develop a psychiatric pathology. The agreement to bear medical costs has to be made in narrow collaboration with clinical practitioners and must be part of a clinical continuity, from the pre-therapeutical evaluation to the remote follow-up care. Finally, it seems important to implement controlled studies, resting on a great diagnostic and methodological rigour, in order to clarify the toxicity mechanisms of interferon and to optimise the agreement to bear medical cost for the patients.
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It is recommended to reduce by one half the dosages of tricyclic antidepressants for patients over 65 years of age, in order to avert the occurrence of side-effects. The question we studied was: is it rightful to prescribe tricyclic antidepressants at half-dose to hospitalized elderly people? It is important, for the following reasons, to specify the rules of prescription of tricyclics in elderly patients: 1) The elderly population is on the increase; 2) There is a high prevalence of depression in elderly patients; 3) Depression exposes the elderly person to an increased risk of suicide; 4) Depression influences the prognosis of associated organic disorders 5) Recourse to tricyclic antidepressants is often necessary within this population group because of treatment resistant forms of depression which impose the use of different families of antidepressants and thus resort to tricyclics despite their lower tolerance. ⋯ In our study, patients were hospitalized and so benefited from closer observation than one can expect in outpatients. In this particular context, the dosages used are close to those advocated for the general population. With the elderly subject, the systematic prescription of half-dose tricyclics runs the risk of infratherapeutic dosage. It is thus preferable to resort to blood level dosage and to look for a maximum dose tolerance before concluding ineffectuality. This allows one to monitor whether the blood levels obtained are included in the therapeutic range; to avoid toxic doses and to check weak compliance in the elderly patient. Our findings do not oppose the use, for the elderly hospitalized depressive, of doses of imipraminics close to those of a young subject. To confirm these results it would be desirable to carry out o prospective study, including a systematised evaluation of adverse effects and a comparison of clinical effectiveness for parallel groups of elderly patients receiving different doses of imipraminic antidepressants.
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In humans, some psychotropic agents (alcohol, drugs, illicit substances) have been suggested to play a role in the occurrence of major behavioural disorders, mainly due to the suppression of psychomotor inhibition. Behavioural disinhibition is a physiological mechanism which allows humans to behave appropriately according to a given environmental situation. The behavioural disinhibition induced by either therapeutic dosage or misuse involves the loss of restraint over certain types of social behaviour and may increase the risk of auto or hetero-aggression and acting out. ⋯ Co-occurrence of substance abuse and other mental disorders is also very frequent. Multiple substance abuse should be avoided, because potential interactions between two or more drugs are more likely to cause violent behaviour. In the future, a specific treatment of these deleterious phenomena will have to be considered in order to reduce drug-induced iatrogenic behavioural disorders.