‘Munchausen's syndrome by proxy’ characteristically describes women alleged to have fabricated or induced illnesses in children under their care, purportedly to attract attention. Where conclusive evidence exists the condition's aetiology remains speculative, where such evidence is lacking diagnosis hinges upon denial of wrong-doing (conduct also compatible with innocence). How might investigators obtain objective evidence of guilt or innocence? Here, we examine the case of a woman convicted of poisoning a child. She served a prison sentence but continues to profess her innocence. Using a modified fMRI protocol (previously published in 2001) we scanned the subject while she affirmed her account of events and that of her accusers. We hypothesized that she would exhibit longer response times in association with greater activation of ventrolateral prefrontal and anterior cingulate cortices when endorsing those statements she believed to be false (i.e., when she ‘lied’). The subject was scanned 4 times at 3 Tesla. Results revealed significantly longer response times and relatively greater activation of ventrolateral prefrontal and anterior cingulate cortices when she endorsed her accusers' version of events. Hence, while we have not ‘proven’ that this subject is innocent, we demonstrate that her behavioural and functional anatomical parameters behave as if she were.

The interest of educational programs concerning crisis intervention in the managament violent behaviour remains a challenge for emergencies departments. A preliminary study done in Geneva (Caihol et al., 2007) showed a significant reduction in violent behavior during 5 months in emergency psychiatry, after the introduction of a specific educational program. The aim of this study was to evaluate the impact of a specific staff educational crisis intervention on managing violent behaviour after the end of the 5 month planned study. Thus, two year after the initial study, we re-evaluated the impact of the educational program by another project focusing on the management of agitation in emergency. We included all patients admitted in emergency during a same 5-month period (N= around 2000 patients), in order to determine if the promising initial published data could be extended on long term? The percentage of patients with violent behaviour will be compared with the data of the previous study, before and after educational programs. The results will be correlated with different factors which could influence the data: sociodemographic factors, diagnosis, staff characteristics.

Cailhol L, Allen M, Moncany AH, Cicotti A, Virgillito S, Barbe RP, Lazignac C, Damsa C. Violent behavior of patients admitted in emergency following drug suicidal attempt: a specific staff educational crisis intervention. Gen Hosp Psychiatry 2007;29: 42-44.

Factors influencing outcomes of depression in clinical practice, especially health-related quality of life (HRQoL), are poorly understood. The Factors Influencing Depression Endpoints Research (FINDER) study is a European prospective, observational study designed to estimate the HRQoL of adults with a clinically diagnosed depressive episode at baseline, and 3 and 6 months after commencing antidepressant medication. We report here the study design and baseline patient characteristics.

HRQoL was assessed by the 36-item Short-Form Health Survey (SF-36) and European Quality of Life-5 Dimensions (EQ-5D). Patient ratings on Hospital Anxiety and Depression Scale (HADS) and pain Visual Analogue Scale (VAS) were also obtained. Results (n = 3468) showed that SF-36 mental component summary (mean 22.2) was more than two SDs below general population norms (mean 50.0) and one SD below clinical depression norms (mean 34.8); the physical component summary (mean 46.1) was similar to general population (mean 50.0) and clinical depression norms (mean 45.0). Mean EQ-5D scores were also lower than general population norms. Mean HADS-Depression and -Anxiety subscores were 12.3 and 13.0, respectively. Fifty-six percent of patients reported an overall pain VAS score of at least 30 mm and 70% of these patients had no physical explanation for their pain.

Further investigation into factors associated with HRQoL in depression after treatment initiation is warranted.

Deficiencies in the delivery of community mental health services in developed countries have been adduced as the reason for the large number of mentally ill in prisons. The large number of mentally ill persons found in prisons in many countries that have different mental health systems, however, could be an indication that system delivery may not be the only reason for this phenomenon. It may be that the “balloon theory” whereby it has been sustained that as mental hospitals beds decrease, prison beds increase and vice-versa will have to be reconsidered. In this presentation, data indicating the flow of mental patients into prisons in several countries will be reviewed. This type of data, however, tends to be statistical aggregates that will need to be contrasted with theoretical considerations and case reviews of mentally ill inmates in order to demonstrate that a relationship between mental illness and crime does exist at different levels of interaction. Such a relationship may be a more fundamental reason for mentally ill persons ending up in prisons than systemic service delivery concerns.

It is unknown whether a ‘jumping to conclusions’ (JTC) data-gathering bias is apparent in specific delusion sub-types. A group with persecutory delusions is compared with a sample of non-clinical controls on a probabilistic reasoning task. Results suggest JTC is apparent in individuals with the persecutory sub-type of delusions.

Antidepressant prescribing patterns and factors influencing the choice of antidepressant for the treatment of depression were examined in the Factors Influencing Depression Endpoints Research (FINDER) study, a prospective, observational study in 12 European countries of 3468 adults about to start antidepressant medication for their first episode of depression or a new episode of recurrent depression. Selective serotonin reuptake inhibitors (SSRIs) were the most commonly prescribed antidepressant (63.3% patients), followed by serotonin-norepinephrine reuptake inhibitors (SNRIs, 13.6%), but there was considerable variation across countries. Notably, tricyclic and tetracyclic antidepressants (TCAs) were prescribed for 26.5% patients in Germany. The choice of the antidepressant prescribed was strongly influenced by the previous use of antidepressants, which was significantly associated with the prescription of a SSRI (OR 0.64; 95% CI 0.54, 0.76), a SNRI (OR 1.49; 95% CI 1.18, 1.88) or a combination of antidepressants (OR 2.78; 95% CI 1.96, 3.96). Physician factors (age, gender, speciality) and patient factors (severity of depression, age, education, smoking, number of current physical conditions and functional syndromes) were associated with initial antidepressant choice in some models. In conclusion, the prescribing of antidepressants varies by country, and the type of antidepressant chosen is influenced by physician- as well as patient-related factors.

Severe mental illnesses such as schizophrenia and mood disorders have a major impact on public health. Disease prevalence and phenotypic expression are the products of environment and gene interactions. However, our incomplete understanding of their aetiology and pathophysiology thwarts primary prevention and early diagnosis and limits the effective application of currently available treatments as well as the development of novel therapeutic approaches. Neuroimaging can provide detailed in vivo information about the biological mechanisms underpinning the relationship between genetic variation and clinical phenotypes or response to treatment. However, the biological complexity of severe mental illness results from unknown or unpredictable interactions between multiple genetic and environmental factors, many of which have only been partially identified. We propose that the use of epidemiological principles to neuroimaging research is a necessary next step in psychiatric research. Because of the complexity of mental disorders and the multiple risk factors involved only the use of large epidemiologically defined samples will allow us to study the broader spectrum of psychopathology, including sub-threshold presentation and explore pathophysiological processes and the functional impact of genetic and non-genetic factors on the onset and persistence of psychopathology.

Rett syndrome is a genetically linked form of autism spectrum disorder (ASD) accompanied by intellectual disability (ID). The disorder is also characterized by cardiorespiratory dysregulation, disturbance in muscle tone, reduced brain growth and scoliosis. Over 300 studies have been published on the disorder, most of which has focused on identification of causative factors, which appears to be the result of mutations of gene MECP2. Rarely have adults with Rett syndrome been studied, and behavioral characteristics in these individuals are largely unknown. The present study aimed to extend what little is known about behavioral characteristics of Rett syndrome in adults, with particular emphasis on social, communicative, and adaptive behavior. Rett syndrome adults with severe ID were matched to autistic adults with ID and ID only controls. The implications of these data for more fully describing and diagnosing the condition in adults are discussed.

Quality of care in emergency psychiatry is correlated with rapid diagnose, application of validated clinical guidelines for emergencies and focus on therapeutic alliance. We propose a specific diagnosis and intervention program for the management of patients with suicidal thoughts and behaviour. The specificity of this program involves the evaluation of the level of suicidal risk, the lethality of the suicidal thoughts and the timeframe planned before the occurrence of the suicidal behavioural. Risk level depends on age, gender, substance use, etc. Evaluation of these items and intervention programs concerning these issues will be discussed in a real life emergency department environment.

In a period of growing interest in expert's guidelines on the management of psychiatric emergencies, there are few empirically validated data in the emergency settings. Based on this observation, we developed an International Research Network in Emergency Psychiatry, by connecting several European Centers (Switzerland, France, Belgium, Romania) and United States. The aims of our collaboration are to evaluate and ameliorate the quality of care, to develop European clinical guidelines, to provide a structured educational program for trainees and students and to conduct international studies focused on Emergency Psychiatry. Clinical research and the use of some standardized tools appear to be successful in improving the quality of care as an ‘effective medication’ administered to the emergency staff [Damsa et al., 2006]. Moreover, introducing new psychotherapeutic models in emergency psychiatry, could avoid unnecessary hospitalizations, by increasing the compliance of the patients to ambulatory follow-up care, and might have a positive economic impact on the health systems. In conclusion, we hope to develop new links with other emergency psychiatric teams, through the Emergency Psychiatry Section from the AEP.

Damsa C, Ikelheimer D, Adam E, Maris S, Andreoli A, Lazignac C, Allen MH. Heisenberg in the ER: observation appears to reduce involuntary intramuscular injections in a psychiatric emergency service. Gen Hosp Psychiatry. 2006; 28: 431-433.