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Les pathologies mentales sévères entraînent à la fois un handicap psychique et une baisse importante de l’espérance de vie de plus de 10 ans . Cette baisse de l’espérance est favorisée par un défaut de suivi des problèmes somatiques. Les SAMSAH (services d’accompagnement médico-social pour adultes handicapés), structures financées à la fois par les ARS et les conseils départementaux peuvent contribuer à l’organisation de ce suivi. Dans le département du Haut Rhin, le SAMSAH de l’association ARSEA est dédié au handicap psychique et couvre la moitié nord du département (soit 4 secteurs de psychiatrie générale). Sur 39 bénéficiaires présentant un handicap psychique et suivis par le SAMSAH, tous ont au moment de leur admission, puis au cours de leur suivi une évaluation de leur état somatique. Face aux plaintes fréquentes de fatigue, celle-ci n’est pas attribuée d’emblée à la pathologie psychiatrique et les facteurs somatiques intercurrents sont systématiques. Ainsi l’équipe a été formée à la détection du syndrome d’apnées du sommeil. Les entretiens cliniques ont fait suspecter un syndrome d’apnées chez six personnes et pour une autre personne ce syndrome était connu mais avec refus de traitement. Trois ont bénéficié d’un bilan qui a confirmé les apnées et celles-ci sont maintenant traitées avec une amélioration visible (moins de fatigue, plus d’activités physiques, moins de plaintes de douleur, meilleure attention, meilleure logique de raisonnement, meilleur insight, meilleure adhésion au traitement). Pour trois autres, l’acceptation d’un bilan est travaillée par approche motivationnelle. Ces observations montrent que le syndrome d’apnées du sommeil paraît deux fois plus fréquent chez les patients souffrant d’un handicap psychique que dans la population générale et qu’il n’est pas rare (10 % des cas) ce qui justifie une attention particulière pour son dépistage.
Background: Although exposure-based therapy is a well-established, effective treatment for post-traumatic stress disorder (PTSD), some practitioners report reluctance to implement it due to concerns that it may exacerbate symptoms of PTSD and commonly comorbid disorders, such as substance use disorders (SUD).
Aim: This study compared the exacerbation of psychological symptoms among participants with comorbid PTSD and SUD who received either SUD treatment alone or SUD treatment integrated with exposure therapy for PTSD.
Method: Participants (N = 71) were treatment-seeking, military Veterans with comorbid PTSD and SUD who were randomized to 12 individual sessions of either (1) an integrated, exposure-based treatment (Concurrent Treatment of PTSD and Substance Use Disorders using Prolonged Exposure; COPE); or (2) a non-exposure-based, SUD-only treatment (Relapse Prevention; RP). We examined between-group differences in the frequency of statistically reliable exacerbations of PTSD, SUD and depression symptoms experienced during treatment.
Results: At each of the 12 sessions, symptom exacerbation was minimal and generally equally likely in either treatment group. However, an analysis of treatment completers suggests that RP participants experienced slightly more exacerbations of PTSD symptoms during the course of treatment.
Conclusions: This study is the first to investigate symptom exacerbation throughout trauma-focused exposure therapy for individuals with comorbid PTSD and SUD. Results add to a growing literature which suggests that trauma-focused, exposure-based therapy does not increase the risk of symptom exacerbation relative to non-exposure-based therapy.
Background: Transdiagnostic psychotherapies are designed to apply the same underlying treatment principles across a set of psychiatric disorders, without significant tailoring to specific diagnoses. Several transdiagnostic psychotherapy protocols have been developed recently, each of which has its own strengths and weaknesses. One promising treatment is Transdiagnostic Behaviour Therapy (TBT), in that it is one of the few transdiagnostic treatments to date shown to be effective in patients with depressive and anxiety disorders. However, TBT has only been investigated via individual psychotherapy. Aims: The present study investigated the effectiveness of a group protocol for TBT, compared with disorder-specific group psychotherapies, in a naturalistic setting. Method: 109 participants with various diagnoses of affective disorders completed either group TBT (n = 37) or a disorder-specific group psychotherapy (n = 72). Measures included assessments of psychiatric symptomatology and transdiagnostic impairment at baseline and post-treatment. Results: Overall, participants in the TBT group demonstrated significant improvements across all measures. When compared with disorder-specific groups, no statistical differences were observed between groups across symptoms; however, participants in the TBT group demonstrated roughly twice the treatment effect sizes in transdiagnostic impairment compared with participants in the disorder-specific groups. In addition, when participants from the most well-represented diagnosis and disorder-specific treatment (social anxiety disorder) were investigated separately, participants in the TBT group demonstrated significantly larger improvements in comorbid depressive symptoms than participants in the disorder-specific treatment. Conclusions: Pending replication and additional comparison studies, group TBT may provide an effective group treatment option for patients with affective disorders.
Background: Post-traumatic stress disorder (PTSD) is a highly prevalent and impairing condition for which there are several evidence-based psychotherapies. However, a significant proportion of patients fail to complete a ‘sufficient dose’ of psychotherapy, potentially limiting treatment gains. Aims: The present study investigated predictors of premature treatment discontinuation during a trial of prolonged exposure (PE) therapy for PTSD. Method: Combat veterans with PTSD were recruited to participate in a randomized clinical trial of PE delivered in person or via telehealth technologies. Of the 150 initial participants, 61 participants discontinued the trial before the completion of eight sessions (of an 8‒12 session protocol). Treatment condition (telehealth or in person) and factors identified by prior research (age, combat theatre, social support, PTSD symptoms) were tested as predictors of treatment discontinuation. Results: A Cox proportional hazards model (a subtype of survival analysis) was used to evaluate predictors of treatment discontinuation. Disability status and treatment condition were identified as significant predictors of discontinuation, with a noted disability and use of telehealth demonstrating higher risk. Conclusions: The present findings highlight the influence of telehealth and disability status on treatment discontinuation, while minimizing the role of the previously identified variables from studies with less sensitive analyses.
New coverage of the recent wars in Afghanistan and Iraq, and the ensuing public education campaigns by the Department of Veterans Affairs and private veterans advocacy groups combine to call the public's attention to the many potential mental health problems associated with traumatic event exposure. Indeed, since 2001, Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) combat and peacekeeping missions have been characterized by high levels of exposure to acts of extreme violence, with often gruesome effects. Less publically discussed is the fact that a surprisingly large number of United States civilians also report exposure to traumatic events, such as severe interpersonal violence, natural disasters, and serious automobile accidents. In fact, approximately 70% of randomly sampled respondents indicated that they have experienced an incident characterized by significant perceived life threat at some point during their lives.
Background: Accumulating evidence supports behavioral activation (BA) as an effective stand-alone treatment for improving depression and related conditions, though little is known about the factors that influence positive outcomes. Such research is ripe for future dissemination and implementation efforts, particularly among vulnerable older adult populations in need of such efficacious and transportable treatments. Aims: Given the central but largely unexamined role that increasing activities plays in BA, we investigated the association between participation in weekly activities and treatment outcome. Method: As a preliminary study of this research question, we report on a sample of 20 older adults with symptoms of depression and complicated bereavement who completed 5 weeks of BA, pre- and posttreatment measures, and weekly planners of BA activities. All activities were coded as either functional or pleasurable (by participants) and if they were social in nature (by trained coders). Results: Overall, BA was associated with reductions in symptomatology. However, participants’ total number of reported activities, and their relative proportion of functional, pleasurable, and social activities, did not significantly relate to their improvement in symptoms. Conclusion: One interpretation of the findings suggests that countering avoidance more generally, potentially independent of the specific type or total amount of activation activities, may be associated with amelioration of symptomatology.
This contribution focuses on the plight of (most of) the old member states, as the new member states are unlikely to face the same problems. The latter are growing faster than the old EU-15. They are likely to continue to benefit from their low production costs, a production base with a relatively well-educated work force, an improving policy framework, and their proximity to the biggest market in the world.
By contrast, the main theme of the Euroland economy continues to be weakness of both demand and supply. And it is not only the economy that is weak, but also the economic policy making. Fiscal policy plans go awry all the time; the Lisbon Agenda is constantly invoked but no action is taken; and so on. This disarray results from the assumptions underlying existing policies: they are geared for a growing economy in which every year growth allows for some redistribution. Growth prospects are now rather dim throughout most of Euroland due to lower productivity growth and, particularly in Germany, due to demographic developments. Economic policy making is squeezed from both sides.
The low growth diminishes the potential for redistribution, which has an impact on both fiscal and monetary policy. Fiscal policy is deteriorating as finance ministers try to save, and then discover every year that despite their attempts at cutting expenditures, the ratio of public expenditure to GDP does not go down. Year after year, deficits are higher than expected.
East Germany used to be considered as the model economy of the socialist bloc. Yet, after unification, little of that economy seemed worth preserving. But the East Germans seemed to be luckier than their eastern neighbours, for reform and reconstruction there would have West German support of a magnitude unavailable to any other former socialist country. Overnight, unification provided the framework and the institutions needed to operate as a market economy and gave access to the financial and managerial resources of West Germany. East Germany thus obtained the necessary legal framework at the stroke of a pen when the unification treaty came into effect on 3 October 1990. Moreover, monetary union (1 July 1990) brought an untrammelled price system, a stable and convertible currency and an efficient capital market. Privatisation was also quickly begun under the management of the Treuhand Agency (THA).
Seen against this backdrop, which combined conditions ideal for a big-bang reform and considerable financial support, East Germany's subsequent vicissitudes are incomprehensible to many. Are the disappointing results due to avoidable policy errors, or was the initial collapse of the East German economy a normal consequence of a big-bang reform that should have been anticipated from the outset? Most observers will acknowledge that the difficulties of restructuring the economy of East Germany may have been underestimated, but they all have their own theories as to the policy errors that may have been made.
Ever since the socialist takeover in Russia a debate has been raging about the profundity of the changes imposed on Russian society. However, looking back on Russia's history since Peter the Great, we find that many features of Russian pre-revolutionary society survived, and indeed were sometimes reinforced, after the Revolution. The Soviet Union remained an empire with its border problems and nationality conflicts, and continued to police its population severely. Democracy was as absent and repression as regular after as before the Revolution. State organisation remained highly centralised and the problems of the periphery were, as always, ignored, misunderstood or repressed. Within the imperial borders the conflict between town and country was as acute in the 1930s as in the seventeenth century. The leadership remained divided between imperial expansion eastwards or westwards, and between opening up to or closing off foreign, mostly Western, influences. The empire invariably rooted its strength in strong ideological grounds: in pre-revolutionary days in absolute monarchy and religion and afterwards in the Marxist framework. Both regimes, each claiming to pursue a superior mission, had expansionary goals for which a strong and influential military was necessary. The need to equip the military, more than the desirability of improving the welfare of citizens, was in each case the driving force behind industrialisation.
As chapter 3 made clear, economists could not agree on a detailed optimal blueprint for reforms. Different countries opted for different approaches. Now, more than ten years later, one can attempt an evaluation of how successful different approaches to reform have been.
We start this chapter with the question in section 1 whether rapid or slow reforms were more successful. Here the evidence is unambiguous: it paid to reform quickly and comprehensively.
One experience common to all transition economies and not anticipated by Western economists was the initial collapse of output. Was the depth or duration of the output collapse avoidable?
Most countries liberalised the price system as one of the first (and administratively easiest) reform measures. The combination of relative price adjustments, lower production and a monetary overhang propelled inflation, in some countries degenerating into hyperinflation. Macrostabilisation became important and urgent, as argued in section 2.
All transition economies liberalised their foreign trade early on and, to varying degrees, capital movements. The rapid reorientation of trade to Western markets is a salient result; foreign direct investments were initially much more modest. The Russian crisis of 1998 was a dramatic reminder that liberalising capital flows is altogether a different matter from liberalising trade. With the opening up, the choice of exchange rate regime became important. From currency boards to ‘dirty’ floating, all regimes were tested somewhere. Section 3 asks whether there are conclusions to be drawn.
‘The one absolute certain way of bringing this nation to ruin, of preventing all possibility of its continuing to be a nation at all, would be to permit it to become a tangle of squabbling nationalities.’
In 1995 we published Winds of Change to treat the key question for transition countries: ‘How to reform?’ In the meantime we can look back on more than ten years of transition experience. No country was able to jump-start its economy on market-based principles and converge rapidly. In all transition countries production fell after opening up. In some countries this fall was short-lived, but in most it lasted several years. In some the level of production is, twelve years after opening up, still below the level of 1989. There is no simple explanation of the diversity in transition performance, but starting conditions did play a central role.
Today, therefore, the question is no longer ‘How to design reforms?’ Rather, it is ‘Why have certain approaches worked and others not?’ This will be a major theme of this book. By implication, in many countries a lot still needs to be done. This is another major theme.
In this book we resist the temptation to produce a complete record of transition experience. We rather select the most significant experiences that may become, over time, classical reference cases. Of course, the overall experience in all transition countries will be presented, but it will not be pursued in depth for each country.
The outline of the book is as follows. In part I we start with a bit of history, an overview of communist experience.
Analysing the key problems facing the transition countries in Central and Eastern Europe, this accessible book describes the legacy of the central planners, the progress achieved so far and the need for further reforms. It documents the outstanding successes and failures, and analyses why certain approaches to transition have worked and others have not. It tests where transition is over and shows how some countries have graduated from 'transition' to 'integration' through their efforts to join the European Union (EU). It discusses the costs and benefits of the eastern enlargement of the EU. The specific experiences of German unification, the Soviet Union's disintegration, and Russia's complex reforms are examined, as are the specific issues that need to be addressed in the Balkans. The book concludes by indicating how the expanding EU could help the poor performers through inclusion in a continent-wide integrated economic area.