Cette recherche aborde la médication psychiatrique à partir du point de vue des usagers. Des entrevues en profondeur ont été réalisées auprès de dix personnes utilisatrices en provenance d’une ressource communautaire et alternative en santé mentale. Les répondants éprouvent ou ont éprouvé des problèmes importants de santé mentale. La majorité des usagers de notre échantillon consomme des neuroleptiques. Les participants sélectionnés ont cheminé avec l’approche de la gestion autonome de la médication en santé mentale (GAM). La GAM constitue un terrain fertile, car l’approche favorise la réflexion critique, la diversité de pratiques autour de la médication psychotrope. Un état des connaissances portant sur l’expérience subjective de la médication est présenté. Les effets de la médication sur les personnes et leur contexte de vie ainsi que les aspects symboliques ont été analysés. Parmi les effets majeurs de la médication, on compte : l’effet de « gel », la grande fatigue, les difficultés d’attribution, le désir d’arrêt et les effets paradoxaux. La médication peut avoir des effets positifs ou négatifs sur l’entourage, le travail, les études ou autres implications sociales. Le rapport des usagers relatif à la médication a évolué vers un usage planifié, modulé et moindre. À cet effet, les dix usagers sont passés d’une phase de « novice » à une « d’expert ». Les résultats de cette recherche indiquent que la notion d’observance au traitement doit être revisitée et la notion d’efficacité élargie. Cette étude qualitative démontre que les versants « intérieurs » de la médication, l’expérience subjective et l’intersubjectif apportent une perspective plutôt rare, mais riche, du médicament en tant qu’objet social. / This research looks at psychiatric medication from the perspective of service users. In-depth interviews were conducted with 10 service users from a community-based, alternative mental health resource. The respondents experience or have experienced serious mental health problems. The majority of service users in our sample take neuroleptics. Selected participants followed the mental-health approach known as GAM: Gaining Autonomy & Medication Management. GAM provides a perfect ground, since this approach encourages critical thinking and promotes diverse practices around psychotropic medication. Current knowledge around the subjective experience of medication is presented. The effects of medication on people and their life contexts are analyzed, as well as their symbolic aspects. Among the main effects of medication are: the “anaesthetizing” effect, intense fatigue, difficulties of attribution, the desire to quit and paradoxical effects. Medication can have positive or negative effects on one’s circle of family and friends, work, studies or other social commitments. The relationship between service users and their medication has evolved toward a planned, adapted and reduced use. In this sense, the 10 service users went from a “novice” phase to that of “expert”. Results from this research show that the notion of treatment compliance must be revisited, and the concept of efficiency, broadened. This research shows that the “interior” dimensions of medication, the subjective experience and intersubjectivity provide rare and rich insights into medication as a social object.

These British Association for Psychopharmacology guidelines cover the range and aims of treatment for anxiety disorders. They are based explicitly on the available evidence and are presented as recommendations to aid clinical decision making in primary and secondary medical care. They may also serve as a source of information for patients and their carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting involving experts in anxiety disorders reviewed the main subject areas and considered the strength of evidence and its clinical implications. The guidelines were constructed after extensive feedback from participants and interested parties. The strength of supporting evidence for recommendations was rated. The guidelines cover the diagnosis of anxiety disorders and key steps in clinical management, including acute treatment, relapse prevention and approaches for patients who do not respond to first-line treatments.

Cette recherche aborde la médication psychiatrique à partir du point de vue des usagers. Des entrevues en profondeur ont été réalisées auprès de dix personnes utilisatrices en provenance d’une ressource communautaire et alternative en santé mentale. Les répondants éprouvent ou ont éprouvé des problèmes importants de santé mentale. La majorité des usagers de notre échantillon consomme des neuroleptiques. Les participants sélectionnés ont cheminé avec l’approche de la gestion autonome de la médication en santé mentale (GAM). La GAM constitue un terrain fertile, car l’approche favorise la réflexion critique, la diversité de pratiques autour de la médication psychotrope. Un état des connaissances portant sur l’expérience subjective de la médication est présenté. Les effets de la médication sur les personnes et leur contexte de vie ainsi que les aspects symboliques ont été analysés. Parmi les effets majeurs de la médication, on compte : l’effet de « gel », la grande fatigue, les difficultés d’attribution, le désir d’arrêt et les effets paradoxaux. La médication peut avoir des effets positifs ou négatifs sur l’entourage, le travail, les études ou autres implications sociales. Le rapport des usagers relatif à la médication a évolué vers un usage planifié, modulé et moindre. À cet effet, les dix usagers sont passés d’une phase de « novice » à une « d’expert ». Les résultats de cette recherche indiquent que la notion d’observance au traitement doit être revisitée et la notion d’efficacité élargie. Cette étude qualitative démontre que les versants « intérieurs » de la médication, l’expérience subjective et l’intersubjectif apportent une perspective plutôt rare, mais riche, du médicament en tant qu’objet social. / This research looks at psychiatric medication from the perspective of service users. In-depth interviews were conducted with 10 service users from a community-based, alternative mental health resource. The respondents experience or have experienced serious mental health problems. The majority of service users in our sample take neuroleptics. Selected participants followed the mental-health approach known as GAM: Gaining Autonomy & Medication Management. GAM provides a perfect ground, since this approach encourages critical thinking and promotes diverse practices around psychotropic medication. Current knowledge around the subjective experience of medication is presented. The effects of medication on people and their life contexts are analyzed, as well as their symbolic aspects. Among the main effects of medication are: the “anaesthetizing” effect, intense fatigue, difficulties of attribution, the desire to quit and paradoxical effects. Medication can have positive or negative effects on one’s circle of family and friends, work, studies or other social commitments. The relationship between service users and their medication has evolved toward a planned, adapted and reduced use. In this sense, the 10 service users went from a “novice” phase to that of “expert”. Results from this research show that the notion of treatment compliance must be revisited, and the concept of efficiency, broadened. This research shows that the “interior” dimensions of medication, the subjective experience and intersubjectivity provide rare and rich insights into medication as a social object.

The morbidity and societal burden of youth bipolar spectrum disorders (BSD) are high. These disorders are multisystemic in that adult populations there are clear interactions with inflammatory processes and steroidal physiological systems. There are much less data concerning these areas of study in youth populations with BSD. This is surprising given the association of youth-onset BSD with puberty and its associated physiological changes. In this mini-review, we overview the theoretical role of inflammatory processes and steroidal physiological systems in youth BSD, describe the greater literature in adult populations, detail the literature in youth populations when available, and overview current proposed molecular mechanistic pathways and interaction effects based on the available data. We also attend to the interplay of this complex system with body composition and weight gain, an especially important consideration in relation to the role of second generation antipsychotics as the first line treatment for youth with BSD in major clinical guidelines. A developmental model of early onset BSD for boys is hypothesized with pubertal hormonal changes increasing risk for first (hypo-)manic/depressive episode. The dramatic androgen rise during puberty might be relevant for first onset of BSD in boys. A shift from general hypercortisolism driven by glucocorticoid resistance to hypocortisolism with further disease progression is assumed, while increased levels of inflammation are functionally associated with endocrine dysregulation. The interacting role of overweight body habitus and obesity in youth with BSD further indicates leptin resistance to be a central moderator of the dynamic neurobiology of BSD in youth. The intent of this mini-review is to advance our knowledge of youth BSD as multisystemic disorders with important contributions from endocrinology and immunology based on a developmental perspective. This knowledge can influence current clinical care and more importantly inform future research.

The morbidity and societal burden of youth bipolar spectrum disorders (BSD) are high. These disorders are multisystemic in that adult populations there are clear interactions with inflammatory processes and steroidal physiological systems. There are much less data concerning these areas of study in youth populations with BSD. This is surprising given the association of youth-onset BSD with puberty and its associated physiological changes. In this mini-review, we overview the theoretical role of inflammatory processes and steroidal physiological systems in youth BSD, describe the greater literature in adult populations, detail the literature in youth populations when available, and overview current proposed molecular mechanistic pathways and interaction effects based on the available data. We also attend to the interplay of this complex system with body composition and weight gain, an especially important consideration in relation to the role of second generation antipsychotics as the first line treatment for youth with BSD in major clinical guidelines. A developmental model of early onset BSD for boys is hypothesized with pubertal hormonal changes increasing risk for first (hypo-)manic/depressive episode. The dramatic androgen rise during puberty might be relevant for first onset of BSD in boys. A shift from general hypercortisolism driven by glucocorticoid resistance to hypocortisolism with further disease progression is assumed, while increased levels of inflammation are functionally associated with endocrine dysregulation. The interacting role of overweight body habitus and obesity in youth with BSD further indicates leptin resistance to be a central moderator of the dynamic neurobiology of BSD in youth. The intent of this mini-review is to advance our knowledge of youth BSD as multisystemic disorders with important contributions from endocrinology and immunology based on a developmental perspective. This knowledge can influence current clinical care and more importantly inform future research.

These British Association for Psychopharmacology guidelines cover the range and aims of treatment for anxiety disorders. They are based explicitly on the available evidence and are presented as recommendations to aid clinical decision making in primary and secondary medical care. They may also serve as a source of information for patients and their carers. The recommendations are presented together with a more detailed review of the available evidence. A consensus meeting involving experts in anxiety disorders reviewed the main subject areas and considered the strength of evidence and its clinical implications. The guidelines were constructed after extensive feedback from participants and interested parties. The strength of supporting evidence for recommendations was rated. The guidelines cover the diagnosis of anxiety disorders and key steps in clinical management, including acute treatment, relapse prevention and approaches for patients who do not respond to first-line treatments.

Background: Shifting the healthcare payment system from a volume-based to a value-based model has been a significant effort to improve the quality of care and reduce healthcare costs in the US. In 2018, Massachusetts Medicaid launched Accountable Care Organizations (ACOs) as part of the effort. Constructing, assessing, and risk-adjusting quality measures are integral parts of the reform process. Methods: Using data from the MassHealth Data Warehouse (2016-2019), we assessed the loss of community tenure (CTloss) as a potential quality measure for patients with bipolar, schizophrenia, or other psychotic disorders (BSP). We evaluated various statistical models for predicting CTloss using deviance, Akaike information criterion, Vuong test, squared correlation and observed vs. expected (O/E) ratios. We also used logistic regression to investigate risk factors that impacted medication nonadherence, another quality measure for patients with bipolar disorders (BD). Results: Mean CTloss was 12.1 (±31.0 SD) days in the study population; it varied greatly across ACOs. For risk adjustment modeling, we recommended the zero-inflated Poisson or doubly augmented beta model. The O/E ratio ranged from 0.4 to 1.2, suggesting variation in quality, after adjusting for differences in patient characteristics for which ACOs served as reflected in E. Almost half (47.7%) of BD patients were nonadherent to second-generation antipsychotics. Patient demographics, medical and mental comorbidities, receiving institutional services like those from the Department of Mental Health, homelessness, and neighborhood socioeconomic stress impacted medication nonadherence. Conclusions: Valid quality measures are essential to value-based payment. Heterogeneity implies the need for risk adjustment. The search for a model type is driven by the non-standard distribution of CTloss.

This revision of the 2005 British Association for Psychopharmacology guidelines for the evidence-based pharmacological treatment of anxiety disorders provides an update on key steps in diagnosis and clinical management, including recognition, acute treatment, longer-term treatment, combination treatment, and further approaches for patients who have not responded to first-line interventions. A consensus meeting involving international experts in anxiety disorders reviewed the main subject areas and considered the strength of supporting evidence and its clinical implications. The guidelines are based on available evidence, were constructed after extensive feedback from participants, and are presented as recommendations to aid clinical decision-making in primary, secondary and tertiary medical care. They may also serve as a source of information for patients, their carers, and medicines management and formulary committees.