M. Le Gueut

L'autopsie psychiatrique

RATIONALEnWithin the framework of an evaluation program for the prevention of suicide in Brittany conducted by the academic department of psychiatry (University of Rennes, Brittany, France), we have addressed the issue of the potential usefulness of psychological autopsy as a tool for the better comprehension of suicide risk factors.nnnMETHODnWe reviewed the appropriate literature in 30 articles found amongst those obtained from the Medline database. These articles were selected according to the quality of their methodology. For the Medline data retrieval search, the following keywords were used: psychological autopsy, psychiatric autopsy, psychological autopsy and methodology, psychiatric autopsy and methodology. This reviews objective was to determine, firstly the nature and the content of psychological autopsies, secondly to evaluate their use as a methodological tool to assist the comprehension and prevention of suicide. Finally, it was also to assess its feasibility for use in France.nnnRESULTSnThe majority of the published studies using psychological autopsy for the evaluation of suicide expertise came from Scandinavian or Anglo-Saxon countries. Schneidman [Schneidman ES. The psychological autopsy. Suicide Life Threat Behav 1981;11:325-40], whose aim was to clarify the causes of sudden death related to psychological circumstances, focused on suicidal intentions and the symptoms exhibited. He coined the term: psychological autopsy. Gradually, the definition of psychological autopsy has evolved and is now being used for the evaluation of death by suicide with a single goal in mind: to retrospectively identify any suicidal predictive and risk factors available at the time of the event. At present, no unequivocal definition of psychological autopsy has been put forth. However, this formerly only descriptive procedure is now becoming more analytical in nature (comparison of psychiatric profiles between pre- and postmortem assessments, research on precipitating factors, comorbidity studies...). Presently, it corresponds to a methodological tool to be used essentially for case reports that vary a great deal and do not permit cross-comparisons with other case-studies. For the past fifteen years, case-control studies in this field have become more frequent with various choices of control groups: healthy subjects with no psychiatric history, as well as attempted suicides, with or without a psychiatric history. Partial standardization of autopsy procedures is now possible with some data extracted from police inquiries, medical charts, or data gathered following interviews with the deceased patients relatives.nnnCONCLUSIONnIn the aggregate, the literature review showed that the aims of psychological autopsy include understanding and prevention of suicide in a population-based sample. It seems difficult to generalize with results from other population references. In France, the use of psychological autopsy as a standardized tool for the assessment of suicidal behaviors would be difficult, due to the complexity of the procedures involved: data coming from external sources, such as medical sources, is nearly impossible to obtain. Practitioners would be required to overcome administrative rules and regulations, plus incurring the high costs of such procedures. They must also take into account ethical considerations that make such interviews with the deceased patients relatives difficult to obtain. Be this as it may, the French Ministry of Health is presently attempting to find a solution in order to alleviate the all too frequent problem of suicide in the population at large and to promote suicide prevention in France.

Sexual assault and MDMA: the distinction between consciousness and awareness when it comes to consent

In France, the term chemical or drug-assisted submission is usually defined as the rendering of a person vulnerable by the surreptitious administration of an active substance with the purpose of prejudicing the person or his/her possessions. If the harm is sexual assault, establishing the victim’s submission involves both proving that a dangerous substance was administered, providing material evidence of the infraction (the assault), i.e. the detection of traces in a physical examination and samples, and proving the absence of consent. We report the case of a woman who was sexually assaulted after having been surreptitiously administered methylenedioxymethamphetamine. In this special case, the woman remained in a state of vigilance (conscious) throughout, so there is doubt about whether or not she consented. In other words, the ability to consent is debatable.

L’indication d’injonction de soins repose-t-elle sur un diagnostic médical ?

UNLABELLEDnCourt-ordered treatment was created in 1998, as part of a law against sexual offense recidivism. The creation of court-ordered treatment is based on the premise that many offenders have psychiatric disorders. If the court-ordered treatment is appraised as an effective way to prevent recidivism by the lawmaker, the preeminent role of psychiatry, in the prevention of recidivism has generated controversy in the psychiatric community. Few studies have been conducted on court-ordered treatment in France, and have concerned epidemiological measures. Court-ordered treatment leads to an extension of the experts mission. In order to prevent recidivism, the interest of a treatment is a new part of the experts mission.nnnPURPOSEnThe main purpose of this study was to assess the kind of diagnosis reported by the forensic psychiatrist who considered the court-ordered treatment as appropriate.nnnMETHODnWe led a descriptive and retrospective study among the experts reports of 68xa0subjects followed by three psychiatrists. We categorized each diagnosis found in the experts reports in reference to DSM-IV-TR axisxa0I and axisxa0II. As the expert has no obligation to refer to the DSM-IV-TR, we also considered the no DSM-IV-TR categorized disorder as a category. The primary outcome was the proportion of each diagnosis category in experts reports, in which the forensic psychiatrist agreed with the indication of a court-ordered treatment.nnnRESULTSnWe analysed 123xa0experts reports in which the mission was to diagnose a mental disorder and to assess the need for a court-ordered treatment. The expert agreed with the need for a court-ordered treatment in 112xa0reports. In those reports the diagnosis was no disorder in 27% of them, no DSM-IV-TR categorized disorder in 26% of them, axis II disorder in 24% of them, axis I disorder in 19% of them, and association of an axis I and an axis II disorder in 4% of them.nnnDISCUSSIONnThe diagnoses were heterogeneous. Their associations with the need for a court-ordered treatment seem to be contradictory when considering the association between no mental disorder and need for a court-ordered treatment found in 27% of the reports. These paradoxical results led us to question the meaning of mental disorder and treatment.

Revue généraleTuberculose et refus de soins : recours à la législation sur les menaces sanitaires gravesTuberculosis and refusal of treatment: Resorting to legislation on serious health threats

INTRODUCTIONnClinicians are regularly confronted with the question of refusal of treatment from patients with tuberculosis. For several years, the French public health authorities have been studying the possibility of compelling treatment or isolation, but no plan has been implemented even though European and American experiences have shown the effectiveness of restrictive measures.nnnBACKGROUNDnNeither the statutory exceptions to the principle of consent to medical treatment nor the conditions of implementation of required care allow legally binding measures against patients refusing care or isolation.nnnVIEWPOINTSnThe legislation on serious health threats has recently been applied to the situation of a refusal of treatment in the context of tuberculosis. It allowed the patient to be ordered to observe prescribed care and the possibility of forced isolation in the event of breach of this order.nnnCONCLUSIONSnThe legislation on serious health threats is a response to the question of refusal of treatment from patients with tuberculosis. However the opinion of the legal authority as to its necessity and proportionality to the risk remains unknown.

Tuberculose et refus de soins : recours à la législation sur les menaces sanitaires graves

INTRODUCTIONnClinicians are regularly confronted with the question of refusal of treatment from patients with tuberculosis. For several years, the French public health authorities have been studying the possibility of compelling treatment or isolation, but no plan has been implemented even though European and American experiences have shown the effectiveness of restrictive measures.nnnBACKGROUNDnNeither the statutory exceptions to the principle of consent to medical treatment nor the conditions of implementation of required care allow legally binding measures against patients refusing care or isolation.nnnVIEWPOINTSnThe legislation on serious health threats has recently been applied to the situation of a refusal of treatment in the context of tuberculosis. It allowed the patient to be ordered to observe prescribed care and the possibility of forced isolation in the event of breach of this order.nnnCONCLUSIONSnThe legislation on serious health threats is a response to the question of refusal of treatment from patients with tuberculosis. However the opinion of the legal authority as to its necessity and proportionality to the risk remains unknown.

L’acte médical réalisé sur un mineur nécessite le consentement des deux parents

potentielle. La souffrance psychique est connue pour être l’un des problèmes majeurs à l’adolescence, et de nombreuses études ont montré que les urgences sont un lieu privilégié pour son expression, souvent sous une forme occulte, ce que notre étude a confirmé. Contrairement à ce qu’affirme P. Alvin, notre e de dépressions avérées ne se traduicliniques explicites (TS, alcoolisations er un questionnaire de dépistage de la urgences, au même titre qu’effectuer mineur nécessite le consentement des deux parents