Clémence Bussière

Nicolas Sirven

Philippe Tessier
email: philippe.tessier@univ-nantes.fr

Does ageing alter the contribution of health to subjective well-being?

Keywords: Europe, Subjective well-being, Value of health, Healthcare evaluation, Ageing, Panel data

1

Introduction

Subjective Well-Being (SWB), or people's sense of wellness-how they feel in and think about their life-has long been considered in healthcare analysis (e.g. [START_REF] Gill | Subjective well-being: Properties of an instrument for measuring this (in the chronically ill)[END_REF]. It is nowadays increasingly advocated as a relevant criterion for the assessment of healthcare programs and general public policies [START_REF] Diener | Beyond Money: Progress on an Economy of Well-Being[END_REF][START_REF] Dolan | Measuring Subjective Well-being for Public Policy[END_REF][START_REF] Layard | Happiness: lessons from a new science[END_REF]OECD, 2013). Measures of SWB, which provide cognitive and affective evaluations of their life by the individuals [START_REF] Diener | Subjective Well-Being: The Science of Happiness and Life Satisfaction[END_REF], may usefully complement the usual health-related quality of life tools and quality of care metrics to inform about the consequences of illness and healthcare [START_REF] Lee | Subjective well-being and the measurement of quality in healthcare[END_REF][START_REF] Mukuria | Valuing the EQ-5D and the SF-6D health states using subjective wellbeing: A secondary analysis of patient data[END_REF].

Besides, these measures better reflect the experience of patients than the preferences of the public over hypothetical health states on which relies Quality-Adjusted Life-Years [START_REF] Dolan | Developing methods that really do value the 'Q' in the QALY[END_REF][START_REF] Dolan | Valuing Mental Health: how a subjective wellbeing approach can show just how much it matters[END_REF]. Although the boundaries of SWB are rather large [START_REF] Skevington | How is subjective well-being related to quality of life? Do we need two concepts and both measures?[END_REF], it is widely acknowledged that it encompasses three distinct yet overlapping components [START_REF] Stone | Subjective well-being: measuring happiness, suffering, and other dimensions of experience[END_REF]: evaluative well-being (life satisfaction), experienced well-being (positive and negative affect) and eudemonic well-being (sense of purpose and meaning in life). Progresses in the measurement of SWB has led to a fast-growing literature exploring its determinants such as health, income, labour force status and major life events, among others [START_REF] Clark | Four Decades of the Economics of Happiness: Where Next?[END_REF]Diener et al., 2018).

A noticeable part of the empirical literature on SWB studies its relationship with age. In crosssectional settings, a frequent finding is that of a U-shaped association between SWB and age, such that SWB decreases since early adulthood, reaches its lowest level around 45-55, and increases afterwards [START_REF] Blanchflower | Is well-being U-shaped over the life cycle?[END_REF][START_REF] Clark | The Curved Relationship Between Subjective Well-Being and Age[END_REF][START_REF] Graham | Happiness, stress, and age: how the U curve varies across people and places[END_REF]Stone et al., 2010). However, the use of panel data and fixed effects models suggests that the U-curve flattens when the analysis considers age as a time-varying rather than a cohort effect [START_REF] Frijters | The mystery of the U-shaped relationship between happiness and age[END_REF][START_REF] Wooden | Panel Conditioning and Subjective Well-being[END_REF]. Still, it remains unclear how ageing individuals could maintain their SWB while facing progressive declines in health over time [START_REF] Case | Broken Down by Work and Sex: How Our Health Declines[END_REF][START_REF] Easterlin | Life cycle happiness and its sources[END_REF].

A potential though understudied explanation is that the individuals adapt to this natural decline so that the contribution of health for their well-being changes over time. In other words, life priorities may change with age [START_REF] Schafer | Age and the tenses of life satisfaction[END_REF]. [START_REF] Frijters | Do individuals try to maximize general satisfaction?[END_REF] indeed found that people tend to ascribe less importance to those areas of their life with which they are less satisfied. Similarly, several studies showed that SWB increases over the years for individuals with chronic health problems, such as disability [START_REF] Oswald | Does happiness adapt? A longitudinal study of disability with implications for economists and judges[END_REF], chronic pain [START_REF] Mcnamee | The effect of chronic pain on life satisfaction: Evidence from Australian data[END_REF], or functional limitations [START_REF] De Hond | Can time heal all wounds? An empirical assessment of adaptation to functional limitations in an older population[END_REF]. However, few studies explored the possibility that adaptation to the progressive alteration of health over time may be a process affecting all individuals, not only those facing chronic conditions. To do so, they typically used longitudinal datasets. [START_REF] Anonymous | Details omitted for double-blind reviewing[END_REF] used panel data for women newly diagnosed with breast cancer in a French hospital. They found that women adapt to illness by giving greater weight over time to the social dimension of life satisfaction. Two studies made use of large panel datasets on the general population, though they do not explicitly address the issue of adaptation. They applied a domain-of-life approach whereby life satisfaction is regressed on measures of satisfaction with various life domains. [START_REF] Bonsang | Retirement and subjective well-being[END_REF] found significant positive interaction terms between age and satisfaction with health in men between 50 and 70 in the German Socio-Economic Panel. For Americans aged 18 and above, [START_REF] Bardo | A life course model for a domains-of-life approach to happiness: Evidence from the United States[END_REF] found that the contribution of satisfaction with health for life satisfaction increases throughout the lifetime, and somewhat stabilizes from about 70. These studies focused on life satisfaction, while available evidence suggests that the importance of life domains may be sensitive to the form of SWB [START_REF] Dolan | The Measure Matters: An Investigation of Evaluative and Experience-Based Measures of Wellbeing in Time Use Data[END_REF]. For instance, [START_REF] Kahneman | High income improves evaluation of life but not emotional wellbeing[END_REF] showed that life satisfaction rises with income, whereas above a certain level of income experienced well-being does not increase anymore. We shall follow the seminal contribution of [START_REF] Stiglitz | Report by the Commission on the Measurement of Economic Performance and Social Progress[END_REF], stating that since "[SWB] encompasses different aspects […], each of them should be measured separately, to derive a more comprehensive appreciation of people's lives." We shall also follow their recommendation that SWB should be analysed from the standpoint of the general population.

The objective of this study is to investigate the dynamics of the contribution of health to various forms of SWB in ageing adults. Using four waves of longitudinal data from SHARE (Survey of Health, Ageing, and Retirement in Europe) between 2007 and 2015, we examine whether and how the relationship between health and SWB may change over time and we test whether the changes differ according to the form of SWB (evaluative, experienced or eudemonic). Our analyses are mainly exploratory since we do not test for an a priori specific pattern of change, although we assume that an increasing SWB with aging could be explained, in part, by a hedonic adaptation process implying a lowering over time of the contribution of health to well-being. This research contributes to the literature in many ways. First, we concur with and expand the analysis of SWB in its various dimensions, adding some evidence about the changing influence of health on evaluative, experienced and eudemonic well-being. Exploring how the various components of SWB may complement each other is in line with recommendations on the type of information that might be required for the production of relevant indicators of social progress [START_REF] Stiglitz | Report by the Commission on the Measurement of Economic Performance and Social Progress[END_REF](Stiglitz et al., , 2018)).

Second, we decompose the influence of "age" on SWB between a cohort and a time fixed effect in a panel data model. We thus provide additional evidence that the contribution of health to SWB may change as time goes by for individuals born at different periods. This issue is largely understudied, though it deserves consideration since averaging out the effects of the determinants of SWB over the lifespan for different generations may produce misleading results and recommendations [START_REF] Lin | Heterogeneity in the relationship between subjective well-being and its determinants over the life cycle: A varying-coefficient ordered probit approach[END_REF], for instance when trying to identify ways to promote successful ageing. Third, the scope of our results is rather large since we address (i) general health issues (using a combination of various health variables) rather than specific illnesses, (ii) amongst individuals aged 50 onwards living in the community, and (iii) in ten European countries. Fourth, our study eventually provides insightful, original information for the normative debate on the way health should be valued for economic evaluation and priority setting in healthcare purposes.

The paper is organised as follows. Section 2 proposes a general formal framework of adaptation to health decline with age that highlights how detecting changes in the value of health to SWB will be useful to unveil this phenomenon. In section 3, we describe our data, measures, and estimation strategy. The results are presented in section 4 and discussed in section 5. Section 6 concludes.

A general framework of adaptation to health decline with ageing

Studies that explored the possibility of adaptation to health conditions are mostly interested in 'hedonic adaptation' which corresponds to a weakening over time in the subjective response to a constant or repeated stimulus [START_REF] Frederick | Hedonic adaptation, in: Well-Being: The Foundations of Hedonic Psychology[END_REF]. It is typically studied by estimating a habituation function which captures an increase over time in SWB after the onset of a chronic condition [START_REF] De Hond | Can time heal all wounds? An empirical assessment of adaptation to functional limitations in an older population[END_REF][START_REF] Mcnamee | The effect of chronic pain on life satisfaction: Evidence from Australian data[END_REF][START_REF] Oswald | Does happiness adapt? A longitudinal study of disability with implications for economists and judges[END_REF]. Our approach to adaptation differs in some respects. First, we study adaptation in a broader sense as a form of 'response shift' [START_REF] Sprangers | Integrating response shift into health-related quality of life research: a theoretical model[END_REF] that is, a change in how much health matters for SWB. In doing so, we define and examine the type of change that could reflect hedonic adaptation, i.e. that may participate to attenuate the fall in SWB due to health decline. Second, we do not restrict our attention to the consequences of chronic health conditions, but rather address the issue of adaptation/response shift due to the alteration of health with ageing. To set our approach, consider the following simple framework where a person's i SWB (evaluative, experienced or eudemonic) is represented by the function :

= ( , … , , … , , , … , , … , ) (1)
In equation [START_REF]Figure 1. Trends of measures of SWB and health over time, by birth cohort 7[END_REF], SWB depends on the individuals' realizations in various life domains ( ) such as income, occupational status, marital status for instance, on health (denoted which may be interpreted as a composite measure of health) and on a set of personal characteristics ( ) such as age ( ) among others. Most studies about the determinants of SWB assume that it is a linear combination of the contributions of the life domains and of personal characteristics. Typically, assuming crosssectional data, this amounts to estimate the following equation:

= + ∑ . + ∑ . + (2)
Where , the and are parameters to estimate and is an error term. Equation (2) allows for a direct effect of age on SWB. To account for the possibility of changes in the contribution of health to SWB (response shift), one may estimate as follows:

= + ∑ . + ∑ . + . + (3)
Where .

is an interaction term combining age and health. We interpret < 0 as a type of response shift consistent with hedonic adaptation since it represents a way to reduce the fall in SWB due to the alteration of health as one ages, all other things equal. This interpretation of adaptation as leading to re-weight the contribution of the domains of life to SWB is found in the study of [START_REF] Powdthavee | What happens to people before and after disability? Focusing effects, lead effects, and adaptation in different areas of life[END_REF] and the theoretical model of adaptation of [START_REF] Bradford | Getting used to it: the adaptive global utility model[END_REF]. Some psychological theories of ageing may support this re-weighting. For instance, the socioemotional selectivity theory [START_REF] Carstensen | Socioemotional Selectivity Theory and the Regulation of Emotion in the Second Half of Life[END_REF][START_REF] Carstensen | Taking time seriously: A theory of socioemotional selectivity[END_REF] asserts that as their time horizon shortens due to their age, the individuals give priority to events that bring them increasingly greater emotional satisfaction.

This could lead them to ascribe less importance to their declining health as they age, thereby maintaining their SWB over time. Equation 3 can be modified to obtain a more general model of adaptation to ageing:

= + ∑ . + ∑ . + ∑ . + (4)
In equation 4, the contribution of all life domains can vary with age. Adaptation to changes in health might lead the individuals to revise the weights of other life domains [START_REF] Powdthavee | What happens to people before and after disability? Focusing effects, lead effects, and adaptation in different areas of life[END_REF], thus modifying the relative contribution of health to SWB. The estimation of a relative weight may be sensitive to the set of life domains considered. For this reason, our main analysis focuses on changes in the absolute contribution of health to SWB. Nevertheless, we allow for varying weights for all dimensions of life in our robustness checks. Some studies estimated models like equation 4, but they did not include the possibility of changes in the weight of health [START_REF] Lin | Heterogeneity in the relationship between subjective well-being and its determinants over the life cycle: A varying-coefficient ordered probit approach[END_REF][START_REF] Movshuk | Why is Life Satisfaction U-shaped in Age?[END_REF].

In what follows, we use equation 3 (main analysis) and 4 (robustness checks) to determine whether and how the contribution of health to SWB changes with age (response shift) and whether it changes in a way suggesting hedonic adaptation to health decline due to ageing ( < 0). We also examine whether the conclusion reached differs depending on the measure of SWB.

Materials and methods

Source and sample

Our empirical analyses use four waves of SHARE (http://www.share-project.org/) between 2007 and 2015. SHARE is a cross-national European cohort of individual data on health, socioeconomic status and social and family relationships of respondents aged 50 or over [START_REF] Börsch-Supan | Data Resource Profile: The Survey of Health, Ageing and Retirement in Europe (SHARE)[END_REF].

SHARE version 6.6 provided 288,736 observations. Individuals were discarded from the analysis if they were less than 50 years old, or nursing home residents. We also excluded individuals surveyed at waves 1 and 3 because the questionnaires did not collect the required information about SWB. A total of 152,130 respondents were thus selected in 10 countries among the four regular panel waves (waves 2, 4, 5 and 6). Of these, 12% was discarded because of missing data; individuals were then kept if at least two observations were available (longitudinal dimension). The final longitudinal sample is comprised of 111,573 observations (unbalanced panel) corresponding to between 14,394 and 36,198 individuals per wave (table 1). The balanced sample consists of 7,606 respondents over four waves (30,424 observations). Respondents mean age is 66 (min 50, max 103, sd 9.3), and 54% are women.

No ethical approval was required for this study as the SHARE data are anonymous and publicly available for research.

---Table 1 should be here ---

Variables

We employ four dependent variables. Evaluative well-being was assessed using a single question asking the respondents, "On a scale from 0 to 10 where 0 means completely dissatisfied and 10 means completely satisfied, how satisfied are you with your life?". Experienced well-being refers to positive and negative affectivity that do not represent opposite symmetric sides. Both are required to obtain a complete picture of experienced well-being [START_REF] Stone | Subjective well-being: measuring happiness, suffering, and other dimensions of experience[END_REF][START_REF] Watson | Toward a consensual structure of mood[END_REF]. The SHARE survey does not contain any validated tool to assess this component of SWB. An oftenemployed strategy consists in constructing proxy measures by aggregating together the answers to questions referring to various feelings or emotions [START_REF] Dolan | The Measure Matters: An Investigation of Evaluative and Experience-Based Measures of Wellbeing in Time Use Data[END_REF][START_REF] Steptoe | Subjective wellbeing, health, and ageing[END_REF]. We follow the approach by Fisher and Sousa-Poza ( 2008) who employed factor analysis to construct measures of positive and negative affectivity using questions from the mental health part of SHARE. According to From SHARE survey we selected questions that may proxy some of the feelings included in the PANAS. To construct a measure of positive affect, we employ four questions with dichotomous answers indicating whether one was able to enjoy doing various things recently, is able to concentrate on reading, is able to concentrate on entertainment and has hopes for the future.

Having hopes is a positive emotion that may be interpreted as the predominance of positive over negative future feelings [START_REF] Staats | Hope: An affective cognition[END_REF]. Negative affect was assessed using a combination of dichotomous answers to questions determining whether, during the last month, one feels guilty or self-blaming, irritable, has cried or felt she would rather be dead, and felt sad or depressed. The obtained proxy measures may be disputable because some of the items we selected are not feelings but are expected to be correlated with them. To get further insights about the measures, in robustness checks we report the estimates for each item separately. Finally, we considered eudemonic well-being which is about developing one-self and realizing one's potential through the fulfillment of certain psychological needs [START_REF] Vanhoutte | The Multidimensional Structure of Subjective Well-Being In Later Life[END_REF]. The Share survey provides this measure of well-being through the CASP-12 questionnaire. This latter explores four needs (Control, Autonomy, Self-realization and Pleasure) that together form a measure of eudemonia in the old age [START_REF] Hyde | A measure of quality of life in early old age: The theory, development and properties of a needs satisfaction model (CASP-19)[END_REF][START_REF] Wiggins | The Evaluation of a Selfenumerated Scale of Quality of Life (CASP-19) in the Context of Research on Ageing: A Combination of Exploratory and Confirmatory Approaches[END_REF]. The CASP-12 is made of 12 questions that determine to what extent each of the four aspects of life is fulfilled by using four-item Likert response scales labelled "Often", "Sometimes", "Rarely" and "Never" and scored from 1 to 4 respectively. Summing the scores of the 12 questions gives rise to a global index ranging from 12 to 48, such that a higher score corresponds to higher eudaimonia. The CASP-12 contains a dimension of pleasure that may be interpreted as related to experienced wellbeing, but the wording of the items clearly evokes pleasure as fulfilment rather than as happiness [START_REF] Vanhoutte | Cognitive, Affective and Eudemonic Well-Being in Later Life: Measurement Equivalence over Gender and Life Stage[END_REF].

A widespread measure of health in the literature on SWB is self-rated health (SRH [START_REF] Jürges | True health vs response styles: exploring cross-country differences in self-reported health[END_REF]. The predicted SRH is thus our main health measure in this study. More precisely, to limit the number of interaction terms and to facilitate interpretation, we use a dummy variable to indicate poor SRH (Table A1, online appendix).

Additional covariates were retained as the usual determinants of SWB. They include the following dummy variables: living alone; being retired (not working) at the time of the survey; social participation over the last 12 months (done voluntary or charity work; attended an educational or training course; gone to a sport, social or other kinds of club; taken part in activities of a religious organization); subjective financial situation (making-ends-meet with difficulties). This latter measure is more consistent over time than objective income in SHARE as its definition does not vary between countries.

Empirical strategy

Given that both health and SWB may be influenced by unobserved individual characteristics, such as stable personality traits or genetic profile for instance, we regressed SWB on health and other covariates in a fixed-effects (FE) panel data model, and we included interaction terms combining the poor health variable with a measure of time. Formally, we estimate the following equation:

= αℎ + γ ×ℎ + β + δ + + ε (5)
Where is the = 1, … ,4 SWB measure for individual ! at time "; ℎ is the measure of poor predicted SRH; encompasses variables in four domains of life (living alone, being retired, social participation, and financial difficulties); is the time fixed effect, i.e. a set of dummy variables for each wave of the survey; stands for the individual fixed effect, εit is the error term with the usual assumptions, and α, γ, β, and δ are the parameters to estimate. The FE model decomposes the effects of 'age' into two components: first, the effect of ageing, i.e. the time that separates someone from her/his year of birth, is captured by dt; second, the cohort effect (the year of birth), is captured by ci.

The FE estimator applied to equation ( 5) thus makes it impracticable to include age in the models [START_REF] Frijters | Investigating the Patterns and Determinants of Life Satisfaction in Germany Following Reunification[END_REF]. Note that dt captures the effect of age and that of period specific attributes not controlled for. We interpret it mainly as an age effect because age rises between waves whereas the changes in unobserved period specific variables are unpredictable. However, strong period-specific effects might potentially override an age-effect and make it difficult to identify.

We assume that the four dependent variables are cardinal although some measures of SWB may be more naturally interpreted as ordinal. Research have shown that relaxing this assumption makes little difference, though available evidence is restricted to life satisfaction [START_REF] Cubí-Mollá | A Study of the Relationship between Health and Subjective Well-Being in Parkinson's Disease Patients[END_REF][START_REF] Ferrer-I-Carbonell | How Important is Methodology for the Estimates of the Determinants of Happiness?[END_REF]. The FE estimator requires the variables in equation ( 5) to be timedemeaned before OLS are applied, so that the individual fixed effect is netted out. The coefficients then represent the within change in the average behaviour. All variables are transformed as z-scores (i.e. standardized) before the FE procedure to allow comparisons between the various estimations.

Estimates in the FE model could be biased if the core assumptions of strict exogeneity and exogeneous sample attrition are violated. Both issues come from model misspecification. In the first case, the use of 'instrumented' SRH (Predicted) or objective health measures helped reduce the bias. In the second case, it may be that respondents drop out of the survey for specific reasons, thus leading to an unbalanced sample. Heckman's correction is a simple way to tackle this issue [START_REF] Heckman | Sample Selection Bias as a Specification Error[END_REF]. We computed a probability to take part in the four waves considered for each individual, at each wave, as a function of individual attributes (age, sex, education level) and interviewers' comments (whether the respondent showed good will, asked for clarifications, understood most questions, took part in SHARE for the first time). The inverse Mill's ratio was then plugged in equation ( 5) amongst the Xit.

We performed three analyses as robustness checks. First, we rerun all analyses substituting predicted poor SRH with alternative measures: i) poor SRH (not predicted) and ii) two objective measures, grip strength and the result of a cognitive test respectively. Second, we estimate all models with interaction terms combining all individual life domains (i.e. dummy variables for having social interaction, living in couple, being retired, having financial difficulties) with time, which corresponds to a general model of adaptation to ageing (equation 4). Finally, we estimated models for each of the items used to assess positive and negative affect and for the four dimensions of the CASP-12 (eudemonic well-being).

In what follows, we interpret 'importance' or 'weight' as representing the contribution of health to SWB inferred from FE regressions of SWB measures. This inferred importance may differ from that obtained by asking the individuals for importance ratings of various life domains (e.g. [START_REF] Hsieh | Age and relative importance of major life domains[END_REF]. In the latter case, importance relates to the respondents' internal standard of well-being, which does not allow to study whether it varies with forms of SWB.

Results

Descriptive statistics

Figure 1 depicts the evolution over time of the four measures of SWB and predicted poor SRH by birth cohort. There are some differences between cohorts in both the baseline levels and the evolution with age of SWB. At the first wave, the oldest individuals have a lower SWB except for life satisfaction. The time trends for life satisfaction are roughly similar, whatever the birth cohort.

Between the first and the last wave, satisfaction with life rises for all cohorts. SWB may have been impacted by the consequences of the 2008 Great Recession [START_REF] Deaton | The financial crisis and the well-being of Americans: 2011 OEP Hicks Lecture*[END_REF] as suggested by the marked kink in the trends for life satisfaction between 2011 and 2013 whatever the cohort. Regarding eudaimonia and positive affect, the trends are roughly monotonous but differences between birthcohorts suggest they are non-linear and not compatible with a U-shape curve over the lifespan. These forms of SWB increase or stabilize over time for the youngest cohorts and decrease with age for the oldest ones. Negative affect rises with time for all cohorts then decreases after 2011. Again, this might be partly attributable to the 2008 financial crisis. As expected, predicted poor health is more frequent in the oldest cohorts, and it increases with age.

---Figure 1 should be here ---Table 2 presents some descriptive statistics of the main variables, as well as the decomposition of the within and between variances. Overall, the means of variables seem to show a relatively good level of SWB. For instance, the average score of life satisfaction in our sample is around 8 (on the 0-10 scale where 10 represents the highest level) which is on top of those reported in the Gallup World Poll data, over the entire age distribution in European countries [START_REF] Exton | Comparing Happiness across the World: Does Culture Matter?[END_REF]. The between and within standard deviations are almost close to each other for these variables, with measures of SWB being a little more volatile between individuals than within over time.

---Table 2 should be here ---

Estimates from main models

The results from our main analysis -the estimation of a FE model per measure of SWB-are provided in table 3. A higher score for negative affect indicates lower well-being, which may partly explain the sign differences in the estimates compared with the other measures. The estimations show that having financial difficulties and predicted poor health are significantly associated with lower SWB whatever the measure. Social participation is associated with higher life evaluation and eudaimonia, and it increases positive and negative affectivity. Living alone reduces all forms of SWB, but the eudemonic one and being retired harms life satisfaction while it is associated with higher eudemonic well-being.

---Table 3 should be here ---Since the estimated coefficients in table 3 are z-scores, and that all regressors are dummy-coded, we can compare the impact of health on the various measures of well-being and with the impact of other life domains. The effect of poor health is of a broadly similar magnitude for all SWB measures, except for that of positive affectivity for which it is sensibly smaller. Poor health is nevertheless the main regressor of positive affectivity, but it comes after financial difficulties for life satisfaction and eudemonic well-being and after living alone for negative affect. The 'pure' effect of age on SWB is captured by the time dummies for which most coefficients are significant. Controlling for various life domains, overall life satisfaction and eudemonic well-being increase with age over the period under consideration, although the rise in life satisfaction is temporarily reduced in 2013. Positive affectivity seems somewhat stable over the period while negative affectivity exhibits rise then fall.

---Figure 2 should be here ---

Our main interest lies in determining whether and how ageing changes how much health matters for SWB. We explore this by examining the coefficients for the interaction terms combining health and time. The F-statistics corresponding to the tests for structural change (Chow tests, table 3) suggest that all models differ depending on time/age. Most interaction terms combining poor health with wave are significant for all measures of SWB. However, the patterns of change vary with the component of SWB. They are represented graphically in figure 2 that shows that life satisfaction behaves differently from eudemonic and experienced well-being. While the impact of poor health on satisfaction with life decreases between the first and last waves -though non monotonically -, it increases for all other measures of SWB. The most striking change concerns positive affectivity for which at wave 6 the influence of poor health has almost doubled in comparison with wave 2 (going from an estimated coefficient of -0.084 to -0.151, the sum of -0.084 and -0.067 in table 3). Besides, whereas at the baseline the effect of poor health is the greatest on life satisfaction, at wave 6 it is eudemonic wellbeing that is the most affected by bad health with a coefficient of -0.196 (sum of -0.122 and -0.074).

However, the contribution of health to life satisfaction does not decrease steadily (figure 2 and table 3). It follows the kink in the trends of the raw data (figure 1) in that its importance drops at wave 5 then rises slightly, but it does not recover its initial level. As stated earlier, this may be due to the wave dummies that, besides that of age, capture the effect of unobserved period-specific factors such as the consequences of the 2008 financial crisis for instance.

Figure 3 depicts the effect of poor health on SWB by birth cohort. For the eudemonic and experienced (both positive and negative) measures, those born between 1920 and 1930 exhibit more pronounced changes in the importance of health for SWB as they get older compared to younger cohorts. For life satisfaction, the changes for this oldest cohort run in opposite directions from those observed for the younger cohorts and become similar to those of other forms of well-being. This indicates that the changes with age in the relationship between health and life satisfaction are not linear. This may also be the case, though to a lesser extent, for positive and negative affect for which the youngest cohort (those born in the 1960's) exhibits trends different from those of older cohorts.

---Figure 3 should be here ---

Robustness checks

The robustness analyses are presented in table A2 (online appendix). Changing the health measure and allowing for the re-weighting of all the life domains leads to results qualitatively similar to those of our main analysis. Allowing for changes in the importance of all life domains lead to some substantial changes when considered in combination with SRH. For instance, the interaction terms between time and health are no more significant for life satisfaction. With predicted SRH, allowing for changes in all life domains weights did not change the coefficients for health and for the interaction between health and time. We found significant interaction terms for other life domains than health (results not shown), which may explain why there are changes in some of the coefficients for the time fixed effects. The age effects on SWB are of the same sign than for the main analysis, though they are weakened for positive affectivity and of an increased magnitude for eudemonic well-being. Finally, we estimated separate models for the items of the positive and negative affect measures and for each dimension of the CASP-12. Concerning the latter, although the signs of the time fixed effects vary between the dimensions, the estimated coefficients for the interaction terms all show an increasing importance of health with time/age whatever the dimension of eudaimonia, which is consistent with our main analysis (table A3, online appendix). Table A4 (online appendix) reports the estimations for the items of the aggregated measures of positive and negative affect. As for our main analysis, they indicate an increase in the importance of poor health with age, whatever the measure of positive affect.

Regarding negative affect, the results suggest that our finding of an increased importance of health with age is mostly explained by the item of thoughts of death and, to a lesser extent, by those of irritability and sadness. By contrast, feelings of guilt and tearfulness show no significant change with age.

Discussion

Main results

The main original finding of this research on Europeans aged 50 onwards is that the contribution of health to SWB changes over time in ways that depend on the cohort of birth and, most notably, of the aspect of SWB considered. An additional finding is that few of the changes in the importance of health are consistent with the assumption of hedonic adaptation to a declining health. These results are summarized in table 4.

---Table 4 should be here ---Consistent with the literature [START_REF] Cubí-Mollá | A Study of the Relationship between Health and Subjective Well-Being in Parkinson's Disease Patients[END_REF][START_REF] Dolan | Do we really know what makes us happy? A review of the economic literature on the factors associated with subjective well-being[END_REF][START_REF] Ngamaba | How strongly related are health status and subjective well-being? Systematic review and meta-analysis[END_REF][START_REF] Ryff | Eudaimonic well-being, inequality, and health: Recent findings and future directions[END_REF][START_REF] Steptoe | Subjective wellbeing, health, and ageing[END_REF], we found health to be strongly correlated with all measures of SWB. Yet, we observed differences between the measures in terms of changes over time in their association with health. Specifically, we found somewhat similar patterns of changes with age for eudemonic and experienced well-being on one hand and a different trend for life satisfaction on the other hand. In addition, we found support for the assumption of hedonic adaptation to health decline with age, only in life satisfaction for individuals under 80.

In our sample, the importance of health for life satisfaction slightly decreases over time for those above 50 and less than 80. This is at odds with some studies showing an increasing contribution of health to life satisfaction between 50 and 70 [START_REF] Bardo | A life course model for a domains-of-life approach to happiness: Evidence from the United States[END_REF][START_REF] Bonsang | Retirement and subjective well-being[END_REF]. This could be due to these studies explaining life satisfaction by measures of satisfaction with health rather than SRH. For instance, assessments of satisfaction with health could be more sensitive to the comparison with same-aged individuals than SRH. Our findings for life satisfaction are consistent with hedonic adaptation since, all other things equal, lowering the importance of poor health may contribute to maintaining SWB over time all other things equal. They also seem to be in line with [START_REF] Frijters | Do individuals try to maximize general satisfaction?[END_REF] who found that people progressively give less importance to these areas of life with which they are less satisfied. Besides, they may be interpreted as in accordance with the psychological socioemotional selectivity theory that has been invoked to explain the increase of SWB in older adults [START_REF] Lin | Heterogeneity in the relationship between subjective well-being and its determinants over the life cycle: A varying-coefficient ordered probit approach[END_REF][START_REF] Steptoe | Subjective wellbeing, health, and ageing[END_REF] since they could be indicative of the prioritization of positive aspects of life over negative ones [START_REF] Löckenhoff | Socioemotional selectivity theory, aging, and health: the increasingly delicate balance between regulating emotions and making tough choices[END_REF]. However, for those individuals aged 80 and above the importance of health strengthens over time (table 4). This indicates that even if hedonic adaptation to health decline as we interpret it occurs in life satisfaction, it may not last permanently.

This result may be consistent with studies that found a late-life decline in life satisfaction [START_REF] Hansen | The age and subjective well-being paradox revisited:A multidimensional perspective[END_REF].

The association between health and eudemonic and experienced well-being becomes stronger as one ages (except for the youngest cohort for experienced well-being). Although this evidence seems to run counter the idea of hedonic adaptation to health decline with age, it may not necessarily be surprising.

First, although the potential differences between measures of SWB have long been overlooked, some studies evidenced differences in their determinants [START_REF] Dolan | The Measure Matters: An Investigation of Evaluative and Experience-Based Measures of Wellbeing in Time Use Data[END_REF][START_REF] Kahneman | High income improves evaluation of life but not emotional wellbeing[END_REF][START_REF] Knabe | Dissatisfied with Life but Having a Good Day: Time-use and Well-being of the Unemployed[END_REF]. Second, the discrepancies we observed regarding the evolution of the importance of health reflect the differences in the trends of SWB data. Third, SWB is known to be shaped by social comparison, that is by assessments made in comparison with similar individuals [START_REF] Clark | Four Decades of the Economics of Happiness: Where Next?[END_REF].

Hence, SWB may also be influenced by health as compared with that of same-aged individuals (relative health). Relative health might not affect all forms of SWB equally, because it evokes more a cognitive rather than an affective assessment. This could explain why the contribution of health to SWB decreases with age only for life satisfaction in our sample. Finally, the different trend in the impact of poor health on the life satisfaction of the oldest old as compared to younger cohorts is puzzling. One potential explanation could be that the interpretation of SRH changes with age. For instance, it has been shown that the link between physical health and SRH weakens with age [START_REF] Idler | What Do We Rate When We Rate Our Health? Decomposing Agerelated Contributions to Self-rated Health[END_REF]. We may hypothesize than as one approaches end of life, the interpretation of SRH shifts from a mainly functional one to a more probability of survival oriented one. This could justify why SRH becomes more important for the life satisfaction of the oldest old and why the negative impact of poor health on eudemonic and experienced SWB is stronger in the oldest cohort.

Limitations and perspectives

Our study has some limitations that provide avenues for further research. First, we do not consider the possibility of reverse causality between health and SWB. Studies indicated that a high SWB may be beneficial for both health and survival [START_REF] Diener | If, Why, and When Subjective Well-Being Influences Health, and Future Needed Research[END_REF][START_REF] Steptoe | Happiness and Health[END_REF]. For instance, the differences between the youngest cohorts and the oldest one we observed for life satisfaction could be due in part to a selection effect if the probability of survival -and thus to continue participation to the SHARE survey -is associated with SWB. Furthermore, empirical observations suggest that the effect of SWB on health may increase with age [START_REF] Diener | If, Why, and When Subjective Well-Being Influences Health, and Future Needed Research[END_REF]. Future research should try to tackle this issue using recursive dynamic panel data methods. Second, the period over which the SWB measures were collected included that of the 2008 financial crisis that is known to have impacted -at least temporarily -the individuals' SWB. This might have temporarily redirected the individuals' attention between their various life domains and may thus have complicated the identification of changes in the health-SWB relationship given that our time dummies capture both the effect of age and that of unobserved period-specific factors. A simple solution would be to try to replicate our results on different periods. Third, we restricted our analyses to absolute changes in the coefficients for health, although we introduced the possibility of changes for other life domains in our robustness analyses.

The relative importance of health may change differently than the estimated coefficient for health.

However, as we mentioned earlier, this relative importance would be sensitive to the set of domains of life considered. Besides, our robustness checks indicate that allowing for changes in the contribution of other life domains do not contradicts our main analysis. Fourth, the SHARE survey does not provide explicit measures of positive and negative feelings, which led us to select questions to serve as proxy for experienced well-being. The obtained constructs may not be as reliable than validated measures. Specifically, our findings regarding negative affectivity are sensitive to the item under consideration which suggests either that our construct is invalid or that the importance of the various items does not converge. Our findings might thus not be generalizable to alternative measures of negative affect. Finally, the changes in the importance of health could be a 'pure' consequence of aging independent of the decline in health. Our empirical approach does not allow to disentangle these two possibilities, but this does not invalidate the finding that the contribution of poor health to SWB changes with aging in ways specific to the form of SWB.

Conclusion

To the best of our knowledge, this research is the first that addresses the possibility that SWB adapts to the natural decline in health with ageing. Its main contribution is to employ a large European survey dataset to provide evidence that the contribution of health to the SWB of older adults varies nonlinearly over time and differently depending on the component of SWB, except for the oldest old.

Besides, we found little support for hedonic adaptation, restricted to the life satisfaction of individuals of less than 80. This might lead to re-interpret previous evidence of hedonic adaptation to health problems. Using SHARE data, de Hond et al. (2019) showed that there is adaptation for long-standing functional limitations such that their impact on life satisfaction lessens as time passes. As the authors note, "Interestingly, this adaptation occurs while the health of the respondents deteriorates" (de Hond et al.,p. 186). Our findings suggest that the reverse explanation could also be invoked whereby the individuals adapt partly because their health deteriorates with ageing, whether they are facing a chronic condition or not. However, our analyses suggest that eudemonic and experienced well-being do not adapt and that, on the contrary, poor health hits these forms of SWB harder as one gets older.

Future research could explore whether our findings are sensitive to the specific measures of SWB we employed and potential explanations for why the contribution of health might vary in opposite directions depending upon the form of SWB except for the oldest old.

Our study should provide insightful, original information for the normative debate about how measures of SWB could be used to inform policy decision making and, more specifically, about the value that should be ascribed to health for the practice of economic evaluation in healthcare. For instance, cost-utility analysis that uses Quality-Adjusted Life-Years (QALYs) to represent the effectiveness of healthcare typically assumes that a QALY is of equal value regardless of the age of the individual. According to our analyses, not only does the value of health, as determined from measures of SWB, may change with age, but it can do so differently depending on the measure of SWB from which it is inferred. Specifically, findings caution against the use of mean estimations over the lifespan to determine the value of health. They also caution against the use of the various forms of SWB interchangeably in public policy analysis and economic evaluations of healthcare.

Table 1 .

 1 Sample's description

		Effects of health shocks -Poor SRH (Predicted)-on well-being over time
	Marginal effect	Positive affects	0.16	Negative affects
			0.14
			0.12
			0.10
			2007	2011	2013	2015
		Time

Table 4 .

 4 Summary results of the main analysis (FE models for SWB) a sign '+' (resp. '-') indicates that the importance of health for SWB increases (resp. decreases) with age

	Component of SWB	Relationship with heath	Evolution of the relationship with
			health according to age*
	Evaluative
	Life satisfaction	+	-then + (>80 years old)
	Experienced
	Positive affectivity	+	+ (except youngest birth cohort)
	Negative affectivity	-	+ (except youngest birth cohort)
	Eudemonic
	CASP 12 scale	+	+

*

668 3,380 3,386 2,695 10,129 Belgium 1,936 3,840 4,387 3,982 14,145 Czech Republic 1,215 3,661 4,037 3,867 12,780 Denmark 1,680 1,969 3,329 3,084 10,062 France 1,506 3,674 3,693 3,032 11,905 Germany 1,271 1,309 3,811 3,696 10,087 Italy 1,858 2,545 3,261 3,143 10,807 Spain 1,480 2,710 4,219 3,980 12,389 Sweden 1,781 1,692 3,372 3,256 10,101

collection has been funded by the European Commission through FP5 (QLK6-CT-2001-00360), FP6 (SHARE-I3: RII-CT-2006-062193, COMPARE: CIT5-CT-2005-028857, SHARELIFE: CIT4-CT-2006-028812), FP7 (SHARE-PREP: GA N°211909, SHARE-LEAP: GA N°227822, SHARE M4: GA N°261982) and Horizon 2020 (SHARE-DEV3: GA N°676536, SERISS: GA N°654221) and by DG Employment, Social Affairs & Inclusion. Additional funding from the German Ministry of Education and Research, the Max Planck Society for the Advancement of Science, the U.S. National Institute on Aging (U01_AG09740-13S2, P01_AG005842, P01_AG08291, P30_AG12815, R21_AG025169, Y1-AG-4553-01, IAG_BSR06-11, OGHA_04-064, HHSN271201300071C) and from various national funding sources is gratefully acknowledged(see www.share-project.org). Declarations of interest: none.


Caroline Pecriaux
email: caroline.pecriaux@aphp.fr

PLACE DE LA VITAMINE B6 DANS LE TRAITEMENT DES NAUSEES ET VOMISSEMENTS GRAVIDIQUES INTEREST OF VITAMIN B6 FOR TREAMENT OF NAUSEA AND/OR VOMITING DURING PREGNANCY

1 Le CRAT a récemment été sollicité par un clinicien au sujet de l'utilisation éventuelle de la vitamine B6 (pyridoxine) à fortes doses (250 mg/j) dans les nausées et vomissements de la grossesse après avoir pris connaissance de recommandations internationales. En effet, s'il n'existe pas en France de recommandations pour la pratique clinique relatives à la prise en charge médicamenteuse des nausées et vomissements gravidiques, aux USA, au Canada et en Australie les recommandations existantes proposent la vitamine B6 par voie orale en 1 ère intention des méthodes pharmacologiques (cf. Figure 1), parfois au même niveau que des méthodes non pharmacologiques (gingembre notamment), dans les nausées et vomissements gravidiques légers à modérés [START_REF]Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 189: Nausea And Vomiting Of Pregnancy[END_REF][START_REF] Lowe | Guideline for the management of nausea and vomiting in pregnancy and hyperemesis gravidarum[END_REF][START_REF] Campbell | The Management of Nausea and Vomiting of Pregnancy[END_REF]. La posologie usuellement recommandée se situe selon les référentiels entre 40 mg/j et 100 mg/j, avec une posologie maximale de 200 mg/j (2).

Que savons-nous du rapport bénéfice/risque de la vitamine B6 dans cette indication ?

La vitamine B6 est une vitamine hydrosoluble qui intervient notamment dans le métabolisme des acides aminés et du glycogène ainsi que dans la synthèse de l'hémoglobine et de neurotransmetteurs (4). Son mécanisme d'action sur les nausées et vomissements de la grossesse n'est pas clairement établi. Elle inhiberait les récepteurs histaminiques H1 et muscariniques et agirait de manière indirecte sur le système vestibulaire ce qui diminuerait la stimulation du centre du vomissement [START_REF] Lowe | Guideline for the management of nausea and vomiting in pregnancy and hyperemesis gravidarum[END_REF].

Selon l'EFSA (Autorité européenne de sécurité des aliments), les apports de référence journaliers en vitamine B6 sont de 1,6 mg/j chez la femme adulte et de 1,8 mg/j chez la femme enceinte (4).

Un excès de vitamine B6 peut être à l'origine d'effets indésirables neurologiques (somnolence, neuropathie périphérique sensorielle et motrice) qui, pour les plus sévères, apparaissent en général à des posologies supérieures ou égales à 500 mg/j (4). Des effets moins sévères peuvent également survenir dès 100 mg/j en cas des prises prolongées. Ces effets sont réversibles à l'arrêt du traitement.

Des spécialités associant de la vitamine B6 à de la doxylamine (Donormyl®) ont une AMM aux USA, au Canada et au Royaume Uni chez la femme enceinte dans l'indication des nausées et vomissements de la grossesse avec une posologie maximale de 40 mg/j pour chaque composant.

Efficacité

Deux essais cliniques randomisés contrôlés testant la vitamine B6 seule par voie orale contre placebo ont été conduits à des posologies de 30 mg/j et 75 mg/j respectivement [START_REF] Sahakian | Vitamin B6 is effective therapy for nausea and vomiting of pregnancy: a randomized, double-blind placebo-controlled study[END_REF][START_REF] Vutyavanich | Pyridoxine for nausea and vomiting of pregnancy: a randomized, double-blind, placebo-controlled trial[END_REF]. L'essai comprenant le plus de patientes (n=173 patientes traitées par vitamine B6 à 30 mg/j pendant 5 jours) a montré une efficacité de la vitamine B6 supérieure au placebo sur la réduction des nausées mais pas sur les vomissements [START_REF] Vutyavanich | Pyridoxine for nausea and vomiting of pregnancy: a randomized, double-blind, placebo-controlled trial[END_REF]. Pour l'autre essai, les effectifs sont trop faibles (n= 31 patientes traitées par vitamine B6 à 75 mg/j pendant 3 jours) pour pouvoir exploiter les résultats.

La vitamine B6 associée à de la doxylamine (Donormyl®) a été testée dans un essai clinique randomisé contrôlé contre placebo [START_REF] Koren | Effectiveness of delayedrelease doxylamine and pyridoxine for nausea and vomiting of pregnancy: a randomized placebo controlled trial[END_REF]. La posologie de vitamine B6/doxylamine utilisée était de 40 mg/40 mg par voie orale maximum par jour (n=140 patientes). Cette association était efficace sur la réduction des nausées et vomissements modérés de la grossesse. D'autres études d'efficacité de la vitamine B6 par voie orale (associée ou non à de la doxylamine) ont été menées en la comparant à d'autres antiémétiques (dimenhydrinate, gingembre, métoclopramide, ondansétron) à des posologies de 20 mg/j à 160 mg/j. Au mieux, l'efficacité est similaire à certaines autres thérapeutiques (gingembre, métoclopramide) mais généralement l'autre traitement est plus efficace (notamment dimenhydrinate et ondansétron). A noter que l'étude comportant une posologie de vitamine B6 de 160 mg/j montre une efficacité supérieure du gingembre sur les vomissements de la grossesse et une efficacité similaire entre la vitamine B6 (n=35), le placebo et le gingembre sur les nausées [START_REF] Firouzbakht | Comparison of ginger with vitamin B6 in relieving nausea and vomiting during pregnancy[END_REF].

Innocuité

Les données de sécurité (risque tératogène et /ou foetotoxique) sont très nombreuses et rassurantes à des posologies de vitamine B6 inférieures ou égales à 40-60 mg/j par voie orale [START_REF] Madjunkova | The delayed-release combination of doxylamine and pyridoxine (Diclegis®/Diclectin ®) for the treatment of nausea and vomiting of pregnancy[END_REF][START_REF] Anderka | Medications used to treat nausea and vomiting of pregnancy and the risk of selected birth defects[END_REF][START_REF] Czeizel | Oral pyridoxine during pregnancy : potential protective effect for cardiovascular malformations[END_REF]. Les études portent majoritairement sur les spécialités en association avec la doxylamine (40 mg/40 mg) [START_REF] Koren | Effectiveness of delayedrelease doxylamine and pyridoxine for nausea and vomiting of pregnancy: a randomized placebo controlled trial[END_REF]. Pour des posologies supérieures, les données sont moins nombreuses sans signal inquiétant retenu à ce jour. Une étude suggère que la vitamine B6 pourrait être utilisée sans risque jusqu'à 200 mg/j [START_REF] Shrim | Pregnancy outcome following use of large doses of vitamin B6 in the first trimester[END_REF]. Cependant ses conclusions sont basées sur un très petit effectif de femmes enceintes exposées à cette posologie (37 exposées à une posologie entre 110 et 200 mg/j, 11 exposées à plus de 200 mg/j).

Pour les posologies les plus élevées de vitamine B6 utilisées dans les maladies métaboliques (de 100 à 750 mg/j selon les études, notamment dans l'homocystinurie et l'hyperhomocystéinémie), il y a très peu de données chez la femme enceinte à ce jour [START_REF] Levy | Reproductive fitness in maternal homocystinuria due to cystathionine beta-synthase deficiency[END_REF][START_REF] Quéré | Vitamin supplementation and pregnancy outcome in women with recurrent early pregnancy loss and hyperhomocysteinemia[END_REF][START_REF] Vilaseca | Two successful pregnancies in pyridoxinenonresponsive homocystinuria[END_REF]. Une trentaine de grossesses sont retrouvées dans la littérature sans signal particulier. Aucun effet délétère n'est observé chez les foetus ou les enfants.

  Pour conclure : Dans quelques études, la vitamine B6 utilisée par voie orale et le plus souvent en association avec la doxylamine (Donormyl°) présente une certaine efficacité dans le traitement des nausées et vomissements gravidiques légers à modérés en comparaison à un placebo. Certaines spécialités ont l'AMM dans cette indication aux USA, Canada, Royaume Uni. L'innocuité de la vitamine B6 par voie orale en cours de grossesse est établie pour des posologies allant jusqu'à 40-60 mg/j. En France : -La question de l'intérêt d'ajouter la vitamine B6 à l'arsenal du traitement des nausées et vomissements légers à modérés de la grossesse pourrait être posée.-Cependant, sur le marché français les seules spécialités disponibles par voie orale contenant de la vitamine B6 seule sont dosées à 250 mg par comprimé (sécable) ou par ampoule injectable et ont une AMM uniquement dans les carences avérées en vitamine B6.-De plus, à ces niveaux de doses, les données disponibles sur l'innocuité de la vitamine B6 sont encore très parcellaires, et les femmes enceintes sont aussi susceptibles que les femmes non enceintes de présenter des effets indésirables neurologiques après de fortes doses et/ou des cures prolongées de vitamine B6.-Ainsi, comme recommandé dans d'autres pays, la vitamine B6 pourrait être proposée par voie orale, seule ou en association avec de la doxylamine, dans le traitement des nausées et vomissements légers à modérés de la grossesse sous forme de préparation magistrale à la posologie maximale de 10 mg quatre fois par jour (16).-En revanche, les arguments en faveur d'une utilisation de doses journalières de vitamine B6 plus élevées ne sont pas suffisamment solides en l'état pour valider cette pratique. *L'auteur déclare ne pas avoir de liens d'intérêt en relation avec le contenu de cet article.


Marion Le Goas
email: marion.legoas@aphp.fr

Tony Roy Edward

Hawa Camara

Amalini Simon

Coconstruire le soin avec les adolescents et leurs familles venus d'ailleurs

Les patients rencontrés à la Maison de Solenn -que ce soient des familles venues d'ici et d'ailleurs, des enfants de migrants ou encore des adolescents confiés -nous amènent généralement à nous confronter à nos propres représentations. En effet, les représentations de la souffrance psychique, de l'adolescence, de la famille ou encore des façons de soigner peuvent varier d'une culture à une autre. Elles peuvent donc s'interposer à nos manières de faire ici. Il peut s'instaurer un éventuel malentendu à la première rencontre, amenant les adolescents à ne pas poursuivre leur démarche. Aussi, le parcours de soins préétabli par l'institution est susceptible d'être un peu modifié. L'infirmière, soignant clé de ces premières rencontres, doit alors ajuster le cadre institutionnel aux représentations et à la temporalité de chacun. Elle doit cependant garder en vue l'objectif principal qui est d'instaurer un accompagnement psychiatrique pour ces adolescents en grande souffrance psychique. Exemple avec trois vignettes cliniques.

T1 Carlos, accueillir les paradoxes

Le premier contact avec Carlos est établi par téléphone. Il a lui-même appelé la Maison des adolescents (MDA) via le numéro dédié aux premiers rendez-vous. Nous recevons rarement des appels émis directement par les adolescents. L'équipe infirmière se charge alors de répondre, d'évaluer et d'orienter ces appels. « Bonjour, je m'appelle Carlos, j'ai 13 ans et j'ai besoin d'aide… Je ne vais plus à l'école depuis deux mois et je ne peux pas rester chez moi… ça m'embête. » « Très bien, Carlos, c'est très courageux de nous appeler. Je te propose de venir rencontrer un pédopsychiatre qui pourra t'aider dans tes difficultés du moment, je vais appeler ta maman pour m'assurer de son accord. » Cet appel à l'aide interpelle d'emblée l'infirmière qui a décroché le téléphone. La poursuite des soins semble ici nécessaire.

T2 Une histoire douloureuse

La maman est contactée et les préoccupations autour de Carlos se révèlent : déscolarisation à la suite de multiples exclusions, troubles du comportement allant de l'insolence aux crises clastiques et conflit familial important. La mère souhaiterait le placement de son fils. L'exclusion de l'internat éducatif intervient au même moment, après de nombreux échecs dans d'autres établissements. Elle évoque également la présence d'autres professionnels auprès de la famille, comme les services de l'Aide sociale à l'enfance (ASE), ainsi qu'un suivi antérieur au centre médico-psychologique (CMP) de proximité. La mère indique aussi la rupture de ce dernier suivi au moment de l'appel. L'infirmière est alors tenue de faire le lien avec ces différents intervenants, pour affiner l'évaluation de la demande. À la prise de contact, les professionnels du CMP évoquent en effet un échec du suivi. Ils souhaitent également un relais dans notre structure, en particulier pour les consultations transculturelles. Ils mentionnent alors une étiologie culturelle imposante, entravant la pensée : Carlos serait un enfant "sorcier". Étiologie qui serait portée par le grand-père, et qui est plus ou moins partagée par la mère, tous deux originaires du Congo. Un suivi est alors initié à la Maison de Solenn, dans ce contexte particulier. Carlos se rend régulièrement aux rendez-vous, qui ont lieu un vendredi sur deux avec l'infirmière qui a reçu son appel. Cependant, il désinvestit rapidement le suivi psychiatrique. Carlos et sa maman diront d'ailleurs : « Les psychiatres, c'est pour les fous, nous on n'est pas comme ça. » Nous nous retrouvons alors face à une injonction paradoxale, avec une demande de soins parallèle à un refus des soins proposés (pédopsychiatrie et psychothérapie individuelle). Le cadre devra donc être quelque peu contourné pour assurer le suivi de Carlos.

T2 Stratégie soignante

Un compromis est proposé : une psychologue s'associera aux entretiens infirmiers. Toutes deux sont des professionnelles sensibilisées à la clinique transculturelle. Après la mise en place de ce nouveau dispositif d'accueil, l'alliance avec Carlos est de meilleure qualité. Les symptômes dépressifs prennent alors le devant sur les troubles du comportement : tristesse, troubles du sommeil, cassure de la courbe de poids, etc. Dans ce nouveau contexte, l'alliance est suffisamment bonne pour étayer le suivi de Carlos. Nous pouvons inclure un nouveau psychiatre référent, tout en maintenant l'investissement de la mère dans les soins. Il sera même possible d'envisager, en situation de crise, une hospitalisation pour Carlos. La mère relate également ses difficultés avec son fils, notamment le rejet de sa famille vis-à-vis de ce dernier. Pourtant, aucun sens n'y est donné. Elle admet que Carlos est singulier. Elle refuse cependant les traitements psychiatriques, et ne parvient pas non plus à recréer un récit autour de ce qui a pu toucher son fils.

T2 Construire un lien

Les consultations transculturelles lui seront alors proposées à ce moment-là. Il aura fallu un an et demi avant qu'elles ne débutent avec Carlos et sa maman. En effet, il était nécessaire de s'adapter au temps du patient et de redonner des "contenants" avant d'aborder le "contenu". Nous avons ensuite pris le temps de créer du lien avec la maman, de valoriser ses compétences de mère, ses savoir-faire d'ici et d'ailleurs, etc. Tout cela par le biais d'échanges autour des valeurs éducatives, de la nourriture, de la langue maternelle, etc. Les consultations transculturelles ont aussi permis d'installer une confiance envers l'institution, en favorisant des échanges avec les différents intervenants comme l'internat éducatif ou l'ASE.

T1 Anastasia, étiologies familiales et questionnements

Anastasia s'est présentée pour la première fois avec sa maman à l'espace santé, avec à la main un courrier d'un service d'urgences psychiatriques. Ce dernier indiquait l'orientation vers une structure de soins, autre que la MDA. Il indiquait également une date de premier rendez-vous avec un psychiatre, dépassée de plusieurs mois. Anastasia et sa maman sont reçues par une infirmière dans ce contexte, a priori, de malentendu sur l'orientation des soins. La migration récente de la famille et les difficultés sociales sont rapidement mises au premier plan. La famille a quitté la Roumanie quatre ans auparavant. Elle est actuellement exposée et fragilisée par la précarité liée au logement. La famille vit à l'hôtel et en change régulièrement. Cela s'explique notamment par la situation administrative et par la non-maîtrise du français. Les parents s'expriment en albanais seulement et Anastasia traduit pour la famille. Sa mère parle également d'un malentendu avec les services sociaux, entraînant un placement d'Anastasia et de sa petite soeur.

T2 Vécu difficile

Anastasia révèle des signes préoccupants lors de ce premier entretien infirmier : baisse de l'humeur, trouble du sommeil, anhédonie, déscolarisation, scarifications. Sa maman évoque des carences en vitamines comme origine de toutes ces manifestations. Il était important ici que l'infirmière d'accueil soit sensibilisée au transculturel pour faciliter l'alliance en abordant, par exemple, la question de l'interprète. Cela dans le but de trouver un sens commun au suivi psychiatrique, afin que l'errance thérapeutique ne perdure pas. L'infirmière d'accueil restait présente tout au long du parcours de soins pour permettre une certaine stabilité, alors que les lieux et les interlocuteurs changent souvent à l'extérieur.

Cette étape autour du sens de chacun a donc été donc indispensable pour la suite. Le cadre préalablement établi par l'institution a été, ici aussi, quelque peu mis à mal par le manque d'accord franc de la famille pour les soins. Le suivi a malgré tout été possible.

T2 Reprise de la scolarité À ce jour, Anastasia est régulièrement présente à la MDA, pour des rendez-vous avec psychiatre, infirmière et pour une mise en place d'un suivi somatique. La maman a accompagné Anastasia une fois. Une interprète est toujours sollicitée, le lien avec la maman pouvant être fait par téléphone. Elle dit par exemple ne pas comprendre les sens des mots "psychiatre" et "dépression". Elle ne s'est cependant pas opposée au suivi mis en place. La prise en charge a permis d'apaiser certains symptômes d'Anastasia, qui a pu reprendre sa scolarité, à l'aide d'un programme d'aide individualisé. La migration et la vie en Roumanie sont des thèmes qui sont difficilement abordés. Anastasia ne dit avoir aucun souvenir. La question des consultations transculturelles, pour permettre une mise en récit commune du parcours de la famille, reste pour l'instant en suspens. En effet, il est préférable d'attendre pour voir l'évolution d'Anastasia, et ainsi mieux estimer la nécessité ou non de ces consultations spécialisées, pouvant permettre une meilleure alliance avec la maman.

T1 Les Diez, différentes manières de "faire" famille En temps normal, nous imposons aux adolescents d'être accompagnés par leurs parents pour un suivi médical, ou du moins par un référent légal. Cependant, il existe certaines situations complexes de migrations, certaines représentations culturelles qui nous obligent à nous adapter face à une réalité qui est autre. Nous exposerons dans la vignette suivante la situation d'un enfant confié. De passage en France, Juan, 17 ans, se présente spontanément à la MDA en compagnie de sa mère et de sa tante. Tous les trois sont originaires du Brésil. Ils sont également reçus par une infirmière formée à la clinique transculturelle. Juan se plaint alors de symptômes dépressifs. Il pleure et dit souffrir de troubles du sommeil. Il sollicite alors la MDA pour apaiser ses symptômes. Il évoque aussi rapidement des conflits familiaux importants, nécessitant l'intervention des services de l'ASE. Sa tante et sa mère pleurent également. Elles approuvent la démarche de demande de soins de Juan.

T2 Prise en charge

Un suivi psychiatrique est mis en place à la MDA à la suite de cet entretien infirmier. Une proposition rapide de consultations est également faite au groupe "Métissages". Ce dernier découle des consultations transculturelles. Il permet un suivi encadré par un groupe de cothérapeutes plus restreint, dans le but d'aborder avec la famille des thématiques plus sensibles et intimes. Cette proposition est motivée par la complexité de l'histoire familiale et l'impact de la violence à différents niveaux. Nous retrouvons en effet de la violence au niveau familial, sociétal (violence de gangs) et migratoire. Il est donc essentiel de connaître précisément le fonctionnement des différents groupes de l'institution, pour assurer au mieux les indications. Cela permet d'abord une bonne orientation des soins, puis une meilleure alliance avec la famille. Les infirmières peuvent ainsi rassurer les familles si besoin, et les préparer au suivi. L'infirmière qui a accueilli Juan la première fois accompagne la famille dans ses consultations. L'ouverture aux familles venues d'ici et d'ailleurs, ainsi que le décentrage culturel nécessaire lors de ces accompagnements, ont permis aux Diez de se présenter au groupe de soins, au sens de ce qui fait famille pour eux. En effet, nous avons reçu également la tante, des enfants confiés, des enfants adoptés ou encore une "grand-mère de coeur" française. Au cours du suivi, la maman de Juan est repartie au Brésil, et trois de ses petites soeurs sont arrivées. La fratrie est donc accompagnée lors de ces rendez-vous par leur tante et par une marraine.

T2 Accompagnement essentiel

Le groupe de soins a été essentiel pour donner du sens à ce qui touche la famille, pour se représenter au mieux cette notion et la place de chacun. Il a pu aussi mettre en lumière des difficultés sociales impossibles à exprimer en suivi individuel, ainsi qu'un mal-être envahissant concernant l'une des petites soeurs, Magdalena, âgée de 15 ans. À ce jour, une orientation en psychiatrie adulte a été faite pour Juan, dans une structure du secteur. Le groupe Métissages reste un rendez-vous trimestriel nécessaire à la famille. Il a permis une alliance suffisamment bonne pour que Magdalena adhère également à un suivi psychiatrique au sein de la MDA. Jeune ado très déprimée et au vécu traumatique, elle rencontre une pédopsychiatre régulièrement. L'infirmière d'accueil demeure une personne repère dans toutes ces étapes (lien avec le CMP de secteur, accompagnante au groupe Métissages, lien avec la pédopsychiatre). En outre, toutes ces rencontres se font bien sûr avec l'aide d'une interprète.

T1 Conclusion

Ces vignettes illustrent la complexité de l'accompagnement des adolescents à la clinique transculturelle. En effet, cette clinique particulière ne correspond pas toujours aux attentes classiques des institutions : accord et présence de la famille, cadre institutionnel, etc. Ces familles s'en trouvent donc fragilisées et échappent encore trop souvent aux systèmes de soins. Nous avons vu pourtant que ces adolescents souffrent tout autant que d'autres. Il semble alors nécessaire d'accueillir les familles autrement. Le décentrage culturel devient clé pour convenir d'un suivi acceptable par tous, institutions et familles. En effet, le décentrage permet d'entendre les représentations de chacun sans y adhérer forcément. Il permet d'accepter par exemple que des idées suicidaires soient attribuées à une carence en vitamine, tout en proposant un suivi pédopsychiatrique. Le recours aux services d'interprètes reste indispensable. L'infirmière, sur qui repose les premiers accueils, se doit d'être vigilante. Elle doit l'être d'autant plus en contexte transculturel, afin d'asseoir le fragile début de relation entre soignant et soigné, sur des bases d'ouverture et de bienveillance. À l'image de chaque adolescent ayant ses spécificités et son parcours unique de soins, la formation des infirmières aux différentes médiations proposées nous paraît primordiale. Elle permet d'optimiser l'accompagnement de façon générale, en favorisant notamment l'alliance aux médiations.

Déclaration de liens d'intérêts

Les auteurs déclarent ne pas avoir de liens d'intérêts.

  Étudiant en master de psychologie clinique, stagiaire à la Maison de Solenn Hawa Camara a,b Psychologue clinicienne, docteure en psychologie clinique Amalini Simon a,b,c Psychologue clinicienne, docteure en psychologie a Maison de Solenn-Maison des adolescents, Hôpital Cochin, AP-HP, 97, boulevard de Port-Royal, 75014 Paris, France b Université Paris-Descartes, PCPP, 71, avenue Édouard-Vaillant, 92774 Boulogne-Billancourt Cedex, France c Hôpital Avicenne, AP-HP, 125, rue de Stalingrad, 93000 Bobigny, France