The	
  French	
  public	
  health	
  framework:	
  
           a	
  model	
  of	
  integrated	
  
          comprehensive	...
Sectorisa?on	
  
•  Establishment	
  of	
  geographical	
  catchment	
  
   areas	
  with	
  dedicated	
  mental	
  health...
The	
  principles	
  
•  Con?nuity	
  of	
  care	
  by	
  a	
  team	
  of	
  professionals	
  
   (	
  nurses,	
  psycholo...
A	
  bit	
  of	
  history	
  

  	
  Adolf	
  Meyer	
  (	
  1915	
  )	
  ar?culates	
  the	
  concept	
  of	
  
   mental...
S.	
  Johnson	
  	
  and	
  G.	
  Thornicro[	
  
                       (	
  1993	
  )	
  
•  Progressively	
  from	
  195...
 	
  	
  	
  Mental	
  Health	
  District	
  (	
  A.	
  Meyer	
  1915	
  )	
  	
  	
  	
  	
  
 



   	
  	
  	
  Centr...
‘	
  Le	
  secteur	
  ‘	
  in	
  France	
  
•  Sectors	
  for	
  mental	
  health	
  service	
  provision	
  were	
  set	
...
•  1968 : Psychiatry is separated from neurology

• 1960 - 1985 :

      A Model predominantly based on a psycho-social
 ...
- Psychiatric sectorization (Dec 31, 1985 Law)
- Same source of funding for inpatient and
outpatient services (December 30...
Data	
  
•  63	
  million	
  inhabitants	
  in	
  France	
  
•  815	
  general	
  psychiatry	
  sectors	
  (	
  adults)	
 ...
Global	
  caseload	
  
Caseload	
  in	
  part	
  ?me	
  services	
  
Personnel/Caseloads	
  
Health	
  economics	
  
•  10%	
  of	
  GNP	
  
•  Mental	
  illness,	
  third	
  category	
  behind	
  CV	
  
   disease	...
Number	
  of	
  psychiatrists/département	
  
                 (non	
  private	
  )	
  
Hospital	
  beds	
  
•    98%	
  of	
  sectors	
  have	
  beds	
  (	
  mean	
  number:	
  54	
  )	
  
•    43173	
  public...
MEAN	
  NUMBER	
  OF	
  BEDS	
  :	
  55	
  
MEAN	
  NUMBER	
  OF	
  OUT	
  PATIENT	
  PLACES	
  :	
  26	
  
Mean	
  length	
  of	
  hospital	
  stay	
  
Souce	
  :	
  Ministry	
  of	
  Health	
  Reports	
  
A	
  balanced	
  approach	
  ?	
  
•  Both	
  community	
  and	
  hospital	
  services	
  are	
  
   necessary	
  in	
  al...
Schizophrenia	
  
             	
  
Diagnosis/gender	
  
Epidemiological	
  data	
  for	
  	
  
                  schizophrenia	
  
•  1	
  %	
  prevalence	
  
•  26	
  %	
  of	
 ...
Diagnosis/age	
  in	
  full	
  ?me	
  
     hospitalisa?on	
  




               DREES	
  2003	
  
Compulsory	
  admissions	
  




           DREES	
  2003	
  
A	
  STUDY	
  OF	
  270	
  PATIENTS	
  WITH	
  SCHIZOPHRENIA	
  TREATED	
  IN	
  20	
  
                                  ...
SERVICES	
  FOR	
  PATIENTS	
  WITH	
  SCHIZOPHRENIA	
  
     A	
  STUDY	
  IN	
  4	
  PSYCHIATRIC	
  SECTORS             ...
Evidence	
  based	
  treatment:	
  the	
  
    use	
  of	
  clinical	
  guidelines
                                      	...
Asser.ve	
  Community	
  treatment	
  



•    First	
  described	
  by	
  STEIN	
  and	
  TEST	
  in	
  1980	
  
•    Num...
STEIN	
  and	
  TEST	
  MODEL
                                                                         	
  
•  Community	
...
Psychosis	
  Informa.on	
  Project	
  




                 	
  Days	
  in	
  Hospital	
  ABer	
  1	
  year	
  and	
  2	
 ...
Psychosis	
  Informa.on	
  Project	
  




     Rehospitaliza.on	
  Rates	
  in	
  Percent	
  ABer	
  1	
  year	
  	
  
  ...
Cogni?ve	
  remedia?on	
  
•  Programmes	
  focused	
  upon	
  improving	
  
   specified	
  cogni?ve	
  func?ons	
  
•  Co...
Rehabilita?on:	
  linking	
  with	
  
  medico	
  social	
  services	
  
Pa?ents	
  with	
  housing	
  problems	
  
GENERAL PSYCHIATRY SECTORS OFFERING SPECIFIC
  SERVICES FOR READAPTATION/REHABILITATION                                  	...
An	
  ar?culated	
  system	
  from	
  care	
  to	
  
             rehabilita?on      	
  
•  Treatment	
  services:	
  the...
Forensic	
  issues
                                              	
  
•  26	
  sectors	
  of	
  forensic	
  psychiatry	
  ...
Other	
  issues
                                     	
  
•  Psychiatry	
  for	
  the	
  elderly	
  (	
  20%	
  of	
  pa?e...
Suicide and
                       attempted suicide



                          French population (60 millions)

Suicida...
Suicide attempts

              ≈ 155 000 suicide attempts managed by the health care
                                    ...
Conclusion	
  
•  The	
  principle	
  of	
  con?nuity	
  of	
  care	
  has	
  shown	
  
   its	
  efficacy	
  for	
  the	
  ...
Psychiatric sectorization
Psychiatric sectorization
Psychiatric sectorization
Psychiatric sectorization
Psychiatric sectorization
Psychiatric sectorization
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Psychiatric sectorization

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\'Le secteur\': principles and present issues

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Psychiatric sectorization

  1. 1. The  French  public  health  framework:   a  model  of  integrated   comprehensive  system                                       «  Le  secteur  »   F.PETITJEAN  
  2. 2. Sectorisa?on   •  Establishment  of  geographical  catchment   areas  with  dedicated  mental  health  staff   providing  services  to  all  pa?ents  living  in  the   area   •  Fondamental  element  in  the  planning  of   community  services  in  most  Western   european  countries  since  the  1980’s  
  3. 3. The  principles   •  Con?nuity  of  care  by  a  team  of  professionals   (  nurses,  psychologists,  psychiatrists,  social   workers..)   •  Treatment  is  to  be  provided  as  early  as  possible   •  Geographical,  cultural  and  social  proximity   •  Going  from  the  mental  hospital  to  the  community   •  Integrate  preven?on,  treatment  and  and   rehabilita?on   •  Hence:  two  different  meanings  (  geographical  and   organiza?on  of  care  )  
  4. 4. A  bit  of  history      Adolf  Meyer  (  1915  )  ar?culates  the  concept  of   mental  health  services  closely  iden?fied  with  a   community     Reemphasized  as  a  basic  premise  of   deins&tu&onaliza&on  with  responsability  of  care   transferred  from  large  state  ins?tu?ons  to  local   community-­‐based  organiza?ons  accountable  for   the  provision  of  services     First  administra?ve  text  (‘  circulaire’)  in  France  in   1960  
  5. 5. S.  Johnson    and  G.  Thornicro[   (  1993  )   •  Progressively  from  1959  to  1985   •  No  na?onal  decision,  but  installed  by  health  districts   •  63%  of  cases  :  one  team   •  10%  of  cases:  dis?nc?on  between  hospital  and   community  teams   •  Tyrer  (  1985,  1989  )  and  Hansson  in  Sweden(  1987  )   show  an  effect  on  the  number  and  the  length  of   hospital  stays  as  well  as  the  number  of  compulsory   admissions  
  6. 6.        Mental  Health  District  (  A.  Meyer  1915  )                    Centre  médico  psychologique          Community  Mental  Health  Centres   (  USA  )          Mental  Health  Ressources  Centres     (  UK  )          Social  Psychiatry  Centres  (  Allemagne  )          Servizi  di  Diagnosi  e  Cura  (  Italie  )  
  7. 7. ‘  Le  secteur  ‘  in  France   •  Sectors  for  mental  health  service  provision  were  set  up  in   the  1960’s  and  1970’s   •  A  mental  health  act  passed  in  1838  had  led  to  the   construc?on  of  large  mental  ins?tu?ons  (  asylums  )   thoughout  the  country   •  Major  role  of  the  historical  context:  a[er  WWII,  a  group   of  psychiatrists  pioneered  a  movement  cri?cal  of  the   asylums   •  Con?nuity  of  this  policy  since  1960,  with  various   legisla?ons  confirming  sectors  as  the  basis  of  the  public   mental  health  system  
  8. 8. •  1968 : Psychiatry is separated from neurology • 1960 - 1985 :   A Model predominantly based on a psycho-social approach   The « Bio » Part is given less Importance • 1970-1985 : a Sharp increase in the number of psychiatrists (1970 : 3000, 1997 : 12000)
  9. 9. - Psychiatric sectorization (Dec 31, 1985 Law) - Same source of funding for inpatient and outpatient services (December 30 and 31, 1985 Laws) - The rights and protection of individuals hospitalized for mental illness (June 27, 1990 Law) -Patients rights. Quality of health care system (March 4, 2002 Law) -New issues: HPST law ( 2009 ), Couty report ( 2008 )
  10. 10. Data   •  63  million  inhabitants  in  France   •  815  general  psychiatry  sectors  (  adults)   •  56  100  inhabitants  per  sector  (  over  20  y  of  age  )   •  80%  of  psychiatric  ac?vity  in  hospitals   •  Approx.  1  151  000  individuals  treated  by  public  mental  health   services  (  mean  1387  per  sector,  a  62%  increase  since  1989  ).   •  26/1000  persons  in  contact  with  mental  health  services   •  54%  of  women     •  Pa?ents  aged  25-­‐44  represent  43%  
  11. 11. Global  caseload  
  12. 12. Caseload  in  part  ?me  services  
  13. 13. Personnel/Caseloads  
  14. 14. Health  economics   •  10%  of  GNP   •  Mental  illness,  third  category  behind  CV   disease  and  diges?ve  (  10,9%  of  total  health   expenditure  )   •  Psychiatric  hospitaliza?on  acounts  for  15,5%   of  total  hospital  costs,  the  highest  propor?on   for  any  illness  
  15. 15. Number  of  psychiatrists/département   (non  private  )  
  16. 16. Hospital  beds   •  98%  of  sectors  have  beds  (  mean  number:  54  )   •  43173  public  adult  psychiatric  beds  in  2000   •  A  gradual  decrease  over  the  years     •  Now  a  major  issue  in  large  ci?es:  finding  a   hospital  bed  for  an  acutely  ill  pa?ent  
  17. 17. MEAN  NUMBER  OF  BEDS  :  55   MEAN  NUMBER  OF  OUT  PATIENT  PLACES  :  26  
  18. 18. Mean  length  of  hospital  stay  
  19. 19. Souce  :  Ministry  of  Health  Reports  
  20. 20. A  balanced  approach  ?   •  Both  community  and  hospital  services  are   necessary  in  all  areas   •  Gradua?on  according  to  the  level  of   ressources  (  low,  medium  or  high  )   •  Studies  by  G.  Thornicro[  and  M.  Tansella   (  2004  ),  by  M.  Coldefy  in  France  (  2010  )  
  21. 21. Schizophrenia    
  22. 22. Diagnosis/gender  
  23. 23. Epidemiological  data  for     schizophrenia   •  1  %  prevalence   •  26  %  of  pa?ents  treated  (  point  prevalence)  in   a  general  psychiatry  sectors  in  2003  (  Le  Fur  et   al.  )   •  230000  pa?ents  ,  75  %  of  them  in  non  private   structures  (Rouillon  ,1992  )  
  24. 24. Diagnosis/age  in  full  ?me   hospitalisa?on   DREES  2003  
  25. 25. Compulsory  admissions   DREES  2003  
  26. 26. A  STUDY  OF  270  PATIENTS  WITH  SCHIZOPHRENIA  TREATED  IN  20   SECTORS   •  Clinical  and  socio-­‐demographic  characteris?cs            270  pa?ents  with  schizophrenia  (DSMIIIR)    Male    Mean  age  34.5  y.o.  2/3      Female  Mean  age  35.4  y.o.  1/3              Mean  dura?on  of  illness                      13  y   •  Rehospitalisa?on  rate  during  24  months  follow  up   •           At  M24  :  42  %  treated  in  a  day  hospital  or  a  day  care  center   VIDON  et  coll  1993              At  M24  :  96  %  have  stable  housing  
  27. 27. SERVICES  FOR  PATIENTS  WITH  SCHIZOPHRENIA   A  STUDY  IN  4  PSYCHIATRIC  SECTORS   KOVESS,  DUBUIS  et  al,   Clinical  and  demographic   1993   characteris?cs   .  167  pa?ents  with  schizophrenia  (ICD  10)   .  Randomly  recruited  in  the  caseloads  of  4  sectors   .  Mean  Age  :  37  y.o.   .  Mean  age  at  first  psychiatric  contact  22  yo   .  70  %  Male   .  13  %  non  sheltered  employment   .  85  %  Perceived  some  form  of  social  benefit                          (social  security  pension  or  AAH).   .  42  %  treated  in  day  hospital  at  inclusion   Follow  up  at  12   month  QOL  (Baker  and  Intagliata)  improved  at   M12  
  28. 28. Evidence  based  treatment:  the   use  of  clinical  guidelines   ACT,  psychoeduca?on,  cogni?ve   remedia?on  
  29. 29. Asser.ve  Community  treatment   •  First  described  by  STEIN  and  TEST  in  1980   •  Numerous  controlled  studies  (BURNS  et  col.2008  )   •  Adapted  in  a  number  of  different  countries:  USA  ,  UK  ,  Italie     •  Has  proved  its  efficacy  in  a  number  of  dimensions:  number  of  hospital  admissions,  quality  of   life  ,  clinical  symptoms….   •  Increases  the  remission  rate  (  Bak,  Van  Os  et  col.  2007  )   •  Par?cularly  for  homeless  pa?ents  ?(  Burns,  2006  )   •  Is  part  of  most  guidelines  (  PORT,  NICE  2009,  McEvoy  ,  Bollini  et  al.  2008,  APA,  2009  ).  
  30. 30. STEIN  and  TEST  MODEL   •  Community  Outreach   •  Mobility  and  Flexibility   •  Most  Services  provided                  directly  (not  brokered  out)   •  24  Hour  Coverage   •  Caseloads  shared  across  clinicians   •  Low  pa?ent  to  staff  Ra?o  (10  :  1)   •  Con?nuity  of  care   •  Time  unlimited  
  31. 31. Psychosis  Informa.on  Project    Days  in  Hospital  ABer  1  year  and  2  years  .    *Mean  39  vs  mean  78  P  <  .05.   BAUML  J.  et  al.  2006.  
  32. 32. Psychosis  Informa.on  Project   Rehospitaliza.on  Rates  in  Percent  ABer  1  year     and  2  years  ,      *  P  <  .05  BAUML  J.  et  al.  2006.  
  33. 33. Cogni?ve  remedia?on   •  Programmes  focused  upon  improving   specified  cogni?ve  func?ons   •  Computer  based  techniques  (  Rehacom,   Recos  )   •  Integra?on  with  other  psychosocial   interven?ons  :  Integrated  Psychological   Therapy  (  Brenner  1990  )  ,  Cogni?ve   Enhancement  Therapy  (  Hogarty  and  Flesher   1999  )  
  34. 34. Rehabilita?on:  linking  with   medico  social  services  
  35. 35. Pa?ents  with  housing  problems  
  36. 36. GENERAL PSYCHIATRY SECTORS OFFERING SPECIFIC SERVICES FOR READAPTATION/REHABILITATION   Source  :  Ministry  of  Health  Reports  
  37. 37. An  ar?culated  system  from  care  to   rehabilita?on   •  Treatment  services:  the  concept  of  balanced   care   •  Specialized  units:  readapta?on,  early  diagnosis   •  Rehabilita?on  services:  SAVS,  SAMSAH,  GEM   •  Voca?onal  rehabilita?on:  ESAT   •  Housing  facili?es  
  38. 38. Forensic  issues   •  26  sectors  of  forensic  psychiatry  services   •  4  units  for  ‘  difficult  pa?ents’,  with  a  total  of  400  beds   •  A  decrease  in  the  number  of  decisions  of  abolished   responsability  for  reasons  of  mental  illness  (  from  0,5  to  0,25%   of  all  criminal  cases  from  1987  to  1997  )   •  May  have  led  to  an  increase  in  the  number  of  individuals  with   mental  illness  condemned  to  a  prison  sentence   •  Recent  studies  show  that  «  3,5  to  4,75%  of  inmates  have  a   diagnosis  of  chronic  psychosis   •  A  growing  concern  ?  Decisions  at  the  highest  level  to  create   new  units:  4  new  UMD,  3  UHSA  (  special  hospital  units  )  
  39. 39. Other  issues   •  Psychiatry  for  the  elderly  (  20%  of  pa?ents   treated  by  public  psychiatry  services  are  over   65  y  of  age  )   •  Psychiatric  emergencies  (  regular  increase  in   the  number  of  medical  emergencies:  4%  per   year  )   •  Specialized  units  for  substance  abuse   •  Child  and  adolescent  psychiatry  
  40. 40. Suicide and attempted suicide French population (60 millions) Suicidal thoughts: 1 million people Attempting suicide: 160 000 people Committing suicide: 12 000 deaths
  41. 41. Suicide attempts ≈ 155 000 suicide attempts managed by the health care sector 72 000 (47 %) by GPs 82 000 (53%) arrive directly in the hospital emergency 55 000 (36%) sent 17 000 (11 %) dept. to emergency dept. stay at home = Total : 137 000 (88 %) 21 000 (15 %) return 116 000 (85 %) remain home directly in hospital Source: drees (Direction de la Recherche des Etudes de l’Evaluation et des statistiques, n°109, April 2001)
  42. 42. Conclusion   •  The  principle  of  con?nuity  of  care  has  shown   its  efficacy  for  the  treatment  of  severe  mental   illness   •  A  necessity  to  create  specialized  units  across   sectors   •  A  reform  in  the  funding  process  shi[ing  from   global  yearly  funding  to  funding  based  on   ac?vity  data:  a  challenge,  an  opportunity  ?  
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