France ranks 13th overall in The Economist Intelligence Unit’s Mental Health Integration Index, but its category results are uneven, ranging from first place in the “Opportunities” category to 20th in “Environment”. The organisation of mental health provision in local sectors enables the creation of some high-quality care systems, but has led to significant inconsistency across the country.

1. 1 © The Economist Intelligence Unit Limited 2014
Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries
France ranks 13th overall in The Economist Intelligence Unit’s
Mental Health Integration Index, but its category results
are uneven, ranging from first place in the “Opportunities”
category to 20th in “Environment”.
The organisation of mental health provision in local sectors
enables the creation of some high-quality care systems, but
has led to significant inconsistency across the country.
This organisational structure has also slowed
deinstitutionalisation, leading to a continuing overuse of
hospitals for mental healthcare.
Weak national policy makes rapid improvement unlikely.
Mental Health Integration Index Results
Overall: 68.4/100 (13th of 30 countries)
Environment : 56.7/100 (20th)
Opportunities: 100/100 (1st)
Access: 71.4/100 (9th)
Governance: 58/100 (13th)
Other Key Data
l Spending: Mental health budget as proportion of
government health budget (2011) 12.9%.
l Burden: Disability-adjusted life years (DALYs) resulting from
mental and behavioural disorders as a proportion of all DALYs
(World Health Organisation estimate for 2012): 13.3%.
l Stigma: Proportion of people who would find it difficult
to talk to somebody with a serious mental health problem
(Eurobarometer 2010): 25%.
SPONSORED BY
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Political leadership is needed to build on early advances
Highlights
Environment
Opportunities
AccessGovernance
Mental Health Integration Index:
Results for France
France Best Average Worst
100
100
80
80
60
60
40
40
20
20
0

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Provision for supporting people with mental illness: A comparison of 30 European countries
Pockets of excellence…
France has a slightly above-average finish in the Mental Health
Integration Index, ranking 13th overall. This aggregate result,
however, reflects wide inconsistencies in different aspects
of mental health provision, rather than steady mediocrity.
In particular, in the Index’s “Opportunities” category, which
deals with the workplace, the country scores maximum points
and ties with Finland in first place. On the other hand, in the
“Environment” section (which assesses the extent to which
conditions allow those with serious mental illnesses to lead a
stable home and family life) it comes 20th, scoring only 56.7
out of 100.
Rather than being a quirk of the index, inconsistency—
across the country’s regions as well as whole fields of service
provision—is widespread in mental health provision in France.
It reflects the evolution of the country’s pioneering efforts in
mental healthcare development several decades ago.
France was one of the first countries to organise mental health
services into separate local units, a policy originally adopted in
1960, but that developed widely only from the mid-1980s when
legislation established rules on organisation and financing.
The country is divided into roughly 850 adult psychiatric
sectors, each a distinct geographic area with coherent socio-
demographic characteristics and populations of about 70,000
people. In every sector, the mental healthcare service is
centred around a hospital unit—either a psychiatric facility or
a specialist ward in a general hospital—that is also responsible
for organising and co-ordinating outpatient services.
Pierre Thomas, professor of psychiatry at the University of
Lille, calls this organisation “a great strength” of the system,
noting that, in principle, it means that wherever patients
live they should be able to access care nearby. Yann Hodé—a
psychiatrist based in the town of Rouffach and head of Pro
Famille, a network dedicated to the education of the families of
those with mental illness—agrees, adding that “in the sector
one knows the social network so it is easier to help people. The
social worker in the sector, for example, knows what facilities
and opportunities are available.” Moreover, organising on
geographic lines rather than by types of pathology means that
all conditions are covered although, notes Dr Hodé, the size of
the sectors can make some highly specialised services—such
as family psycho-education, cognitive remediation or early
detection of psychosis—difficult to organise.
When the system works as intended, the results are impressive.
The psychiatric sector in eastern Lille is one of the leading
sources of best practice in France. The unit organising it is a
World Health Organisation Collaborating Centre specialising
in community-based mental health services and the
empowerment of service users and carers.
Lille has, through efforts spanning nearly four decades,
gone from almost entirely hospital-focused mental health
provision, where all treatment was compulsory, to having
82% of professional staff work on ambulatory, community-
based services. Continuity of care is effective. Alternatives to
hospitalisation include the ability to provide intensive care in
up to ten homes at a time as well as places with therapeutic
host families, where the family provide lodgings for the
individual, and a nurse, along with the social and medical
team, manage medical care and support. Inter-sectoral co-
operation is also substantial and aimed at social inclusion
as well as service provision. Roughly 150 apartments are
available throughout the city for those cared for by the mental

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Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries
health service; vocational and rehabilitation services involve
collaboration between psychiatric and local employment
services, as well as other community partners; two user
self-help groups have been established; and there is even a
dedicated team that helps organise activities and promote
social inclusion in all of the artistic, cultural, and sporting
venues in eastern Lille.
Improvements have been dramatic over the decades, and are
ongoing. The number of individuals under treatment nearly
tripled between 1971 and 2002, while hospitalisation dropped
during the same period from around 77,640 people days to just
4,248. More recently, between 2002 and 2010, the number of
instances of ambulatory care more than doubled, while people
days in hospital fell by a further 41%.
Lille has also benefited from a long-running experiment in
organising collaboration. From the early 1970s a not-for-
profit Medical Psycho-Social Association, made up of various
stakeholders, has met to co-ordinate activities. By 2010 this
included the six mayors of the administrative units within
eastern Lille, along with representatives of users and families
of mental healthcare services, and of artistic and cultural,
low-income housing, social welfare, and psychiatric services.
The association was renamed the Mental Health Local Council
and has been the model for such bodies in several dozen areas
across France.
…in a sea of hospitalisation
As Lille shows, well-run sectors can be effective. Unfortunately,
note Dr Hodé and Mr Thomas, even though they are a great
strength of the French system, they are also a significant
weakness. As Mr Thomas notes, “there are differences
between each sector and some inequalities. Some sectors
are well equipped, and some [are not]. It depends on their
governance.”
Substantial disparities manifest themselves in various ways.
The ratio of adult psychiatric beds to ambulatory places in
the best- and worst-provisioned sectors is 13 to 1, compared
with 4 to 1 for general medicine and surgery. A 2009 study
found that 37% of sectors had poor levels of personnel and
provided relatively little community-based care.1
Rural areas
are particularly badly served, as 80% of all psychiatrists
live in cities of more than 50,000 inhabitants. In particular,
the greater Paris region has over one-third of all French
psychiatrists2
, but only 18% of the national population.
The issues go further than care provision. The proportion
of patients being treated involuntarily varies across French
départements (administrative regions) from under 8% to
over 35%3
, despite there being little or no differences in
the prevalence of conditions. This suggests that improper
assessment of need in some départements is affecting the
human rights of those with a mental illness.
Worse still, overall the sectoral approach has left mental
healthcare in France strongly hospital based. In the Index,
France ranks 27th out of 30 in the “deinstitutionalisation”
category, reflecting both that a majority of those living with
a mental illness continue to be treated in long-stay hospitals
and institutions, and that there is no strong national policy to
reduce their number.
Unlike in many other European countries, French psychiatric
reform has never been aimed at reducing the central role
of hospitals, per se: they are the core units around which
sectors are organised. The goal has instead been to create
1
Magali Coldefy et al, “Fifty Years of Deinstitutionalisation Policy of
Psychiatric Services in France: Persistent Inequalities in Terms of Resources
and Organisation Between Psychiatric Sectors”, Institut de Recherche et
Documentation en Economie de la Santé, Questions d’Economie de la Santé
145, August 2009.
2
Cour des Comptes, “Organisation of psychiatric care: Effects of the
“Psychiatry and mental health” plan 2005-2010: Summary of the public
thematic report,” December 2011.
3
Isabelle Leroux and Patricia Schultz, “Cartographie régionale de l’offre
de soins en santé mentale”, DREES Statistics Series, April 2011. 4
Cour des
Comptes, “Organisation of psychiatric care”.

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Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries
a hospital-centred system that also provides much of its
care in the community. This approach allowed for significant
deinstitutionalisation. The number of beds per 100,000
population fell from 201 in 1985 to 90 in 2008. Nevertheless,
this was still one of the highest per head in western Europe.
Moreover, these beds are generally full because hospitals
continue to be used inappropriately for mental healthcare. The
Cour des Comptes, a quasi-judicial audit body of the French
state, estimated in December 2011 that about 10,000 people
in these institutions could live in the community if appropriate
services were available. It found that despite some progress
over the preceding five years, “the objective of encouraging
extra-hospital care and freeing up some full-hospitalisation
beds has not been achieved.”4
Nor are hospital facilities
necessarily fit for the purpose intended. Before a major,
still ongoing, investment programme began in 2005, these
psychiatric institutions had become extremely dilapidated,
and only one-quarter of patient rooms had a toilet and shower.
More generally, the Cour des Comptes estimated that before
the investment programme, technical services were insufficient
at 86% of the hospitals.5
Consistent with the continued dominance of hospitals in
mental healthcare, strong community-based services have
not developed. Since 2000 France has seen over a dozen
public reports on the state of mental health provision. These
have almost universally commented on the need for better
co-operation between hospitals and general practitioners,
improved continuity of care, the decompartmentalising of
health and social services, and the creation of networks of
care in the community.6
Most of these problems persist, with
perhaps the biggest barrier to successful integration being a
lack of appropriate housing in the community for those with
a mental illness, which on its own is thought to be keeping a
large number of people in hospital.7
As Dr Hodé explains, “very
often people who need psychiatric help need something other
than medical care, not from the health system, but from the
social system. We need more integration. Many people could be
discharged from the health system if we were able to organise
something for them within the social system.”
The reasons for slow progress are partly institutional: Dr Hodé
sees institutional culture as one barrier. “The director of the
hospital wants to have a unit in the hospital,” impeding the
creation of more appropriate, community-based facilities,
he says. With the hospital playing such a key role in the
organisation of sectors, it would require political intervention,
either local or national, to bring about change.
The politics of weak policy
Such action, however, has been sorely lacking in much of
France. Jean-Luc Roelandt, director of the eastern Lille
psychiatric sector, recently summed it up: “the problem with
the sector in France has been the lack of political courage
to move the sector away from hospitals.”8
Mr Thomas also
notes that, at the local level, the barrier to change is mainly
political: “when a deputy of a town or a region has to protect
the people’s employment, it is harder to do away with
hospital care. To be re-elected, politicians have to support the
maintenance of hospitalisation.” The issue is also problematic
at the national level, he adds: “a lot of politicians think that
mental illness is something shameful. They do not want to
talk about it and do not feel that they can be re-elected if they
support mental healthcare programmes; a lot of people think
that these will cost a lot of money.”
4
Cour des Comptes, “Organisation of psychiatric care”.
5
French Senate, “Rapport d´information fait au nom de la commission des
affaires sociales relatif à la prise en charge psychiatrique des personnes
atteintes de troubles mentaux”, December 2012.
6
For a comparative chart analysing these reports and their recommendations,
see French Senate, “Report”.
7
Cour des Comptes, “Organisation of psychiatric care”; Haut Conseil de la
Santé Publique, “Évaluation du Plan Psychiatrie et Santé mentale 2005-
2008”, October 2011, Direction de la recherche, des études, de l’évaluation et
des statistiques (DREES), “Organisation de l’offre de soins en psychiatrie et
santé mentale: Actes du séminaire recherche”, Working Paper 129, April 2014,
pp. 78 ff.
8
DREES, “Organisation de l’offre de soins en psychiatrie et santé mentale:
Actes du séminaire recherche”, p. 104.

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Provision for supporting people with mental illness: A comparison of 30 European countries
Adding to these political barriers are fears about those living
with a mental illness being a danger to the general population.
Mr Thomas explains that “in the media there is a strong link
between violence and mental illness” and that “people are
frightened” of having more people with these conditions
living in the community. In fact the tension between security
concerns and a desire to provide humane treatment for those
with a mental illness has been a constant in France throughout
the era of modern psychiatric reform.9
This political calculus around mental health has resulted
in more than a decade of weak policy. As early as 2001 the
Piel-Roelandt report, commissioned by the French Ministry
of Health, called for a thorough reform of mental healthcare,
including increasing the involvement of people with mental
illnesses in their own care, more community-based care relying
on a network of medical and social providers, and a ten-year
plan to close psychiatric hospitals. Efforts to turn the report
into policy failed when the government changed following an
election.
Under the new government, the health ministry commissioned
another report, by different experts, who drew similar
conclusions. The response, the Plan Psychiatrie et Santé
Mentale 2005-08, had laudable intentions, including
decompartmentalising care through better use of general
practitioners and the development of community mental
health networks; improving access to housing; increasing the
rights, and the role in treatment decisions, of service users
and their families; and investing in improving the dilapidated
infrastructure of existing mental health hospitals.
In 2011, however, after the plan had run its course and been
extended for two years, two reviews of its implementation—
one by the Cours des Comptes and another by the Ministry
of Health’s Haut Conseil de la Santé Publique—found that
it had achieved only limited success. The Haut Conseil
report found that, despite a variety of advances, notably to
hospital infrastructure, efforts to improve ambulatory and
community care were uneven; that the plan itself, despite
acknowledging the need for better integration between the
medical and social elements of care, lacked specific measures
to decompartmentalise these; and that a lack of appropriate
housing remained a serious problem. The report by the
Cour des Comptes had similar findings, adding that in its
assessment only one-third of the plan’s specific measures had
been either mostly or fully implemented by 2010. Moreover,
88% of investment had gone into hospitals—typically for
refurbishment—and the remaining 12% was insufficient to
break down the silos between different types of care.10
The very limited success of the 2005-08 plan did not bring
any immediate push for change. Instead, the current mental
health plan seems unlikely to accomplish much. Although it
supposedly covers the years 2011 to 2015, it was not issued
until 2012, and is really a restatement of grand ambitions
rather than a practical document: the preamble justifying its
existence is twice as long as the section on putting its aims
into practice. The latter section is particularly short because,
rather than a list of concrete measures, it mostly calls on other
bodies, in particular regional health authorities, to come
up with their own plans. The national plan also provides no
additional funding for new projects. How it will bring about
concrete change on the ground is unclear.
An exception demonstrating the potential of a
strong legal framework
France’s best result in the Index is its perfect score in the
“Opportunities” category. This outcome arises in large part
9
Bernard Basset, “L’introuvable politique de santé mentale en France”,
Actualité et dossier en santé publique, 2013; Raphaël Gourevitch et al, “Law
& Psychiatry: The Evolution of Laws Regulating Psychiatric Commitment in
France”, Psychiatric Services, 2013.
10
Cour des Comptes, “Organisation of psychiatric care”; Haut Conseil de la
Santé Publique, “Évaluation du Plan Psychiatrie et Santé mentale 2005-
2008”.

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Provision for supporting people with mental illness: A comparison of 30 European countries
because, since 2002, mental health has been explicitly
included under the country’s stringent occupational health
and safety (OHS) laws. Equally important, OHS disputes are
more likely to be settled by courts in France than through
mediation, the European norm. In the area of mental health,
the courts have tended to be sympathetic to employees. For
example, they have ruled that, when restructuring, companies
must address the increased stress levels that any change might
bring about, and even required one bank to pay damages
to workers and stop using a benchmark-based employee
evaluation system because it was considered too stressful.
This is consistent with the French legal doctrine that in health
and safety issues employers are judged not on the existence of
reasonable measures to reduce risk, but on the actual outcome
of policies. Thus, they may be liable if employee mental health
suffers even when existing best practice is being followed.
Given the complexity of mental health, this is a heavy burden
in practice, but it is likely to lead to a greater focus on how
to create workplaces where mental health issues are a high
priority.11
Although French labour law is national, this does not prevent
the benefits of the sectoral approach from being maintained.
In its 2011 report, for example, the Haut Conseil de la Santé
Publique found that any progress that had been made between
2005 and 2010 in the area of social support for people living
with mental illness was largely the result of a 2005 law on the
rights of those with disabilities, including people living with
mental illness. The policy specifically aimed at those with
mental health conditions had only had an amplifying effect.
Overall, despite being a pioneer in the integration of those
with mental illness into society, and the existence of some
regions with excellent practice, France as a whole has not
lived up to its early promise. As Mr Thomas notes, the sector
represents a useful way of organising care, but its structure
was developed in the 1960s. “It is important that the local
setting and organisation of care evolves with society. This is
very difficult, and we are always late.” As a result, weak policy
and a lack of attention have led to a highly uneven provision of
services across France’s many sectors; and where progress does
occur it often does so as a side-effect of strong policies in other
areas.
11
For a discussion of French occupational health and safety law as it relates
to mental health, see “France et RPS, quelle approche juridique de la santé
mentale au travail?, entretien avec Loïc Lerouge,” DIM Gestes, 2014, http://
gestes.net/distinction-francaise-laccent-mis-sur-la-prevention-des-rps-
entretien-avec-loic-lerouge/

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Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries
This study, one of a dozen country-specific articles on the
degree of integration of those with mental illness into society
and mainstream medical care, draws on The Economist
Intelligence Unit’s Mental Health Integration Index, which
compares policies and conditions in 30 European states.
Further insights are provided by two interviews—with Yann
Hodé, a psychiatrist based in the town of Rouffach and head
of Pro Famille, a network dedicated to the education of the
families of those with mental illness; and with Pierre Thomas,
professor of psychology at the University of Lille—as well as
extensive desk research. The work was sponsored by Janssen.
The research and conclusions are entirely the responsibility of
The Economist Intelligence Unit.
About the research