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International Review of Psychiatry, August 2012; 24(4): 363–368

The organization of psychiatric care in France: Current aspects and future challenges

DENIS LEGUAY1 & PATRICE BOYER2
1Psychiatre

des Hôpitaux, Angers, France, and 2Department of Neurosciences and Psychiatry, Université Paris 7, Paris, France

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Abstract In the last four decades, psychiatric care in France has led to the development of catchment area-based service provision. Within each geographical area teams are now responsible for psychiatric care both at outpatient and inpatient levels. However, financial and economic constraints have led to a reduction in beds and staffing levels. The numbers of psychiatrists in private practice has remained more or less the same over the years due to steady demand and other factors. As in many other western European countries, de-institutionalization has been a major driver in the evolution of psychiatric care delivery in France. This is linked with several developments, including the introduction of more efficient pharmaceutical drugs which have reduced the likelihood of relapse. Other factors which have influenced this include the progressive ‘de-stigmatization’ of psychiatric disorders and policy changes leading to significant bed reduction. All of these factors are inter-linked and have influenced psychiatric care delivery. In this paper we provide an overview of the current state of psychiatric care and its delivery in France.

Introduction In 1945 all the French scientific organizations linked to psychiatric practice met during a national conference and agreed on a general policy to restructure psychiatric care in France (Ayme, 1995). The two keywords which were considered as the leading messages to conduct this restructuring were ‘humanization’ and ‘de-institutionalization’. A clear mission was assigned to the public health system which, ever since then, has been in charge of ensuring the prevention of mental health problems, the continuity of care and the implementation of walk-in clinics. It is on the same basis that in the early 1970s the secteur psychiatrique (psychiatric sector or psychiatric catchment) was created (Loi 85–1468, 1986). The secteur or sector was defined as a precise geographical catchment area for which a single, comprehensive team took responsibility for mental healthcare delivery in the geographical area. Therefore, all the patients belonging to the same sector were followed by the same multi-professional team, composed of physicians, psychologists, nurses and social workers. The same team was responsible for the prevention, for outpatient and inpatient care and for the follow-up. The

organization of the different sectors was extended to the whole French territory from 1975 to 1990 both in adult and in child and adolescent psychiatry. This system still constitutes the main basis for psychiatric care in France (Leguay 2002). In parallel to the implementation of the public sector, private practice in psychiatry has undergone a very significant development since 1970. The main reason for this has been the separation of neurology and psychiatry as medical specialities after May 1968. Until 1968, a limited number of ‘neuro-psychiatrists’ were following academic degree courses before shifting to private practice. After 1970, the number of psychiatrists trained in different French universities dramatically increased, resulting in the setting up of more and more private practices. Most of these private psychiatrists received a psychodynamic training which explains why the main orientation of private ambulatory care was psychoanalytically linked in this period. Contemporaneous with the leading roles played by the public health and the private ambulatory care systems, private hospitals have existed since the 19th century. These private hospitals have been maintained but currently their geographical location is rather

Correspondence: Patrice Boyer, European Psychiatric Association (EPA) President, CMME, 100 rue de la Santé, 75014 Paris, France. Tel: ϩ 33 1 53804941. E-mail: phmboyer@gmail.com (Received 14 June 2012 ; accepted 14 June 2012 ) ISSN 0954–0261 print/ISSN 1369–1627 online © 2012 Institute of Psychiatry DOI: 10.3109/09540261.2012.703953

2005).000 inhabitants). There are many reasons for this tendency. a significant amount of urgent cases are transferred to the ambulatory ward. the number of patients referred to the public health system has enormously increased (ϩ 90%). In this respect the French parliament passed a law in 2005 recognizing psychiatric disorders as being responsible for social Question raised by the current organization of psychiatric care in France As has been previously mentioned and similar to what has happened in many other European countries (to different degrees). The current figure is 9 private psychiatrists for 100. paradoxically the total nursing staff has been reduced (Ϫ 10%). Another solution to compensate for this shortage in treatment capacities is to refer some difficult cases to medico-social services which are sufficiently advanced (Charzat. The proportion of patients followed by the sector over a year and for which hospitalization is necessary is around 15%. thus offering the possibility for patients to be taken in charge by specific social structures (Loi 2005-102. The last partners for the delivery of psychiatric care in France include different non-profit associations which are mainly orientated towards specific specialist care after patients have been discharged from hospital. These . Since the capacity in term of beds is not sufficient and the non-voluntary hospitalizations are mandatory.e. The number of inpatient beds has also been reduced to a ratio of 60 beds for 100. 2007).com by Universitat Autonoma Barcelona on 07/16/13 For personal use only.000 inhabitants (a reduction of 60% over 15 years) (Coldefy. Among them. Private hospitals The activity of this branch has also remained pretty stable over the last decades (25% of psychiatric patients hospitalized over one year have been hospitalized in private hospitals. 2011). Of course the reduction in the number of beds is justified by the ‘de-institutionalization’ process which started half a century ago. The ‘real’ coverage for reimbursement of the care provided in private practice is rather variable. Patients are younger. Over the two last decades. as a consequence. Private practice The number of physicians having a private practice in psychiatry has been stable since the year 2000. 2002). currently employed. The global number of these private specialists will probably decrease over the next 10 years (Ϫ20%) before increasing afterwards (Conseil National de l’Ordre des Médecins. heterogeneous (they are predominantly located in the south-west and south-east of France as well in the Parisian area). Only patients who give their consent (i. A total of 2. by now the number of beds is more or less stable since it would not be reasonable to reduce the beds further. The recent evolution of psychiatric care is probably (and unfortunately) better explained by economic and budget restrictions and financial reasons rather than by the evolution of techniques and treatments. the main provider in terms of therapeutic services. Leguay & P. It must be remembered that the medical care provided by the public health system for this type of pathology is free of charge for patients and their families. During the same period of time. The public health system A total of 2. The current evolution of psychiatric care in France Int Rev Psychiatry Downloaded from informahealthcare. de-institutionalization has been the main trend in the evolution of psychiatric care in France.7% of the general population aged above 20 are treated through the psychiatric public health system which is. It must be remembered that by the nature of private practice and the condition.000 inhabitants (compared to 11 psychiatrists in the public sector for 100. in theory it is around 70% (the social security rate) but everything depends on the honoraria charged by the physician (highly variable) and on the coverage provided by other insurance systems (‘mutuelles’).. 18% correspond to non-voluntary hospitalizations. The first and perhaps the most significant reason is probably linked to the introduction of more efficient therapeutic drugs. the profile of patients consulting a private psychiatrist is rather different from the profile of patients treated in a public institution. suffering relatively milder disorders and eager to benefit from a rapid change in their mental status. 2004).5% of the French population are treated in private practice (Alonso et al. The geographical distribution of this type of practice is extremely heterogeneous (the highest density being recorded in the Parisian area and in the southeast of France. voluntary patients) may be hospitalized in private hospitals. The two most frequent groups of disorders treated in the sector are psychotic disorders (30% of active cases) and severe mood disorders (30% of active cases). the ‘wealthy’ part of France). which represents 20% of the total number of psychiatric beds).364 D. Boyer disability (handicap).

Of course there was not only a theoretical perspective behind such a decision. Lack of homogeneity The most striking example for lack of homogeneity is the very variable standard of care (if any) which is available for a given pathology depending on the sector where a patient is treated. Finally (and partly thanks to the reduction in the number of beds and staff). As a result. In 1986 new public rules of procedures were adopted to transfer towards dispensary care. 2001). there is a general agreement on the efficacy of the main psychotropic drugs and of the necessity to provide ‘psychotherapeutic’ support to the patient.com by Universitat Autonoma Barcelona on 07/16/13 For personal use only. fixing the rules for a general direction everyone had to follow. CBT orientated. Often teams believe very strongly in their own therapeutic methods specifically developed by them. In principle. one can say that the amount of money available to treat psychiatric conditions has decreased. Of course emergency cases have to be prioritized. . for example. Of course. chlorpromazine. the sector policy responsible for delivery of mental healthcare is a major factor in the de-institutionalization process in France. the quality of care they will receive still remains highly variable (Kovess. and advocacy and consumers groups. The first neuroleptic ever. even for the most chronic and disabling cases. depending on the sector team. 1979). Today. whether psychiatric patients are living in the Parisian area. Care provided by the sector 365 As noted above there are advantages and disadvantages in this approach. thus blocking the introduction of other methods widely accepted and evidence from elsewhere. The outcome has produced an extremely heterogeneous situation with a high variability in the access to care. But another important consequence of de-institutionalization includes progressive ‘de-stigmatization’ of psychiatric patients. This. Limited systematic evaluation of the impact of the different treatments has been conducted. Some of the disadvantages are described below. No technique was proposed to proceed to such an assessment and the major goals in term of public health were never clearly formulated nor announced. Since the global cost for treatments has increased. Quite remarkably. but a practical one as well: switching from inpatient to outpatient care allowed for a significant reduction in staffing. the idea was good. There may be variability in access to specialists within the team or even in the constitution of the team. psychological or neuropsychological explorations. expenditure linked to psychiatric care has increased half as fast as the costs due to other medical conditions. but principally at the expense of better continuing and ongoing care for patients with other conditions. as are in-depth clinical. In some cases there is an inordinate delay in translating research and evidence-based data into clinical practice. socially orientated. combined with pressure from patient and carer organizations. implementation of strategy of prevention against relapse. the ‘continuity of care’ often consists of minimal support. But once again. 2001). outreach teams and ambulatory follow-up the funding previously dedicated to hospitalizations. In summary. but in fact there has been no assessment of the nature and of the importance of the means requested to switch from one type of care to the other. without taking into account what the local situation was and what the technical and human resources available on site were (WHO. institutionally orientated. but several aspects can be criticized.Psychiatric care in France medications made relapses less likely and less frequent (leading from the age of asylum to the age of small inpatient units. Continuity of care and adequate means Another aspect of the sector policy which can be criticized is the systematic (and necessary) priority to provide emergency care in crisis situations. the peak of the ‘de-institutionalization’ movement has corresponded to a time where a claim has been made for reducing health and medical costs. in a medium-sized city or in a rural area. for which society recognizes the status of normal citizens. either referring the patient to a day hospital or giving appointments at an outpatient clinic (dispensaire) with closer focus on routine prescription rather than psychotherapy or combination of therapies. was created and developed in France and successfully prescribed to patients with psychosis by Delay and Deniker at the Sainte Anne Hospital in Paris (Deniker 2002)). Int Rev Psychiatry Downloaded from informahealthcare. The head psychiatrist in each sector has a direct responsibility for the delivery of care provided by the team to a given population. this may lead to constant pressures to deal with emergencies at the expense of other types of care. Under these circumstances psychoeducation delivered to the patient or the family is too often lacking. As a result. In France all the pressure for the deinstitutionalization process has been supported by the public sector (Goffman. however. Certainly too great a freedom is offered in the absence of any assessment of the therapeutic orientations chosen. a ‘global’ political decision was taken. the main course of treatment will be quite different: psychoanalytically orientated. has also influenced move from asylums to community care.

Perspectives The mission of the ‘sector’ and the re-organization of care As has been mentioned. The sector is in charge of the full range of care. it is also apparent that the saturation of these units has already been the case over the last 5 years: after a period of transfer to ambulatory care the demand for inpatient care has progressively increased. As a consequence. Int Rev Psychiatry Downloaded from informahealthcare. the type of practice of most of these psychiatrists has remained the same over the years. and it can be said that the policy of ‘care’ and the policy of ‘cure’ are hardly convergent in France. but poorer areas are significantly lacking physicians. yet special skills may be needed to meet more specific needs. In July 2011 a specific law was voted in by the French parliament stipulating more stringent control of care delivered to patients who represent a threat to public order (Loi 2011803. is related to follow-up. Another issue which will have to be addressed urgently by the profession as well as other stakeholders is the participation of private psychiatrists in the care of more severe cases.com by Universitat Autonoma Barcelona on 07/16/13 For personal use only. Due to problems linked to the (lack of) national policy in term of continuous medical education. Hence a clear lack of competency exists in this domain. The problem is that in France the vast majority of psychiatrists are not trained to deliver support and assistance to disabled people. choice of new therapeutic methods and cognitive remediation. Media and politicians have debated on law and order. the law of course slows down the different steps of the process of hospitalization against a patient’s will (hospitalization without consent represents 20% of all psychiatric hospitalizations in France). and the discharge of a patient after a compulsory hospitalization will be closely controlled and monitored as well. social psychiatry is not extensively taught during the specialization process. and the reverse is true as well. and about the available treatments and responses. Regarding these patients. Unlike some other European countries (as in the UK for example). 2010). concept of recovery. principally related to psychodynamic theories. Slowing down the discharge process of course leads to overcrowding in the inpatient units. This diversity of tasks results in a lack of specialization.366 D. in many cases the evolution of practice (when it occurred) did not come from psychiatrists themselves but from their clients. Another major psychosocial aspect of psychiatry. In France the problems related to disability depend on the competency of different political bodies which deal with social inequalities. All matters linked to disability have to be considered under the current legal rules in term of insurance policies. the number of psychiatrists in private practice dramatically increased in the 1970s and the1980s. The core measures of the law are twofold: the general frame of the psychiatric care delivered to the patient is to be placed under the control of a judge (instead of an administrative officer). private psychiatrists are not involved in the process of compulsory hospitalizations. total health costs are increasing where the density is the highest. follow-up after hospital discharge. Hence. Mental health problems are in a way ‘de-stigmatized’ by the media (if not by society itself) since many articles are dedicated to this topic. Leguay & P. From the perspective of everyday practice. Risk to others has taken on a major impetus. and resolution of societal problems. and the social re-integration of patients presenting chronic and severe conditions. certain ‘old fashioned’ attitudes and practices from the 1970s have been maintained. in France as in many other countries. The most problematic issue linked to private practice is the unbalanced distribution of private practices from a geographical perspective. and security concerns have been increasing since isolated cases of murders or crimes have been reported. concerns have been raised in relation to safety issues for society. Boyer Care provided in private psychiatry practice As mentioned earlier. from early detection and diagnosis to crisis intervention. It is too early to assess the real impact of this law. not directly linked to disability. Usually the patients who attend private practices are generally mild or moderate cases. the mission devoted to the public health system and the sector is extremely large and perhaps over-demanding. ambulatory care. As a consequence. The density is the highest in the richest regions. There is much less taboo than in the past when a patient consults a psychiatrist (Giordana et al. Up to now any attempt to solve this question by a ‘centralized’ decision has failed. For all these reasons. private practice remains numerically important but has to be challenged regarding some of these aspects. New techniques . In fact. Patients are now extremely well informed about the different pathologies and different theories. At the same time. the decision whether to hospitalize. 2011).. Societal aspects Over the years the sector has more and more often been asked to answer (and to solve) all types of difficulties occurring in the medico-social field as well.

Now professionals are requested to face and solve problems arising in a much larger domain and of a greater diversity: social exclusion. the media and society at large require psychiatrists to give their advice to enable policymakers to take what are supposed to be the right decisions. for example. . Whatever one’s personal opinion is in this respect. Being an expert supposes a vast preliminary training (thousands of hours) whereas becoming a ‘super’ expert will require ‘super’ training. 2005. vulnerability. but the frame for it retained a broadly medical approach even though applied to a full multidisciplinary team. and the different measures they could potentially recommend have to remain entirely ethical from a medical perspective. a consensus seems to have emerged to organize the healthcare system stage by stage. One can wonder: do the possible answers to these problems still belong to the field of psychiatry? In fact. professional stress. The level of awareness and of information of these different associations is increasing and they want their opinion and advice to be taken into consideration by the health authority. Concomitantly. The second stage would correspond to the collaboration between different sectors in the case of specific needs required by the treatment (e. The problem of suicide in France Another huge problem in France is linked to the high suicide rate reported in recent years. prevention programmes decided at a political level may not focus on general societal considerations or on the detection of specific components of the suicidal behaviour. The first stage would correspond to the ‘standard’ care delivered by the sector (which will be responsible for ensuring the continuity of the treatment). however. 367 Usually suicide is regarded as a consequence of the primary mental disorder the patient is suffering from (e. any debate regarding the choice or standardization of psychiatric care cannot be separated any longer from a more general discussion regarding the boundaries of an adequate ‘mental health policy’. The sector was envisioned as the best possible therapeutic answer to many different mental problems. But inflation of the skills is fraught with difficulties. whatever their personal opinions are. consumers’ associations and advocacy groups in the organization of the healthcare system and choice of the most appropriate treatments. psychiatrists will be asked to propose new types of interventions even if these interventions sometimes are not directly linked to usual medical practice. in France as in other countries. its clear mission was to offer society the most efficient way to take charge and to cure the mental disorders which could be encountered in the general population.com by Universitat Autonoma Barcelona on 07/16/13 For personal use only. antisocial behaviour. Of course there is a major risk behind such requests: a psychiatrist is a physician as well as a citizen. Conclusion The organization of psychiatric care in France has known significant transformation over the last two Int Rev Psychiatry Downloaded from informahealthcare.g. the role of these associations will have to be clearly recognized and a consensus will have to be found to work as harmoniously as possible for the sake of patients (Roelandt & Desmons. The third stage would consist in referring some patients to ‘expert centres’ more specialized in difficult cases and in the treatment of specific conditions such as psychotic or bipolar disorders. Family and consumers associations Another recent ‘hot topic’ which has arisen in France as in other European countries is the role and importance to be given to families. Mental health versus psychiatry? Finally. Quite recently a very tense debate took place in France regarding the types of treatment which were proposed for autistic children (Circulaire DGAS. Increasingly. Interestingly. Family associations have challenged the routine habits of some centres where most recent developments evidenced by the literature in this field have not been incorporated into their treatment techniques. the three levels of interventions would have to be carefully harmonized. The most recent data in the domain of research on suicide are not yet translated into clinical practice.. conduct disorders and conducts at risk. 2002). specific social aspects of the case). access to family. both in setting standards and the access to care. Of course. or post-traumatic stress (this last stage corresponds in a way to what ‘tertiary care’ is in English-speaking countries). 2008). drug and alcohol addiction. The psychiatrist seems to be permanently in the position of an expert.g. depression. the mental health profession does not consider this as a specific problem requiring specialized centres or the development of new techniques adapted to this kind of risk. schizophrenia). When the politique de secteur was created 50 years ago. to avoid overlap and duplication. This expertise is probably part of their necessary psychiatric skills. On the positive side. 2009). Hochmann.Psychiatric care in France for assessment or treatment are not well known and not introduced in the armamentarium of therapies (particularly in the rehabilitation field) (Leguay et al.

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