HomeExpressions by MontaigneThe French Brief - Four Good Reasons to Change Our Mental Healthcare System Institut Montaigne features a platform of Expressions dedicated to debate and current affairs. The platform provides a space for decryption and dialogue to encourage discussion and the emergence of new voices.15/12/2020The French Brief - Four Good Reasons to Change Our Mental Healthcare System France HealthcarePrintShareAuthor Angèle Malâtre-Lansac Former Associate Director - Healthcare Policy The French BriefIt is no news that the pandemic generates uncertainty, fear, isolation and grief. This has, and will have, strong consequences on mental health. Between late September and early November 2020, the prevalence of depressive disorders has doubled in France, particularly affecting young people and the most parts of the precarious population. The psychological impacts of the pandemic will undoubtedly be one of the major challenges of the coming years.Changing the way we deliver mental healthcare by breaking down the silos between physical and mental health care, and focusing on patient centered approach has proven to be the most effective way to expand access to care, improve the well being of patients, and reduce costs. Half of adults with mental disorders don’t get access to care One in five people will be affected by any mental condition every year. Depression, anxiety, substance use disorders: everyone knows, either directly or through a relative, the difficulties in accessing care and the consequences of these illnesses on the person affected and for their relatives. Despite how frequently they occur, these disorders continue to be perceived as shameful, stigmatizing, and most often incurable. However, those who are affected can recover, if they are well cared for. In France, mental health care is delivered separately from the rest of healthcare, in a totally distinct and parallel system.When approaching the subject of mental health in public policy, it is important to look at the resources invested (input) and the results obtained (outcomes). In the case of psychiatry, the findings are disastrous for France and should be a warning signal. In terms of invested resources, psychiatric disorders are the most expensive conditions for the French national health insurance and cost far more each year than cancer or cardiovascular diseases.This lack of access is due to several factors among which: the stigma around mental illnessesa lack of knowledge regarding existing resourcesthe complexity of mental healthcare delivery: France is organized into psychiatric sectors, depending on the patient's residency, a system that is overall perceived as very opaquelong waiting lists to access specialized carefinancial barriers: psychologists are not covered by the national mandatory health insurance (Assurance maladie) and the ongoing reliance on co-payments by many psychiatrists create affordability barriers for many peoplea poor coordination between mental and physical care. Separating physical and mental health care is both inadequate and expensive The mind and body are connected. Two in three individuals with a mental health condition also suffer from a chronic somatic disorder, and one in three individuals with a chronic somatic disorder also suffer from a mental health condition. Yet, the quest to understand the relationship between the mind and the body constitutes an ongoing debate. René Descartes, the 17th century French philosopher, pinned down the concept of "dualism", which considers the body and the mind as two totally separate entities. Cartesian dualism thus played a very important role in the separation of physical care from that of "soul". The biological aspects of human diseases have become predominant, to the detriment of a more integrated approach.In France, mental health care is delivered separately from the rest of healthcare, in a totally distinct and parallel system. This very siloed approach is reflected in funding, care delivery and training. It also has very serious effects on patients: excess mortality of psychiatric patients is both a health scandal and a collective failure of which few are aware. Thus, people with severe psychiatric disorders die on average between 13 (for women) and 16 (for men) years earlier than the rest of the population. It also has adverse consequences on the healthcare system. People with mental illnesses are often complex and expensive patients, who are poorly cared for. They use more unscheduled hospital care and their rate of attendance in general emergency departments is 3.2 times higher than that of the general population. Research shows that having a mental illness increases total health costs by 45%. Changing our vision by having a more integrated approach could be part of the solution.Primary care is already "the de facto mental health system"There is a large body of evidence showing that integrating mental health services into primary care is one of the most viable ways of closing the treatment gap and ensuring that people get the mental and physical health care they need.In 1978, the American psychiatrist Darrell A. Regier published an article titled "Primary care is the de facto mental health system". This title still seems to be relevant today in France, with nearly 60% of consultations for mental disorders being carried out in primary care.We know that approximately 30% of all patients seen in primary care suffer from a mental condition. For general practitioners (GPs), the treatment of mental illnesses is a daily reality. It is also a priority among others: management of acute illnesses, prevention, chronic physical illnesses, emergencies, etc.The responsibility for mental health care therefore very often falls on the GPs as first line professionals, all the more so as access to specialized care in psychiatry is difficult. GPs generally report unsatisfactory relationships and a lack of coordination with mental health professionals. Alongside a lack of time (average consultation time is 15 minutes), some GPs also have knowledge gaps about mental health. Furthermore, GPs lack time and linkages with social services. There is a large body of evidence showing that integrating mental health services into primary care is one of the most viable ways of closing the treatment gap and ensuring that people get the mental and physical health care they need. However, despite decades of research, this approach is little known in France. Solutions exist, and we can learn from other countriesWhile France is seriously lagging behind in this area, other countries such as the Netherlands, New Zealand, the UK or Australia very early on decided to implement a genuine integration of mental health into primary care, in order to to detect illnesses as early as possible, provide a comprehensive and improved care for patients, and to increase patient satisfaction. Many efforts have been made to improve the integration of mental health into primary care as promoted by the World Health Organization. Traditionally, these efforts have focused on four main areas: improving GPs’ knowledge and ability to detect disorders, especially the most common ones: depression, anxiety, addictionsimproving access to psychological therapies and linkages with social servicesimproving communication with specialized medicine: reinforced referrals, shared records, exchange of information and expertiseadopting a stepped care approach, intervening in the least intensive way from self care and across primary care, community and specialist servicesgiving support, training and resources to GPs such as nurses or primary care mental health workersAlthough there are interesting programs in the field, the integration of mental health in primary care is a poorly known and little evaluated concept in France. An interesting definition of what Americans call "Behavioral Health Integration" was formulated by a consensus of experts gathered in 2013, by the Agency for Healthcare Research and Quality (AHRQ): "Behavioral health integration is the care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization".The Covid-19 pandemic has galvanized the topic of mental health in France and put it on the political agenda.An integration model called the collaborative care model, has been studied in particular, and has shown very interesting results both on mental conditions and on the management of physical conditions in more than 80 randomized controlled trials. This model constitutes a systematic approach to the treatment of frequent mental health disorders in primary care. It involves care managers working within the GPs’ practice and consultant psychiatrists: it is proactive and populational.Indeed, patients who are well cared for, both physically and mentally, will see their adherence to treatment increase, and their lifestyle and overall health status improve. The effects of integration can also be seen in the total costs of healthcare, as the use of general emergency services by patients who are treated in an integrated manner decreases and their health status improves. Finally, the greater satisfaction of both health professionals and patients is also an observed effect of integrated care.The Covid-19 pandemic has galvanized the topic of mental health in France and put it on the political agenda. Recent changes in the organization of the French health care system and the recognition of the importance of mental health provide a favorable context for mental health integration in primary care. Public policy reforms could be made to enable better integration of care in France, to the benefit of both patients and the health system. Copyright: Anne-Christine POUJOULAT / AFPPrintSharerelated content 11/17/2020 The French Brief - Reinventing Retirement in the Midst of a Pandemic Victor Poirier