Challenges and Hopes for French Psychiatry

Following the joint publication of a first study in 2014, Institut Montaigne, in collaboration with FondaMental, a foundation for scientific cooperation dedicated to the fight against psychiatric disorders, just published a book on the way mental health is dealt with in France:Psychiatrie, l’état d’urgence(which translates into Psychiatry, a State of Emergency). This work collects existing data in France and abroad to draw up an inventory of psychiatry in France.

Key figures on mental disorders

• 1st global cause of disability by 2020 (WHO)
• 38% of Europeans from 18 to 65 years old are affected by a psychiatric disorder
• 804,000 people commit suicide each year worldwide
• Suicide mortality rate is 15,4 per 100 000 inhabitants in Europe (17,7 in France)
• Between 2% and 4% of the funding for research in psychiatry is dedicated to French biomedical research (20% for cancer)

Why this book?

Despite the recent multiplication of plans to improve the prevention and management of psychiatric diseases, the latter remain at the margins of public health policies and suffer from a glaring lack of data and resources. However, these diseases are at the crossroads of numerous problems that affect not only health issues but also education, professional life and social cohesion. The gap between the importance of these disorders in society and the general denial that seems to surround them is striking. This book aims to alert public authorities of the urgent necessity to act in the field of psychiatry.

Who’s concerned?

According to the WHO, one in three individuals has or will have a mental disorder during their lifetime, and  20% of children and teenagers suffer from mental disorders in the world. In 2018, epidemiological studies show that one in five French people suffers from mental disorders. The most widespread pathologies are depression, bipolar disorders, schizophrenia and autism spectrum disorders. Most of them appear between ages 15 to 25, which highlights the importance of early care. However, mental disorders are often misdiagnosed, which can have dramatic consequences on patients, such as the reduction of their life expectancy from 10 to 20 years, particularly due to suicides. Moreover, there is a lack of care for the most vulnerable: the homeless, migrants or detainees. In French prisons, psychiatric disorders affect 78.5% of the men and 73.7% of the women imprisoned. 

Why this state of emergency?

The main reason for this disaster lies in the inadequacy, poor quality and heterogeneity of healthcare provision. This phenomenon is reinforced by a lack of infrastructures and medical ressources: the demand is exploding with 2 million consultations per year and an additional 300,000 patients in the last decade. However, only  2.4% of university professors and 5.8% of medical students work in the field of psychiatry. Hospitals remain at the heart of French psychiatry and alternatives to hospitalization have not been sufficiently developed. Between 1990 and 2011, France closed more than half of its psychiatric beds (from 120 000 to 55 000) without developing alternative care.

Then, there is the significant cost psychiatry represents. According to the National Health Insurance Fund, psychiatry costs more than €22 billion per year, and is thus the most expensive pathology, ahead of cancer and cardiovascular diseases. However, due to the low reimbursement rate of therapies by the Health Insurance, families regularly give up on care. For instance, for autism, the average annual cost of an adapted support of 25 hours per week is worth €26 000 per child, yet the Health Insurance only covers a maximum of €18 000.

Lastly, taboo and stigmatization are the scourges of psychiatry. Fear of mental disorders is too often due to ignorance, lack of training and lack of information. 1 out of 3 French would be embarrassed to share a meal or work next to a person suffering from psychiatric disorders, and 75% consider that psychiatric patients are dangerous for themselves or for others.

What hopes?

Research and technological development are the main hopes for patients and their relatives. More and more startups show interest in psychiatry. For instance, Doctoconsult is specialized in visio consultation in psychiatry and pedopsychiatry. Its goal is to avoid that patients break away from healthcare, especially in fields where the waiting time for appointments is very long (in France, it amounts to 67 days on average, 21 in general psychiatry and 116 in child and youth psychiatry).     

Another startup called Nouveal provides a software for healthcare centers and professionals allowing them to keep in touch with their patients whilst they are convalescing at home. They use automated protocols to assist early-stage identification of complications and are now developing protocols in psychiatry. These solutions propose personalized follow-ups to prevent patients from relapsing and being re-hospitalized. 

Furthermore, research made great progress in the past few years. Psychiatric diseases were long defined, as opposed to neurological diseases, by the absence of brain damage. Although it remains generally true that neurology focuses more on the brain’s structure and psychiatry on its functioning, IRM and TEP technologies tend to prove that most psychiatric illnesses also affect the brain’s architecture. These findings pave the way towards a better detection and management of psychiatric diseases.

A new discipline, immuno-psychiatry, is achieving promising results in the fight against depression. Rather than the neurons, which constitute its "processor", immuno-psychiatry focuses on the brain's "safety system", that is, its immune cells. It opens new perspectives on the potential development of a vaccine to combat depression. 

It is crucial to fund research and development in order to find new solutions. Research is one of the main tenets emphasized in the book's proposals.

To conclude, modernizing the way psychiatry is dealt with in France is a matter of urgency. Our 25 proposals aim to provide concrete and innovative solutions to define a new mental health policy in six key areas: prevention, early detection, care, life paths, professional trainings and research. 

Proposal 1: Creating a unique operator in charge of defining and implementing a strategic and coordinated vision of psychiatry and mental health at the state level

Proposal 2: Building a national information web portal accessible to the general public in order to inform and propose personalized responses

Proposal 3: Launching campaigns to change public opinion and combat stigmatization. Three targets will be privileged: 15-25 year olds, the professional environment and the media

Proposal 4: Mobilizing the existing national system of "houses for adolescents" to organize early identification of diseases and orientation

Proposal 5: Transforming multidisciplinary care homes into a new gateway towards comprehensive, non-stigmatizing, community-based care for psychiatric disorders

Proposal 6: Developing early detection tools for general practitioners

Proposal 7: Offering a specialized, multidisciplinary and personalized level of recourse

Proposal 8: Ensuring comprehensive psychiatric and somatic care for patients by setting up multidisciplinary consultation meetings

Proposal 9: Multiplying mobile medical teams to reduce the need for hospitalization

Proposal 10: Facilitating the access to care by deploying and reimbursing adapted therapies, such as psychotherapy or psychosocial therapies

Proposal 11: Developing and evaluating e-health devices to provide wider access to psychosocial therapies

Proposal 12: Measuring the quality of care through patient assessments

Proposal 13: Meeting the needs and expectations of families and integrating them within the care system

Proposal 14: Acting on funding methods in order to accelerate the propagation of innovative practices in psychiatry

Proposal 15: Developing social and medico-social support by rethinking existing systems

Proposal 16: Encouraging the creation and deployment of case managers in psychiatry to improve the coordination of career paths

Proposal 17: Extending the length of medical internships in psychiatry to five years and developing specializations

Proposal 18: Developing training in psychotherapy

Proposal 19: Developing the overspecialization of specialized clinical nurses

Proposal 20: Encouraging specialized social and medico-social training courses for the support of people experiencing psychological suffering

Proposal 21: Creating training courses for case managers in healthcare

Proposal 22: Supporting the development of training for users and peer helpers in mental health

Proposal 23: Developing a research policy guided by programs and privileging partnerships between public and private research

Proposal 24: Facilitating the access to quality services and infrastructures: cohorts, databases, biobanks, technological platforms, etc.

Proposal 25: Creating the conditions and incentives to attract industrial partners