\'Le secteur\': principles and present issues

1. The
French
public
health
framework:
a
model
of
integrated
comprehensive
system
«
Le
secteur
»
F.PETITJEAN

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. 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. 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. 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.
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. ‘
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. • 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. - 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. 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. Global
caseload

13. Caseload
in
part
?me
services

14. Personnel/Caseloads

15. 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

16. Number
of
psychiatrists/département
(non
private
)

17. 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

18. MEAN
NUMBER
OF
BEDS
:
55
MEAN
NUMBER
OF
OUT
PATIENT
PLACES
:
26

19. Mean
length
of
hospital
stay

21. Souce
:
Ministry
of
Health
Reports

22. 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
)

23. Schizophrenia

25. Diagnosis/gender

26. 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
)

27. Diagnosis/age
in
full
?me
hospitalisa?on
DREES
2003

28. Compulsory
admissions
DREES
2003

29. 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

30. 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

31. Evidence
based
treatment:
the
use
of
clinical
guidelines
ACT,
psychoeduca?on,
cogni?ve
remedia?on

32. 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
).

33. 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

34. 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.

35. Psychosis
Informa.on
Project
Rehospitaliza.on
Rates
in
Percent
ABer
1
year
and
2
years
,
*
P
<
.05
BAUML
J.
et
al.
2006.

36. 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
)

37. Rehabilita?on:
linking
with
medico
social
services

38. Pa?ents
with
housing
problems

39. GENERAL PSYCHIATRY SECTORS OFFERING SPECIFIC
SERVICES FOR READAPTATION/REHABILITATION
Source
:
Ministry
of
Health
Reports

43. 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

44. 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
)

45. 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

46. Suicide and
attempted suicide
French population (60 millions)
Suicidal thoughts:
1 million people
Attempting suicide:
160 000 people
Committing
suicide:
12 000 deaths

47. 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)

48. 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
?