Relevance of a subjective quality of life questionnaire for long-term homeless persons with schizophrenia.

BACKGROUND: Increasing numbers of programs are addressing the specific needs of homeless people with schizophrenia in terms of access to housing, healthcare, basic human rights and other domains. Although quality of life scales are being used to evaluate such programs, few instruments have been validated for people with schizophrenia and none for people with schizophrenia who experience major social problems such as homelessness. The aim of the present study was to validate the French version of the S-QoL a self-administered, subjective quality of life questionnaire specific to schizophrenia for people with schizophrenia who are homeless. METHODS: In a two-step process, the S-QoL was first administered to two independent convenience samples of long-term homeless people with schizophrenia in Marseille, France. The objective of the first step was to analyse the psychometric properties of the S-QoL. The objective of the second step was to examine, through qualitative interviews with members of the population in question, the relevance and acceptability of the principle quality of life indicators used in the S-QoL instrument. RESULTS: Although the psychometric characteristics of the S-QoL were found to be globally satisfactory, from the point of view of the people being interviewed, acceptability was poor. Respondents frequently interrupted participation complaining that questionnaire items did not take into account the specific context of life on the streets. CONCLUSIONS: Less intrusive questions, more readily understandable vocabulary and greater relevance to subjects' living conditions are needed to improve the S-QoL questionnaire for this population. A modular questionnaire with context specific sections or specific quality of life instruments for socially excluded populations may well be the way forward.

[Infants' attachment security in a vulnerable French sample]. / Sécurité de l'attachement des jeunes enfants dans une population française vulnérable.

INTRODUCTION: Attachment is a long lasting emotional link established between infants and their caregivers. The quality of early relationships allows infants to safely explore their environment and contribute to the establishment of a broad range of social skills. Several intervention programs targeting infant attachment have been implemented in different contexts, showing diverse degrees of efficacy. OBJECTIVE: The present paper describes, for the first time, children's attachment quality distributions in a French multi-risk population, with a preventive intervention, usual or reinforced. METHOD: In the CAPEDP study (Parenting and Attachment in Early Childhood: reducing mental health disorder risks and promoting resilience), a sub-sample of 117 women was recruited to assess the effects of this home-visiting program on children's attachment security. With that intent, the Strange Situation Paradigm was used when infants were between 12 and 16 months of age. RESULTS: In the intervention group, 63% (n=41) of the infants were coded as secure, while 15% (n=10) of them were coded as insecure-avoidant and 22% (n=14) as insecure-ambivalent/resistant. 56% (n=29) of control group infants (usual care) were coded as secure, while 27% (n=14) were coded as insecure-avoidant and 17% (n=9) as insecure-ambivalent/resistant. Even if the percentage of children with a secure attachment in the reinforced intervention group was higher than that of the control group, this difference did not reach the threshold of significance [Chi2 (2)=2.40, P=0.30]. DISCUSSION: Intervention group distributions were closer to normative samples, and these distributions show the clinical impact of our program. In general, preventive interventions focused on attachment quality have moderate effects but, in our case, several factors might have contributed to lower the statistical impact of the program. Firstly, the control group cannot be considered has having received zero intervention for two reasons: (a) the French usual perinatal health system (Maternal and Infant Protection System) is particularly generous and (b) the effect of this usual system might have been increased by the project intensive assessment protocol (6 visits during 28 months). Secondly, it is possible that the full effect of the intervention had not yet been detected because, when a child's attachment was assessed, only two thirds of the intervention visits had been performed (29 of 44 visits). A "sleeper effect" is still possible: we hope that a more clear result will be seen when children are assessed again, at 48 months, in our follow-up study (CAPEDP-A II). By clarifying the mechanisms involved in the development of a secure attachment, our study aims to contribute and refine the development of early preventive intervention strategies in high perinatal and psychosocial vulnerability contexts.

[A mental health awareness anti-stigma program including user-trainers has a significant impact on knowledge, beliefs and attitudes of job centre professionals in Paris]. / Impact significatif auprès des conseillers à l'emploi d'une action de sensibilisation à la santé mentale et de déstigmatisation incluant des usagers-formateurs.

BACKGROUND: Developing programs and actions to fight stigma and discrimination against people living with mental disorders is a priority both internationally and in France. Involving mental health service users in these anti-stigma programs has proved to be a key element for effective programs. The present study evaluates the impact of user-trainers in an anti-stigma campaign with job counselors on their knowledge, beliefs, and desire for social distance with regard to mental illness and the mentally ill. METHOD: Eighty-nine professionals participated in eight mental health awareness days from December 2008 to June 2009. Each training day was built around two pedagogical units: firstly, a psychiatrist providing a theoretical overview of mental illness and care and secondly, user-trainers describing their point of view on mental illness and exchanging with participants. A questionnaire administered at the beginning and at the end of the mental health awareness day assessed the impact of the day on participants' knowledge, beliefs, and desire for social distance. Answers to open questions were evaluated using thematic qualitative analysis. RESULTS: The intervention had statistically significant positive effects on all three training objectives: knowledge, beliefs and desire for social distance. Analysis of qualitative data confirmed participants' need for information and training with regard to providing support to clients with mental health problems; participants frequently attributed their improved self-confidence at the end of the day with regard to providing job coaching for this population group to the presence of user-trainers. CONCLUSION: A mental health awareness day using mental health service users and psychiatrists as trainers had significant positive effects in terms of reducing stigma with regard to people with mental illness. Further research is needed to understand whether the impact of such awareness approaches can be maintained in everyday professional practice over time.

Health services and the treatment of immigrants: data on service use, interpreting services and immigrant staff members in services across Europe.

BACKGROUND: The number of immigrants using health services has increased across Europe. For assessing and improving the quality of care provided for immigrants, information is required on how many immigrants use services, what interpreting services are provided and whether staff members are from immigrant groups. METHODS: Structured interviews were conducted with 15 health services (9 primary care, 3 emergency departments, 3 mental health) located in areas with high immigrant populations in each of 16 European countries (n=240). Responses were collected on the availability of data on service use by immigrant patients, the provision of interpreting services and immigrant staff members. RESULTS: Data on service use by immigrants were recorded by only 15% of services. More than 40% of services did not provide any form of interpreting service and 54% of the services reported having no immigrant staff. Mental health services were more likely to use direct interpreting services, and both mental health and emergency services were more likely to have immigrant staff members. DISCUSSION: For assessing and improving the quality of care provided for immigrants, there is a need to improve the availability of data on service use by immigrants in health services throughout Europe and to provide more consistent access to interpreting services.

[Mental health disorders, medical care and social support in a vulnerable population: the example of the maternal centres in Paris]. / Troubles de santé mentale, recours aux soins et au soutien social chez une population vulnérable : l'exemple des centres maternels de Paris.

INTRODUCTION: The negative effect of social deprivation and poverty on mental health has been the subject of numerous publications since the 1960s, with studies generally showing a higher prevalence of mental health disorders in homeless, unemployed or low income populations. Women in perinatal contexts are also at greater risk for psychopathology: the relative risk for being hospitalised is up to 60% higher in the perinatal period than during the two years preceding pregnancy. Access to social care and informal support is therefore particularly important for pregnant women in vulnerable social conditions. In France, socially excluded mothers access shelter and accommodation in maternal centres. Over the last few years, staff in these centers report what they perceive to be as an increase in the prevalence of mental health problems in the mothers using these services. The current study, CEMAT, set out to examine this question. METHODOLOGY: Based on a participatory research method, a qualitative and epidemiological study was carried out in order to evaluate the reality and needs in terms of mental health care in this population, as well as to evaluate available care and support networks. The study took place in 2005. All stakeholder groups in six maternal centres agreed to participate in focus groups and, in addition, residents were invited to respond to epidemiological and qualitative questionnaires, including the Mini International Neuropsychiatric Interview (MINI 5.0.0) and its qualitative questions aimed at evaluating use of medical and social network resources. Overall, 95 women took part in this study, representing 61% of all residents. Subjects were young (64% under 26) and 57% had been living in their centre for over 12 months. RESULTS: A percentage of 68% (N=65) of the participants were identified as having a mental health disorder, according to the MINI. Of these 65 women, 55 (85%) had consulted a physician (mainly general practitioners and gynecologists) during the preceding two months. Ninety seven per cent of women validating one or more MINI diagnoses had specifically looked for help for these disorders, 17% seeking only professional help (GP, psychiatrist, psychologist, social worker, expert in non conventional medicine or traditional care), 23%looking for an informal source of support (partner, family, friends) and 57% using both professional care and informal support. High rates of satisfaction (69% for professional services, 81% for informal support) showed the capacity of this population to request relevant social and medico-social support. DISCUSSION: Results tend to confirm the links between psychosocial vulnerability and mental health disorders. On the other hand, the women's ability to ask for and to access specific psychological care, whether it be from professionals or informally from friends and family is to be underlined. The high satisfaction rates tend to prove that, though psychologically vulnerable, this population has coping capacities that should be recognized and valorized. Options open to such structures do not necessarily involve the sole development of internal mental health resources, but need to acknowledge and strengthen existing support networks.

Mental health care in Paris.

AIM: Characterised by its population density, cultural and ethnic diversity, familial fragmentation and high levels of HIV/AIDS, crime and homelessness, Paris poses specific problems with regard to mental healthcare. METHODS: Epidemiological studies show high rates of generalised anxiety and drug and alcohol abuse and dependence, greater use of psychoactive medication and, at the same time, apprehension about looking after mentally ill family members at home. RESULTS: Although the Greater Paris area has a much higher density of GPs and specialists than the national mean, there are considerable variations within the region itself, with the central area having up to four times as many GPs or psychiatrists as the outer suburbs. On the other hand, although the number of mental health medical acts and the number of people receiving mental health care have been rising dramatically over the last 15 years, Paris has considerably less adult psychiatry beds and day care places per head of population than the rest of France. DISCUSSION: Current planning targets include a more equitable distribution of mental health care service provision for the rapidly evolving urban population, early prevention of psycho-affective disorders, suicide and drug and alcohol misuse and the creation of low threshold services for adolescents in difficulty.