[Reflection on the psychiatric financial allocation in France]. / Réflexion sur la péréquation financière de psychiatrie en France.

For 25years work has been underway in France for the implementation of an alternative to public financing of health care. In the absence of progress, some regional health agencies are engaged in work related to the reallocation of public finances between psychiatric institutions. We propose a reflection with suggestion on the method proposed by the Provence Alpes Côte d'Azur Regional Health Agency. Without questioning the need for a reallocation of resources between psychiatric institutions, the method proposed here needs to evolve further to be applied in a legitimate and appropriate manner. There is a kind of urgency for a reallocation of resources between psychiatric institutions in France, but it implies a collective thinking and especially the definition of evaluation procedures for the selected models. These conditions are necessary to guarantee the quality of French psychiatry and equity in access to psychiatric care.

[Evolution of the social autonomy scale (EAS) in schizophrenic patients depending on their management]. / Évolution de l'autonomie sociale chez des patients schizophrènes selon les prises en charge. L'étude ESPASS.

It is becoming clear to clinicians that functional prognosis is the issue that should be guiding their choice of therapeutic strategy offered to people with schizophrenic disorders. An individual's degree of social autonomy is one of the principal factors determining functional prognosis, and it has become essential to identify the variables that influence it. The ESPASS survey was set up to follow a cohort of 6000 schizophrenic patients in a naturalistic setting, and was conducted over six months by 1170 psychiatrists. Patients were required to meet DSM-IV TR criteria for schizophrenia, with the exception of those suffering from an acute psychotic episode, and to either need a change in their antipsychotic treatment or its initiation. Data collected included patients' sociodemographical characteristics, types of treatment (pharmacological and non-pharmacological), illness characteristics (as determined by the DSM-IV TR criteria), degree of social autonomy (EAS), effectiveness (IAQ scale), overall severity of the illness (CGI - S scale) and patient satisfaction with medical treatment (PASAP self-questionnaire). Concerning the non-pharmacological aspects of treatment that offer patients programmes to increase their autonomy, the survey made it possible to collect data describing real practices and to measure the actual availability of rehabilitation services. It has been verified that the sample of psychiatrists included in this survey, as well as the schizophrenic patients under evaluation, were representative of the French psychiatrist and patient populations. Most importantly, the survey made it possible to objectively evaluate the healthcare services available in France. It seems that the vast majority of public-service psychiatrists have access to hospital and ambulatory facilities for treatment (medical-psychological centers, day-care hospitals and rest centers), as well as access to facilities providing simulated real-life activities. Psychiatrists who are private practitioners have less access to such arrangements for their patients. The vast majority of psychiatrists in both categories are unable to offer their patients active rehabilitation techniques: training in social skills (25%), cognitive remediation (16%), cognitive-behavioral therapies (20%), even though psychoeducation is quite widespread (44%). However, the survey demonstrated that the actual use of these methods was much lower still (2%, 1% and 2%, respectively), although the use of alternative facilities to hospitalization was quite high (day-care hospitals 9%, rest-centers 8%). In total, at the end of the study, the proportion of patients benefiting from some kind of programme to increase their level of autonomy was 41%. These results have demonstrated a link between the evolution of patients' clinical symptoms and their social autonomy. Within the findings, the items that varied most were patient's level of personal care and relations with others, whereas the ability to manage resources seems difficult to influence. Moreover, the results have shown that better development of social autonomy is significantly correlated with the prescription of second-generation antipsychotics. Regarding non-pharmacological treatment, better development of social autonomy is significantly correlated with setting up programmes to achieve this objective, including the use of active rehabilitation techniques. Overall, the survey confirmed the results of earlier work to validate the scale of social autonomy (EAS), and confirmed the robustness of its objective measurements.

[Prevalence of trauma-related disorders in the French WHO study: Santé mentale en population générale (SMPG)]. / Prévalence des troubles psychotraumatiques en France métropolitaine.

INTRODUCTION: Trauma-related disorders are disabling affections of which epidemiological data change according to the country, population and measuring instruments. The prevalence of posttraumatic stress disorder (PTSD) appears to have increased over the past 15 years, but one cannot tell whether it has indeed increased or whether the standardized procedure has improved. Moreover, very few epidemiologic studies among the general population have been conducted in Europe, notably in France. DESIGN OF THE STUDY: The "Santé mentale en population générale" (SMPG) survey, that took place in France between 1999 and 2003 among more than 36 000 individuals, gives an estimation of the prevalence of psychotraumatic disorders in the general population. Multi-varied analyses were performed on PTSD-related variables and comorbid disorders. The instantaneous prevalence (past month) of PTSD was of 0.7% among the whole SMPG sample, with almost the same proportion of men (45%) and women (55%). There was a high rate of comorbidity among PTSD individuals, notably with mood disorders, anxiety disorders and addictive behaviour. There was an obvious relationship with suicidal behaviour, with 15-fold more suicide attempts during the past month among the PTSD population. RESULTS: This survey analysed the consequences of a psychic traumatism over and above complete PTSD according to DSM-IV criteria, observing for instance the consequences for people exposed both to a trauma and suffering from at least one psychopathological symptom since the trauma. Those who suffered from a psychotraumatic syndrome, according to our enlarged definition, represented 5.3% of the population, half suffered from daily discomfort and a third of them used medication. Then, we compared those psychotraumatic syndromes to complete PTSD from a sociodemographic, functional and type of care point of view. There was little difference in prevalence of PTSD between men and women in the SMPG survey (45% vs 55%), which is clearly distinct from the other epidemiologic surveys named above. Regarding age, as in the ESEMeD survey, anxiety disorders appeared to be more frequent among younger people. The originality of the SMPG survey is obviously in the fact that it studied the functional impact of the psychic disorder, the type of care and the satisfaction level after care. Only 50% of the PTSD population feels sick which is, however, twice as high as for the psychotraumatized population. This doesn't fit either with the fact that 100% of the PTSD population say they feel uncomfortable with other people. The type of care is in the same vein: 50% of psychotherapies and 75% of medication, but also 25% of mild medicines and 25% of traditional medicines. Moreover, among the drugs, antidepressants (that are still the first choice treatment in all international recommendations) represent only 30%, whereas anxiolytics, hypnotics and phytotherapy represent the remaining 70%. DISCUSSION: Regarding the type of care, the differences between the psychotraumatized population and the PTSD population are obvious. They are obvious in that which concerns the type of care, since the medication is similar. From a very global point of view, patients suffering from a subsyndromal PTSD rarely choose medical care (religion, mild or traditional medicine), while full PTSD patients definitely choose classical medical care (drugs, psychotherapy, and 30% of hospitalization). The prevalence of those who ask for care is very close to that observed in the ESEMeD survey, which was four individuals out of 10 suffering from PTSD. CONCLUSION: The SMPG data show that its necessary to maintain the distinction between subsyndromal PTSD and full PTSD since the populations differ, but both need care.