Crazy'App: A web survey on representations and attitudes toward mental disorders using video testimonies.

In the international context of efforts to combat the stigmatization of people with mental health problems, representations and attitudes about these illnesses have not to date been widely investigated in France. However, new technologies offer an unprecedented opportunity to collect such information on a large scale and to deploy more efficient action against stigma. OBJECTIVES: The Crazy'App survey was designed as an instrument for studying potentially stigmatizing representations and attitudes towards mental disorders. It asks respondents to react, rather than to standard diagnostic labels or case vignettes, to video testimonies by people with different mental disorders talking about their experiences. METHODS: The web survey was made available on smartphone or computer and advertised on various media and during a French exhibition about mental disorders, mental health and well-being ("Mental Désordre", Cité des sciences, Paris, 2016). It consisted of short (<2min) video testimonials by four people presenting respectively anorexia, bipolar disorder, obsessive-compulsive disorder and addiction to alcohol. Each testimony was immediately followed by series of questions to which participants were to respond using visual analog scales. The questionnaires investigated different domains, such as the causes of each of these mental disorders, the possible treatments and the respondent's personal attitudes in hypothetical situations (e.g. working with the person seen in the video). After having completed the survey, respondents were offered an opportunity to compare their own responses to those of the other respondents, and watch expert psychiatrists interviews delivering clinical and scientific knowledge and sharing their own attitudes. RESULTS: The respondents (n=2600) were young, mostly women, educated and concerned about the subject. They exhibited good knowledge of the disorders. They reported a multi-causal view of the etiologies, where psychological causes were rated higher than neurobiological causes (although less so for respondents reporting having had a mental disorder themselves), while other types of causes (environmental, spiritual, and nutritional) received much lower ratings. Respondents also expressed high potential social proximity, but this result varied according to the type of disorder, in particular, the social distance and the perception of dangerousness were greater for addiction and bipolar disorder. CONCLUSIONS: Crazy'App operationalizes emerging strategies in the efforts to combat stigma, implementing what is known as a "contact based intervention" in English-speaking countries. While it does not erase the differences in attitudes observed from one pathology to another, this type of survey-intervention based on video testimonies could help to reduce the desire for social distancing from people with mental disorders, even in a particularly sensitized and informed population. Multimedia technologies are an efficient way to offer rich, potentially interactive content better able to embody people and their actual experiences than clinical descriptions or even life narratives. However the use of videos could put the focus on the individual characteristics (physical, gestural, verbal, nonverbal…), and this should be cautiously taken into account according to the anti-stigma objectives. Connected technologies also make it possible to enhance the more classic de-stigmatization actions focused on the deconstruction of preconceived ideas, making the action more participatory, while simultaneously assessing their efficacy. By mediating contact with individuals and behaviors perceived as deviant, the aim would be to develop psycho-social skills and concrete abilities for action in the general population, to include people with mental disorders in the community.

Use of general practitioners versus mental health professionals in six European countries: the decisive role of the organization of mental health-care systems.

OBJECTIVE: To investigate patterns of use of general practitioners (GPs) and/or mental health professionals (MHPs) for mental health reasons, across six European countries, and the extent to which these patterns of use are associated with differences in mental health-care delivering systems. METHODS: Data are based on the European Study of the Epidemiology of Mental Disorders (ESEMeD): a cross-sectional survey of a representative sample of 8,796 non-institutionalized adults from six European countries, conducted between 2001 and 2003 using computer-assisted interviews with the CIDI-3.0. Countries were classified into: MHP- for countries where access to medical professionals tends to predominate (Belgium, France, Italy), and MHP+ where access to non-medical MHPs predominates (Germany, Spain, The Netherlands). RESULTS: Among respondents consulting GPs and/or MHPs in the past year (n = 1,019), respondents from the MHP- group more often consulted GPs (68 vs. 55 % in MHP+ group), GPs and psychiatrists (23 vs. 14 %). People from the MHP+ group more often used MHPs only (45 vs. 32 %), GPs and non-medical MHPs (16 vs. 8 %). GPs from the MHP+ group were more inclined to refer patients to MHPs. Factors associated with use of GPs versus MHPs were: being over 49 years, not highly educated, lower income and suffering from mood or severe mental disorders. CONCLUSIONS: Differences in the use of GPs versus MHPs are markedly linked to individual as well as organizational factors. Interventions are needed, in countries fostering medical access, to reimburse sessions with non-medical MHPs and improve cooperation between professionals to obtain better practice in access to care.

[Initial training in psychotherapy for psychiatrists in France: results of a national survey]. / La formation aux psychothérapies des internes de psychiatrie en France : résultats d'une enquête nationale.

INTRODUCTION: According to a recent change in the French legislation (2010) regarding the regulation of the use of the title of "psychotherapist", psychiatrists are now allowed to use this title at the end of their training, without any additional training. However, various publications from 2000 have shown that there is no specific training in psychotherapy at a professional level during the training of psychiatrists. GOALS: To study the current situation of the Academic training of French psychiatrists in psychotherapy during their residency, their interest for these therapies, their level of satisfaction regarding their training, and the importance of additional private training programs. METHODOLOGY: A survey was carried out among residents in psychiatry from October 2010 until January 2011. An anonymous questionnaire covering five domains (academic teaching, psychoanalysis, extra-academic training, interest in a more developed model of training, supervision) was sent by the French Federative Association of Psychiatrists Trainees (AFFEP) to all French psychiatrist trainees, through their local trainee associations (n=26). RESULTS: The questionnaire was answered by 869 of the 1334 psychiatry residents (65%). The vast majority of the trainees reported being interested in psychotherapy, but 75% thought that their training in psychotherapy (psychoanalysis, cognitive-behavioral therapy [CBT] and systemic therapy) is insufficient. In 20 of the 26 universities, more than half of the trainees reported that their training was insufficient in the three fields; in four universities, more than half of the trainees were satisfied with at least one field. Yet, satisfaction rates were very different among universities: for example, 27% were satisfied with their psychoanalytic training in Paris and 87% in Strasbourg; 7% were satisfied with their CBT training in Strasbourg, but 65% in Nice. The vast majority (97%) believes that supervision about therapeutic relationship is necessary during residency rotations in the hospital. More than three quarters (78%) would like to have supervision at least twice a month. Yet, only 51% of respondents have such supervision. Once again, large disparities were observed between different Academies: for example 74% had supervision in Montpellier, but only 29% in Marseille. The vast majority (95%) of trainees would like a two-phase model of training (general theoretical teaching plus in-depth training in one or more methods), which is different to the current training model. CONCLUSION: Our results show a clear discrepancy between the importance of training in psychotherapy for psychiatrists, the interest of psychiatry students for these therapies, and the very high rate of dissatisfaction for the training received, as well as the rate of students supervised during their training period at the hospital. These results differ from what is observed in other countries, where satisfaction rates are much higher among students, and various psychotherapy training methods are proposed in a much more homogeneous manner. More research is required to understand the reasons for these difficulties with the psychotherapy training of psychiatrists in France, and to propose new models of training to improve this situation.

[National information campaigns on depression. A biopsychosocial anthropology?]. / Les campagnes nationales d'information sur la dépression. Une anthropologie biopsychosociale?

INTRODUCTION: Information and prevention campaigns are privileged tools for public health institutions in their risk reduction policies concerning heath disorders and their consequences. Mental health in general, and depression in particular, have been the focus of several public campaigns in different countries for 20 years. AIM OF THE STUDY: The aim of this paper is to analyse depression campaign messages, to highlight their underlying logics and to show some of their effects, in particular in relation to contextual conflicts between professionals that possibly emerge because of these campaigns. MATERIAL: Previous depression campaign materials were analysed, and the recent French campaign launched in November 2007 was the subject of specific attention. RESULTS: Common messages of the campaigns are centred on the prevention of emergence, recurrence, worsening and individual, social and economic consequences of depressive disorders. Depression is always presented as "a disease"; a position which differs from international classifications describing depression as "a disorder", a much less affirmative statement. This choice, which has important "performance" values is based upon several factors including the difficulty to "popularise" psychological technology, a consensus resulting from a political struggle between professionals, a reaction to the current norms of autonomy implying a new set of rights and responsibilities from and towards the people who are "sick", and the importance given to the reduction of stigmatisation from which the "mentally ill" suffer. From all of these aspects appears a logic of "dementalisation" corresponding to a "deficit" model, in which depression is presented as something external to the individual, and where treatment is supposed to "fix" the deficit. DISCUSSION: The French campaign shares many of those fundamental characteristics: prevalence, seriousness of the disease's consequences, low level of services use, preference for biological monoaminergic theories, and environmental risk factors to explain the disease (an aetiology which is more bioenvironmental than really biopsychosocial), presentation of the main chemotherapeutics and psychological treatments, referring first to a general practitioner, importance of reducing stigmatisation, and presentation of depression as a disease. However, the French campaign differs from other campaigns in its use of an organising concept for the symptoms (slowing down) and a more precise description of the frontiers between normal and pathological functioning. Furthermore, beyond the usual biological and environmental elements, greater importance is given to the psychological mechanisms and to phenomena that are not only in the "real world", such as symbolic losses. Nevertheless, it does not explicitly recommend any psychotherapy "brand". CONCLUSION: This "specificity" reflects the compromise found between the different French professional positions and the opposing paradigms that govern them. The campaign led by the French Institut national de prévention et d'éducation à la Santé (Inpes) on depression is a first step of prevention and heath promotion of mental health in France. The analyses presented in this paper highlight the present orientations in this domain, its underlying tensions and the importance of respecting and preserving the multiple aspects of this domain, which are many different ways to explore the complex object that is mental health. This paper also replaces those campaigns in the complexity of their logic and their context, in an attempt to provide elements for a dispassionate reflection for all of the actors concerned by these questions.

[Use of services and treatment adequacy of major depressive episodes in France]. / Recours aux soins et adéquation des traitements de l'épisode dépressif majeur en France.

INTRODUCTION: Though depressive disorders are major problems of public health, general population data about use of services and treatment adequacy are scarce in France. The literature suggests that the percentage of people suffering from mental disorders who are adequately treated is low. AIM OF THE STUDY: The objective of this study was to estimate the 12-month use of services in the French general population suffering from major depressive episodes (MDE) and levels of treatment adequacy. METHOD: This analysis was conducted on data from the Health barometer 2005, an epidemiological survey concerning several health topics. Thirty thousand five hundred and fourteen individuals from 12 to 75 years old were interviewed by telephone from October 2004 to February 2005. Depressive disorders were assessed by a standardized tool, the CIDI-SF, according to DSM-IV classification. RESULTS: The mental health questions were answered by 16,883 individuals; i.e. by 60% of individuals aged 15 or older. One year prevalence of MDE was 7.8%. In this group, 58.2% used services in a 12-month period, though only 21% of the service users received adequate treatment. Amongst those who used services, 2/3 consulted health care professionals (i.e. 1/3 of people presenting a MDE). The remaining percentage - 21.4% - of people presenting a MDE used psychotropic drugs without mentioning any use of services for mental health problems. The vast majority of individuals with MDE who used services (34.6% of those with MDE) consulted a professional trained to treat depression (general practitioner, psychiatrist, psychologist and psychotherapist). Only a small proportion (19.9%) of those consulting a professional went to a non-specialist professional as well; and even less (6%) consulted only a non-specialist professional. Amongst trained professionals, most consultations (61%, or 21.1% of the MDE group) concern general practitioners; another 38.4% (13.3% of the MDE group) involved psychiatrists; and 27.8% (9.6% of the MDE group) went to psychologists or psychotherapists. Amongst the psychologists and psychotherapists, most consultations were with psychologists (74.1%). The proportion with adequate treatment differed according to the type of professional. Consulting a general practitioner is associated with the lowest levels of adequate treatment (37.2%, and for general practitioners only, 21.5%). Consulting a psychiatrist is associated with higher proportions of adequate treatment (65.1%, and for consulting a psychiatrist only, 60.7%). Consulting both a general practitioner and a psychiatrist is associated with the highest levels of adequate treatment (79.7%). Antidepressants (ATD) are used far more frequently than psychotherapy (PT): 33.4% of individuals with MDE used ATD, and among the latter, 58.4% had also used anxiolytic drugs (AXL). Finally, 26.9% of the MDE group used AXL, 7.5% without any use of ATD. For PT, 10.8% used PT, and 8.1% used PT and ATD. DISCUSSION: Improving use of professionals and treatment adequacy are two primary objectives from a public health perspective. Since most adequately treated people used an antidepressant therapy (90%), and only 30% a PT, use of psychotherapeutic approaches might be improved. Moreover, levels of treatment adequacy are very low in people presenting an MDE who did not consult for "mental health reasons". Improving the recognition of symptoms of depression might contribute to better treatment adequacy.

[Factors associated with treatment adequacy of major depressive episodes in France]. / Facteurs associés à l'adéquation des traitements de l'épisode dépressif majeur en France.

INTRODUCTION: Level of treatment inadequacy amongst people suffering from a major depressive episode (MDE) remains an important issue in the literature. Moreover, from a public health perspective, it's important to know how this situation can be improved. AIM OF THE STUDY: The objective of this study was to identify which factors are associated with adequate treatment for depression in France. A More specific objective was to investigate if being adequately treated is associated with the type of health care professionals consulted and, furthermore, to test the specific effect of providers taking sociodemographic and clinical variables into account. METHOD: This study was carried out from the data of the Health Barometer 2005, a random survey on various health topics. Thirty thousand five hundred and fourteen individuals from 12 to 75 years old were interviewed by telephone from October 2004 to February 2005. Depressive disorders were assessed by a standardized tool (CIDI-SF) according to the classification of the DSM-IV (16,883 individuals had answered the questions of mental health: 60% of the individuals aged 15 or older). RESULTS: Levels of treatment adequacy are higher for women, more severe disorders, and for people living in Paris or Central Eastern regions. They are lower for students. Significant differences were found between types of professionals and levels of treatment adequacy. They are higher for psychiatrists than for psychologists and psychotherapists and higher than for general practitioners. Lowest levels of adequate treatment were found for depressed people who used services without considering this recourse being for "mental health reasons". There are also some significant differences in sociodemographic and clinical patient characteristics between health care professionals. The population of depressed people consulting without "mental health reasons" is older and less educated. The population of depressed people consulting a psychiatrist suffers from more severe disorders and is more educated than those consulting a general practitioner. The population of depressed people consulting a psychologist or a psychotherapist is younger and more educated. Taking sociodemographic and clinical variables into account, the probability of receiving an adequate treatment increases when using specialized care only, or conjointly with the primary care sector. To be retired and to be yet another "inactive" is associated with better treatment adequacy, as is living in Mediterranean, Paris or Central Eastern regions. Severe MDE also increases the probability of being adequately treated. DISCUSSION: Levels of treatment adequacy differ between health professionals, even when sociodemographic characteristics of their patients and the severity of their disorders are controlled; specialized care, in particular when associated with primary care use of services, is correlated with the highest rates of adequate treatments, and should therefore be recommended. Geographical areas are associated with adequation of treatments, but not with use of healthcare systems. This suggests that disparities in the organization of the healthcare systems and in the collaboration between professional might exist in the different areas.

[Psychotherapeutic practices in France: results of a professional-based health insurance participant survey]. / Usage des psychothérapies en France: résultats d'une enquête auprès des mutualistes de la MGEN.

INTRODUCTION: Today in France, little empirical data on the use of psychotherapy is available. This paper presents an empirical study of psychotherapeutic practices, from the patient's point of view. We will present results regarding frequency of psychotherapies, patients' characteristics, associations between different kinds of therapy, where they take place, and the reasons given for beginning psychotherapy. METHODOLOGY: Data is based on a general and mental health survey conducted by MGEN(1) foundation among 6,500 persons, as well as on general population data collected by the BVA survey institute. RESULTS: Depending on the population studied, between 5 to 11.5% of people have had psychotherapy sessions at least once in their lifetime. Women born at the beginning of the sixties and men born at the beginning of the fifties are those who consulted the most. The vast majority of these psychotherapies are individual, in private practice. They often last more than one year, with a frequency of once per week or more. Thirty percent declare that they have undergone several psychotherapies. The reasons for consultation reported by users are mainly depression or anxiety. There are significant differences between genders for the reasons for consultation, women being concerned by depression, problems with sleep and food, and men being concerned by obsessive thoughts and addiction (alcohol, tobacco). People undergoing psychotherapy give an average of 2.5 reasons for this psychotherapy, and only 28% gave only one reason. A relationship exists between the number of consecutive treatments and the number of reasons given for undergoing psychotherapy. More than 25% of the psychotherapies last less than 6 months. "Intensive psychotherapy" (at least 6 months and a frequency of 2 to 3 times per month) concern 5.9% of the whole population studied, and represent 51.4% of all psychotherapies. People are quite satisfied by their psychotherapy; 90% are satisfied with the results and 60% believe that their condition has been much improved in a durable manner. 16.6% were unsatisfied with the results. There is (in women only) an association between satisfaction and intensity of treatment; satisfaction is lower in those women undergoing intensive psychotherapy; 77. 7% of users have also used some sort of drugs for the problem (80.6% of women and 69.9% of men) with psychotropic drugs most frequently used: 70.8% of the psychotherapy users had taken such drugs for their problem (women 72.9%, men 65.4%). CONCLUSION: In France, psychotherapies are playing an important role and it is necessary to study these techniques better in order to give them the place they deserve in the French mental health policy.

[New directions for psychotherapy research: an evaluation of a research protocol and a methodological and technical framework proposal]. / Nouvelles perspectives pour la recherche en psychothérapie: évaluation d'un protocole de recherche et proposition d'un dispositif méthodologique et technique.

INTRODUCTION: A recent report of the French research institute INSERM, based on a comprehensive review of the work done on the evaluation of psychotherapies Psychothérapies: trois approches évaluées, has shown the lack of research in France on this topic, notably in psychodynamic psychotherapy. The development of such research is needed. The first part of the paper deals with the limits of the third generation of studies on psychotherapy (medical model, use of RCT, DSM...) on which the INSERM report is based and reviews the existing propositions for a fourth generation of research in the field. METHODOLOGICAL FINDINGS: In the second part, a process-outcome research protocol developed by the authors, according to these new proposals as well as several on-going researches [J Clin Psychol, 27 2 (1998) 217-26, J Pragm Case Stud 3 (2000)(2), Arch Gen Psychiatry 59 (2002) 505-10, Psychother Res 12 3 (2002) 251-72 and Br J Psychiatry 165 (1994) 4-8] is presented. The proposed methodology is based on controlled single case studies. Quantitative and qualitative data are associated for the definition of the diagnosis, as well as initial, intermediate and final measures. Process analysis is used to describe the main characteristics of the on-going psychotherapy at different moments in time. It is thus possible to gain access to what is really done during the therapy and not only to what is supposed to be done, based on a manual or even on the name of the theory used by the therapist. DESIGN OF THE STUDY: This methodology was tested during a one-year pilot study, in true conditions of psychotherapy with outpatients. The different phases of the analysis are presented: several tools dedicated to the observation, formalisation and data analysis are integrated in a coherent iterative process during the whole therapy. The interests and limits of each tool (ESM, DSM, PPQS, Hoglend, CORE...) are described together with the first results of the pilot study. DISCUSSION: The overall architecture of a database designed to collect, search and analyse data is provided in the last part of the paper. CONCLUSION: This framework offers two possibilities at the same time: it provides therapists with the ability to follow the evolution of their cases and to compare them with similar cases. It provides researchers with the ability to drive true comparative analysis, based on psychotherapies conducted in real situations and on detailed-enough descriptions to obtain significant outcomes.

[Distinction, limits and complementarity between efficacy and effectiveness studies: new perspectives for psychotherapy research]. / Distinction, limites et complémentarité des recherches d'efficacité potentielle et d'efficacité réelle: nouvelles perspectives pour la recherche en psychothérapie.

Perron et al. (2004) criticize the collective expertise conducted by the INSERM on the efficacy of different psychotherapy methods for different mental disorders. They say the work is biased in favour of Cognitive and Behavioral Therapies (CBT), while there is a negative bias regarding other methods, in particular psychodynamic therapies. Philippe Cialdella, a specialist of methodology and quantitative analysis in psychiatry, exposes an counter-argument in 10 points and brings welcome clarifications on the methodology and statistics. There is neither statistical bias in the INSERM report (which anyway is not a meta-analysis, but a literature analysis), nor in the first or second level studies on which it is based, mainly Randomised Controlled Trials (RCT). Though some arguments of P. Cialdella could be discussed in detail, his work comes to the conclusion that we can thus trust the results of the INSERM on one point: positive results can be obtained by psychotherapy with the experimental patients involved in the RCTs, and these findings are reliable. This is an important result in favour of psychotherapy, but it does not answer a very fundamental question: do we have reliable evidence that there is no systematic difference between the population constituted of patient-treatment-therapist (as a whole) found in RCTs, and the population constituted of patient-treatment-therapist (as a whole) in real contexts? A detailed analysis of what are efficacy studies and their methodology shows that this is not the case, and that it is hence not possible to generalize the results obtained by RCTs to clinical practice in real situations. Comorbidities and complex pathologies, choice of the therapist by the patient, interpersonal factors, conditions of use of manuals, contextual and social parameters, amongst other parameters make the real situation radically different from the RCT one, and the results impossible to generalize. Effectiveness studies in real situations do not solve the problem either. They have low internal validity, and though the population studied is close to a real one, too many uncontrolled parameters make the results unreliable. Moreover, outcome studies, whether they are efficacy or effectiveness studies, generally test a therapy "as a whole" versus another one, as defined in a manual, or by psychotherapy "trademarks". This design totally fails to offer a detailed view of what really happens during the therapy between the patient and the therapist, and it gives no possible insights into the change process elements. Only clinically highly representative quasi-experimental prospective studies can help us to understand change processes in real situations and incrementally improve treatment procedures. Daniel B. Fishman in the year 2000 made an ambitious and really interesting proposal about using pragmatic case studies in a systematic and scientific manner. Numerous reliable methodological tools, such as the Psychotherapy Process Q-Sort for example, as well as the tremendous innovations made in information and communication technologies make it possible today to implement such a proposal. It will enable us to really compare the resulting differences between the different approaches used in clinical settings, in relations with the type of intervention carried or in the real therapies, during clinically significant periods of time, and with various and ecologically valid samples. This is a possible solution to the difficult question of the use of outcome research to improve psychotherapy practice.