[PLAID-Care: Research into the reduced use of coercion in France]. / PLAID-Care : une recherche sur le moindre recours à la coercition en France.

The use of coercion is a common practice in psychiatry despite its deleterious effects and insufficient evidence of benefits. It is so deeply rooted that the mention of establishments that make little use of it arouses a form of incredulity. However, the history of psychiatry and the international literature provide numerous examples of a psychiatry that is hardly coercive and numerous experiences of a reduction in the use of seclusion and/or restraint in psychiatric facilities. Today, in France, there are also less coercive establishments, which, for example, do not use mechanical restraint, have all their units open, or have reduced their use of seclusion and restraint. With regard to the stated policy objectives of reducing the use of coercion, it is surprising that most of these facilities receive little attention. PLAID-Care research aims to contribute to the visibility and analysis of these institutions and the factors involved in the reduced use of coercion. While these factors have already been identified in the international literature, the research is based on the multiplication of disciplinary perspectives (nursing, sociology, anthropology, geography) and the mobilization of a multi-level analytical framework that allows us to embrace their multiplicity and better understand their articulation. The originality of the research also lies in its historical dimension, which allows us to understand, on the scale of an institution, how a policy and practices aiming at the least recourse emerge and are consolidated. The project timeline is divided in three tasks: firstly, an inventory of "low-coercion" facilities in France; secondly, we will select and research four traditionally "low-coercion" facilities in France; thirdly we will focus on recently emerged "low-coercion" practices. PLAID-Care aims to revitalize French research on this theme which to date has been relatively lagging behind the numerous international studies. It will bring together and articulate the knowledge, tools and forms of organization and collaboration that contribute to making a policy of lesser use of coercion operational.

Opening the black box of hospitalizations in French high-secure psychiatric forensic units.

INTRODUCTION: Basic epidemiological data are rare concerning the activity of specialized forensic psychiatric facilities in France. Here, we investigated the activity of the ten (640 beds) French "units for difficult patients" (unités pour malades difficiles [UMDs]). METHOD: We used the Programme de médicalisation des systèmes d'information (PMSI) database to describe the characteristics and evolution of psychiatric hospitalisations in UMDs between 2012 and 2021, as well as the age, sex, and principal diagnoses of the patients hospitalized in these facilities. RESULTS: Between 2012 and 2021, 4857 patients were hospitalized in UMDs (6082 stays). Among them, 897 (18.5%) had more than one stay. The number of admissions ranged from a minimum of 434 to a maximum of 632 per year. The number of discharges ranged from a minimum of 473 to a maximum of 609 per year. The mean length of stay was 13.5 (SD: 22.64) months with a median of 7.3 months (IQR: 4.0-14.4). Among the 6082 stays, 5721 (94.1%) involved male patients. The median age was 33 (IQR: 26-41) years. The most frequent principal psychiatric diagnoses were psychotic disorders and personality disorders. CONCLUSION: The number of individuals hospitalized in specialized forensic psychiatric facilities has been stable for 10 years in France and remains lower than in most European countries.

Breast Cancer Care Pathways for Women with Preexisting Severe Mental Disorders: Evidence of Disparities in France?

The excess cancer mortality in persons with severe mental illness (SMI) has been well documented, and research suggests that it may be influenced by care-related factors. Our objective was to assess breast cancer care pathways in women with SMI in France, using an exhaustive population-based data-linkage study with a matched case-control design. The cases were 1346 women with incident breast cancer in 2013/2014 and preexisting SMI who were matched with three controls without SMI presenting similar demographics, initial breast cancer type, and year of incidence. We compared cancer care pathways and their quality for cases and controls, using a consensual set of indicators covering diagnosis, treatment, follow-up, and mortality (until 2017). After adjusting for covariates, cases had lower odds to undergo the main diagnostic tests, lumpectomy, adjuvant chemotherapy, and radiotherapy, as well as hormone therapy, but higher odds for mastectomy. Suboptimal quality in cancer pathways was observed for both groups, but to a higher extent for cases, especially for not receiving timely care after diagnosis and post-treatment follow-up. Breast cancer mortality, considering competing risks of deaths, was significantly elevated in women with SMI. These findings highlight disparities in cancer care pathways for individuals with SMI, as well as specific aspects of the care continuum which could benefit from targeted actions to reach equity of outcomes.

Excess mortality of people living with a mental disorder: lessons from literature and perspectives / Surmortalité des personnes vivant avec un trouble psychique : enseignements de la littérature et perspectives

AIM: Considering the persistent excess mortality of people living with a mental disorder, this article provides an overview of potential causes to identify relevant research perspectives and to support the development of short-term measures in the French context. METHODS: We rely on a narrative review of the literature, both quantitative and qualitative, to define a conceptual framework of the different factors which could contribute to this excess mortality. Particular attention is given to research carried out in France to identify possible measures to implement in line with the specificities of the national context. RESULTS: The excess mortality of people living with a mental disorder represents a health inequality resulting from a combination of factors, which are not only linked to individual behaviors and living conditions detrimental to health but also to the health system – both in terms of its organization and of the health professionals involved. Questions relating to the extent of the role played by the different factors and to the way they interact (specific social processes, combination of inequalities or a particular convergence at the crossing of all these factors…) remain. CONCLUSION: These findings support the development of complementary research, relying on mixed methodologies, as well as of measures promoting access to somatic care for people living with a mental disorder throughout their care pathways (stronger development of prevention and patient education, better integration of somatic and psychiatric care teams, alternative modes of funding supporting a holistic approach to health…).

Objectif: Face au constat d'une surmortalité persistante des personnes vivant avec un trouble psychique, cet article dresse un état des lieux de ses causes potentielles afin d'identifier des perspectives de recherche et d'étayer la mise en place d'actions à court terme dans le contexte français. Méthodes: Nous nous appuyons sur une revue narrative de la littérature, quantitative et qualitative, mobilisée pour proposer un cadre conceptuel des différents facteurs pouvant jouer un rôle dans cette surmortalité. Une attention particulière est portée aux recherches françaises afin d'identifier des pistes d'actions adaptées aux spécificités de ce contexte national. Résultats: La surmortalité des personnes vivant avec un trouble psychique constitue une inégalité de santé résultant d'une combinaison de facteurs qui ne sont pas uniquement liés à des comportements individuels et des conditions de vie défavorables à la santé, mais également au système de santé ­ tant du point de vue de son organisation que des professionnels y intervenant. Des interrogations, relatives à l'ampleur du rôle joué par les différents facteurs et à la façon dont ils interagissent (traitement social spécifique, cumul d'inégalités ou conjonction singulière au croisement de ces facteurs…), demeurent. Conclusions: Ces résultats appellent la mise en œuvre de recherches complémentaires, mobilisant des schémas d'études mixtes, ainsi que de mesures favorisant l'accès aux soins somatiques des personnes vivant avec un trouble psychique, tout au long des parcours de soins (prévention, éducation thérapeutique, meilleure intégration des services somatiques et psychiatriques, modes de financement des soins encourageant une prise en charge globale de la santé…).

Development and Calibration of the PREMIUM Item Bank for Measuring Respect and Dignity for Patients with Severe Mental Illness.

Most patient-reported experience measures (PREMs) are paper-based, leading to a high burden for patients and care providers. The aim of this study was to (1) calibrate an item bank to measure patients' experience of respect and dignity for adult patients with serious mental illnesses and (2) develop computerized adaptive testing (CAT) to improve the use of this PREM in routine practice. Patients with schizophrenia, bipolar disorder, and major depressive disorder were enrolled in this multicenter and cross-sectional study. Psychometric analyses were based on classical test and item response theories and included evaluations of unidimensionality, local independence, and monotonicity; calibration and evaluation of model fit; analyses of differential item functioning (DIF); testing of external validity; and finally, CAT development. A total of 458 patients participated in the study. Of the 24 items, 2 highly inter-correlated items were deleted. Factor analysis showed that the remaining items met the unidimensional assumption (RMSEA = 0.054, CFI = 0.988, TLI = 0.986). DIF analyses revealed no biases by sex, age, care setting, or diagnosis. External validity testing has generally supported our assumptions. CAT showed satisfactory accuracy and precision. This work provides a more accurate and flexible measure of patients' experience of respect and dignity than that obtained from standard questionnaires.

Use of electroconvulsive therapy for individuals receiving inpatient psychiatric care on a nationwide scale in France: Variations linked to health care supply.

BACKGROUND: A comprehensive understanding of variations in the use of electroconvulsive therapy (ECT) among health care providers in charge of ECT referrals is lacking. OBJECTIVE: Our objectives were to document ECT use and its variations on a nationwide scale in France and to identify the factors that were significantly associated with these variations. METHODS: Administrative health claims data on hospitalization were used to perform a descriptive analysis of ECT use for adult patients receiving inpatient psychiatric care in mainland France in 2019 and its variations across hospitals in charge of ECT referrals. Based on a conceptual framework drawn from the literature on medical practice variations, a multilevel logistic regression was then conducted to identify patients, hospitals and contextual characteristics that were significantly associated with ECT treatment using non-ECT-treated patients receiving inpatient psychiatric care as the reference population. RESULTS: Patients receiving ECT (n = 3288) were older, more frequently female and had more severe diagnoses than other patients seen in inpatient care (n = 295,678). Significant variations were observed in the rate of ECT use across hospitals (n = 468), with a coefficient of variation largely above one. In the multivariable analysis, ECT treatment was associated with patient characteristics (which accounted for 6% of the variations) but also with characteristics of the hospitals and their environments (44% of the variations), including the type of hospital and its distance to the closest facility providing ECT. CONCLUSIONS: Variations in ECT use were strongly linked to health care supply characteristics, which raises questions about access to quality mental health care.

Measuring the Patient Experience of Mental Health Care: A Systematic and Critical Review of Patient-Reported Experience Measures.

BACKGROUND: There is growing concern about measuring patient experience with mental health care. There are currently numerous patient-reported experience measures (PREMs) available for mental health care, but there is little guidance for selecting the most suitable instruments. The objective of this systematic review was to provide an overview of the psychometric properties and the content of available PREMs. METHODS: A comprehensive review following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines was conducted using the MEDLINE database with no date restrictions. The content of PREMs was analyzed using an inductive qualitative approach, and the methodological quality was assessed according to Pesudovs quality criteria. RESULTS: A total of 86 articles examining 75 PREMs and totaling 1932 items were included. Only four PREMs used statistical methods from item response theory (IRT). The 1932 items covered seven key mental health care domains: interpersonal relationships (22.6%), followed by respect and dignity (19.3%), access and care coordination (14.9%), drug therapy (14.1%), information (9.6%), psychological care (6.8%) and care environment (6.1%). Additionally, a few items focused on patient satisfaction (6.7%) rather than patient experience. No instrument covered the latent trait continuum of patient experience, as defined by the inductive qualitative approach, and the psychometric properties of the instruments were heterogeneous. CONCLUSION: This work is a critical step in the creation of an item library to measure mental health care patient-reported experience that will be used in France to develop, validate, and standardize item banks and computerized adaptive testing (CAT) based on IRT. It will also provide internationally replicable measures that will allow direct comparisons of mental health care systems. TRIAL REGISTRATION: NCT02491866.

Care coordination for severe mental health disorders: an analysis of healthcare provider patient-sharing networks and their association with quality of care in a French region.

BACKGROUND: For patients with multiple and complex health needs, such as those suffering from mental health disorders, outcomes are determined by the combined actions of the care providers they visit and their interactions. Care coordination is therefore essential. However, little is known on links between hospitals providing psychiatric care and community-based care providers which could serve as a basis for the creation of formal mental care networks supported by recent policies. In this context, we first aimed to identify and characterize existing types of healthcare provider patient-sharing networks for severe mental health disorders in one French region. Second, we aimed to analyse the association between their characteristics and the quality of the care they provide. METHODS: Patient flows among healthcare providers involved in treating severe mental health disorders in the Provence-Alpes-Côte-d'Azur region were extracted from the French national health data system, which contains all billing records from the social health insurance. Healthcare provider networks that have developed around public and private non-profit hospitals were identified based on shared patients with other providers (hospitals, community-based psychiatrists, general practitioners and nurses). Hierarchical clustering was conducted to create a typology of the networks. Indicators of quality of care, encompassing multiple complementary dimensions, were calculated across these networks and linked to their characteristics using multivariable methods. RESULTS: Three main types of existing healthcare provider networks were identified. They were either networks strongly organized around the main hospital providing psychiatric care; scattered networks involving numerous and diverse healthcare providers; or medically-oriented networks involving mainly physician providers. Few significant associations between the structure and composition of healthcare provider networks and indicators of quality of care were found. CONCLUSIONS: Our findings provide a basis to develop explicit structuring of mental care based on pre-existing working relationships but suggest that healthcare providers' patient-sharing patterns were not the main driver of optimal care provision in the context explored. The shift towards a stronger integration of health and social care in the mental health field might impact these results but is currently not observable in the administrative data available for research purpose which should evolve to include social care.

Disparities in the Use of General Somatic Care among Individuals Treated for Severe Mental Disorders and the General Population in France.

Individuals with severe mental illnesses (SMI) face a striking excess and premature mortality which has been demonstrated in several national contexts. This phenomenon, which constitutes a red-flag indicator of public health inequities, can be hypothesized to result from healthcare access issues which have been insufficiently documented so far. In this context, our objective was to explore patterns of general somatic healthcare use of individuals treated for SMI in comparison to those of the general population in France using national health administrative data and a matched case-control study. Differences in the use of general and specific somatic preventive care services, primary care, routine specialized somatic care and admissions to non-psychiatric hospital departments for somatic causes were described between cases and controls after adjustment on differing clinical needs, socio-economic status, and living environment. Our results show a lower use of general preventive care services and of routine specialized somatic care in the SMI population, despite more frequent comorbidities, and a higher occurrence of avoidable hospitalizations, despite higher contacts with primary care physicians. These findings suggest that the health system fails to address the specific needs of this vulnerable population and support the development of measures aimed at reducing this gap.

Experimenting locally with a stepped-care approach for the treatment of mild to moderate mental disorders in France: Challenges and opportunities.

In France, publicly funded mental care services are mostly hospital-based and focused on treating severe illnesses. Mild to moderate mental disorders are typically managed by general practitioners (GP) who often lack specific training to treat these conditions. Antidepressant prescribing levels for mild to moderate conditions are inadequately high. Public reimbursement for psychotherapies provided by psychologists is generally not available. This paper presents a local experiment with a stepped-care approach for the treatment of mild to moderate mental disorders in four French départements launched in 2018. The experiment includes the introduction of a standardized assessment protocol for GPs, clear referral guidelines, and full reimbursement of visits to psychologists upon GP referral. Seemingly simple, the policy raises several issues related to the regulation, training and reimbursement of psychologists, and illustrates the need for careful preparation and workforce planning to ensure success and stakeholder support. An independent evaluation of the local experiments is planned, which provides the opportunity to fine-tune the policy before any broader rollout. The issues raised in France and the on-going debate is relevant for other countries preparing similar policies for improving mental care.

The Patient-Reported Experience Measure for Improving qUality of care in Mental health (PREMIUM) project in France: study protocol for the development and implementation strategy.

BACKGROUND: Measuring the quality and performance of health care is a major challenge in improving the efficiency of a health system. Patient experience is one important measure of the quality of health care, and the use of patient-reported experience measures (PREMs) is recommended. The aims of this project are 1) to develop item banks of PREMs that assess the quality of health care for adult patients with psychiatric disorders (schizophrenia, bipolar disorder, and depression) and to validate computerized adaptive testing (CAT) to support the routine use of PREMs; and 2) to analyze the implementation and acceptability of the CAT among patients, professionals, and health authorities. METHODS: This multicenter and cross-sectional study is based on a mixed method approach, integrating qualitative and quantitative methodologies in two main phases: 1) item bank and CAT development based on a standardized procedure, including conceptual work and definition of the domain mapping, item selection, calibration of the item bank and CAT simulations to elaborate the administration algorithm, and CAT validation; and 2) a qualitative study exploring the implementation and acceptability of the CAT among patients, professionals, and health authorities. DISCUSSION: The development of a set of PREMs on quality of care in mental health that overcomes the limitations of previous works (ie, allowing national comparisons regardless of the characteristics of patients and care and based on modern testing using item banks and CAT) could help health care professionals and health system policymakers to identify strategies to improve the quality and efficiency of mental health care. TRIAL REGISTRATION: NCT02491866.

Organization of mental health care: the role of general practitioners / Organisation des soins en santé mentale : le rôle des médecins traitants.

Organization of mental health care: the role of general practitioners. In the evaluation of the National French Psychiatry / Mental Health plan 2011-2015, as carried out by the High Public Health Council, some points concern the role of general practitioners and the difficulties they encounter regarding their patients suffering from psychiatric disorders ; are mentioned access to urgent or planned specialized psychiatric care, their role in the management of the physical health of their patients suffering from psychiatric disorders, the vigilance that they must exercise with regard to the over prescription of psychotropic drugs, the announcement of an experiment in the reimbursement of psychotherapies conducted by psychologists and the importance of initial and continuing training of general practitioners in adult and infant-juvenile psychiatry. The regard on psychiatric patients must be changed and the role of general practitioners in this change is important.

Organisation des soins en santé mentale : le rôle des médecins traitants. Dans l'évaluation du Plan psychiatrie santé mentale 2011- 2015, tel qu'il a été réalisé par le Haut Conseil à la santé publique, certains points concernent le rôle des médecins généralistes et les difficultés qu'ils rencontrent concernant leurs patients souffrant de troubles psychiatriques ; sont évoqués l'accès aux soins spécialisés de psychiatrie, urgents ou programmés, leur rôle dans la prise en charge de la santé physique de leurs patients souffrant de troubles psychiatriques, la vigilance qu'ils doivent exercer vis-à-vis de la sur-prescription de psychotropes et l'annonce d'une expérimentation de prise en charge de psychothérapies conduites par des psychologues, ainsi que l'importance d'une formation initiale et continue des médecins généralistes en psychiatrie adulte et infanto-juvénile. Il est nécessaire de changer le regard porté sur les patients psychiatriques et le rôle des médecins générales dans ce changement est important.

The geography of institutional psychiatric care in France 1800-2000: historical analysis of the spatial diffusion of specialised facilities for institutional care of mental illness.

As in other European countries, specialised psychiatric hospitals were established throughout France during the 19th Century. The construction of these hospitals can be considered as the concrete expression of a therapeutic innovation which recognized insanity as an illness that could be treated in such specialised institutions. The spatial diffusion of these innovative institutions through 19th and 20th century France is analysed and we explore how far this can be understood through theories of diffusion of innovations including geographical models of hierarchical and expansion diffusion (or whether other conceptual models are more appropriate). The research reported here particularly focuses on the period 1800-1961. It involved the construction of an original historical database of both psychiatric hospitals and information on the cities where these institutions were located. This was used to examine and interpret the different phases of development of psychiatric institutions and the parts of the country and types of geographical setting where they were concentrated. A multiple correspondence analysis was then performed to examine the connections between different aspects of the diffusion process. The study shows the limitations of classical models of spatial diffusion, which are found to be consistent with some, but not all aspects of the development of psychiatric institutions in France. An alternative political ecology approach seems more appropriate to conceptualise the various processes involved; national policies, social representations, medicalisation of care of mental illness, and urban and economic growth all seem to be associated with the emergence of a variable and complex pattern. This paper also opens a large field of research. Compared with other western countries, the geography of French psychiatric care is relatively under-researched, although there has been a strong spatial dimension to mental health policy in the country. This analysis provides a context for studies of more contemporary processes of French deinstitutionalisation, which is strongly structured by the past heritage of these large asylum facilities.