Analysis of the Recomposition of Norms and Representations in the Field of Psychiatry and Mental Health in the Age of Electronic Mental Health: Qualitative Study.

BACKGROUND: For the World Health Organization, electronic health (eHealth) is seen as an effective way to improve therapeutic practices and disease prevention in health. Digital tools lead to major changes in the field of mental medicine, but specific analyses are required to understand and accompany these changes. OBJECTIVE: Our objective was to highlight the positions of the different stakeholders of the mental health care system on eHealth services and tools, as well as to establish professional and user group profiles of these positions and the uses of these services. METHODS: In order to acquire the opinions and expectations of different categories of people, we carried out a qualitative study based on 10 focus groups (n=70, from 3-12 people per group) composed of: general practitioners, psychiatrists, psychologists, social workers, occupational therapists, nurses, caregivers, mental health services users, user representatives, and the general public. The analyses of focus group discussions were performed independently by four investigators through a common analysis grid. The constant comparative method was adopted within this framework. RESULTS: The interviewees expressed different problems that new technologies engender in the field of mental health. What was previously strictly under the jurisdiction of physicians now tends to be fragmented and distributed over different groups and locations. New technologies reposition care in the field of domestic, rather than therapeutic, activities, and thus the conception of care as an autonomous activity in the subject's life is questioned. The ideal of social autonomy through technology is part of the new logic of health democracy and empowerment, which is linked to a strong, contemporary aspiration to perform. Participants emphasized that there was the potential risk of a decrease in autonomy for the digitally engaged patient, while personal empowerment could become a set of obligations. CONCLUSIONS: This qualitative research highlights the heterogeneity of opinions among the groups and within each group. It suggests that opinions on electronic mental health devices are still far from being stabilized, and that a change management process should be set up to both regulate the development and facilitate the use of these tools.

From e-Health to i-Health: Prospective Reflexions on the Use of Intelligent Systems in Mental Health Care.

Depressive disorders cover a set of disabling problems, often chronic or recurrent. They are characterized by a high level of psychiatric and somatic comorbidities and represent an important public health problem. To date, therapeutic solutions remain unsatisfactory. For some researchers, this is a sign of decisive paradigmatic failure due to the way in which disorders are conceptualized. They hypothesize that the symptoms of a categorical disorder, or of different comorbid disorders, can be interwoven in chains of interdependencies on different elements, of which it would be possible to act independently and synergistically to influence the functioning of the symptom system, rather than limiting oneself to targeting a hypothetical single underlying cause. New connected technologies make it possible to invent new observation and intervention tools allowing better phenotypic characterization of disorders and their evolution, that fit particularly well into this new "symptoms network" paradigm. Synergies are possible and desirable between these technological and epistemological innovations and can possibly help to solve some of the difficult problems people with mental disorders face in their everyday life, as we will show through a fictional case study exploring the possibilities of connected technologies in mental disorders in the near future.

[Costs and benefits of a funding program for psychotherapies for French people suffering from depressive or anxious disorders]. / Coûts et bénéfices d'un programme de financement des psychothérapies auprès des Français souffrant de troubles dépressifs ou anxieux.

Objectives Depressive or anxious disorders are a major source of social and economic burden. Many international good practice guidelines recommend structured psychotherapy for treating depressive or anxious disorders. The positive impact of psychotherapy on health, quality of life, productivity, and on the direct and indirect costs has been widely demonstrated. Nevertheless, the psychotherapies provided in private practice with a non-medical psychotherapist are not reimbursed to patients by French health cover systems.This article aims (1) to assess the cost and benefit of providing a funding program for psychotherapies for the community for French adults suffering from severe or recurrent depressive or anxious disorders, and (2) to estimate the number of psychotherapists that this program would be needed.Methods Data are based on the Enquête Indicateurs de santé mentale dans quatre régions françaises: a cross-sectional survey of a representative sample of 20,777 adults in the general population conducted in 2005. The questionnaires were administered by a telephone interview with the Composite International Diagnostic Interview - short form. A financial evaluation of covering the cost of psychotherapies was performed using the methodology of the British program Improving Access for Psychological Therapies adapted to the French context. The annual cost generated by depressive disorders was estimated at EUR4,702, cost generated by anxiety disorders at EUR1,500. The remission rate attributable to psychotherapies was assessed to be 30% ±10%. The number of sessions to be covered was defined according to clinical guidelines of the National Institute for Health and Clinical Excellence. The cost of a session was estimated at EUR41, the reimbursement rate by the compulsory health insurance system at 60%.Results The yearly cost for the cover of psychotherapeutic care - for 12.1 sessions on average was M EUR 514 (M EUR 308 for the compulsory systems) to treat 1,033M individuals in France, or 2.3% of the population. In terms of the cost-benefit ratio, EUR1 invested in psychotherapeutic treatment could, save from EUR1.14 (0.76-1.52) to EUR1.95 (1.30-2.60) for anxious or depressive disorders respectively.France has the 14,300 professionals qualified to provide the psychotherapies required to treat this population.Conclusion A funding program for psychotherapies proves to be a cost-efficient investment for the community from the short term, for both direct (health costs) and indirect (productivity, quality of life) costs, that is further that the positive impact and costs of psychotherapy on somatic disorders were not taken into account.With a view to providing appropriate care for patients, inter-professional collaboration among GPs and mental health professionals, and between clinical psychiatrists and psychologists, appears essential. These recommendations should be defined in national good practice guidelines.

[Initial training in psychotherapy for psychiatrists in France, a national qualitative study]. / La formation aux psychothérapies des internes en psychiatrie en France : résultats d'une analyse qualitative.

Objectives To explore the level of satisfaction among residents regarding their training in psychotherapies, the interest they have in these therapies, and their wishes in the area of training.Methods A survey including both a quantitative and qualitative methodology was undertaken among 869 residents out of 1,334 enrolled in the psychiatric residency program. In the 2009-2010 academic year. The survey included five themes of study: theoretical academic training, psychoanalysis, training in institutes outside the university, supervision, wishes in the area of training. This article presents results from the qualitative sociological survey using a semi-guided interview with 27 residents. Their conceptions and practice in the field of psychotherapy, and its place in psychiatric practice were questioned in-depth.Results The vast majority of residents were interested in psychotherapy, but simultaneously dissatisfied with the training they had received. Almost half opted for various sorts of extra-curricular training, costly in time and money. The psychotherapeutic orientations among these residents were varied, and a plurality of methods and theoretical approaches was advocated both for reasons of having a wider viewpoint and good practice in psychiatry, and because the residents considered this plurality to be an essential component in their training. They saw psychotherapy as a medical practice, and considered that it is the responsibility of the psychiatric discipline to provide training in psychotherapies.Conclusion The absence of any real training in psychotherapies for residents in psychiatry is damaging for care quality in psychiatry. The recent creation of a protected title of psychotherapist for psychiatrists without the need of additional training suggests an urgent need to develop a training course. A proposal by the authors should be discussed in light of reflections and proposals already underway in other countries.

Costs and benefits of improving access to psychotherapies for common mental disorders.

BACKGROUND: Structured psychotherapies are treatments used in common mental health disorders (CMHDs) that are recommended by international good practice guidelines. Their efficacy and positive impact on health--and thereby on the reduction of related costs for health insurance schemes and society--have been widely demonstrated. However in France, despite the considerable financial burden of CMHDs, psychotherapies with a non-medical psychotherapist are not reimbursed by the health insurance schemes. AIMS OF THE STUDY: To assess the cost of coverage for psychotherapies by the health insurance bodies for adults aged 18 to 75 with CMHDs--depressive or anxious disorders, severe or recurrent--and to estimate the cost-benefit ratio for these psychotherapies for the community. METHODS: The data was derived from l'Enquete Indicateurs de sante mentale dans quatre regions francaises 2005, which is a cross-sectional study on 20,777 adults in the general population. Telephone interviews were backed up by the CIDI-SF. The Sheehan Disability Scale was used to assess the severity of the disorders. The proportion of patients who would agree to and then attend psychotherapies was estimated using the methodology developed in the UK in the Improving Access to Psychological Therapies programme, adapted to the French setting. The number of sessions to be covered was defined according to recommendations by the National Institute for Health and Clinical Excellence. The cost was estimated to be 41 per session, the reimbursement rate was set at 60% for the compulsory health coverage system. The annual costs engendered by CMHDs were estimated to be 4,702 for depressive disorders and 1,500 for anxiety disorders. The remission rate attributable to psychotherapies was estimated to be 30% pm10%. RESULTS: For average series of 10 sessions (anxiety disorders) to 18 sessions (depressive disorders) the yearly cost of psychotherapies would be 514 million Euros, of which 308 million would be covered by the compulsory coverage system, to treat 1.033 million patients, or 2.3% of the population. For patients with depressive disorders, 1 spent by the community for the psychotherapy would enable the community a saving of 1.95 (1.30-2.60), and for anxiety disorders a saving of 1.14 (0.76-1.52). DISCUSSION: This programme for provision of coverage for psychotherapies would have a positive impact for the community as a whole, in terms of quality-of-life, health and absenteeism. Funding psychotherapies proves to be a cost-efficient investment in the short and the long term, and this is backed up further by the fact that the impact of psychotherapies on somatic disorders interacting with CMHDs was not taken into account here. IMPLICATIONS FOR HEALTH POLICIES, HEALTH CARE PROVISION AND USE: Decision-makers in the health insurance schemes will thus have reliable medico-economic data available to assist in decisions for a possible policy for reimbursement of psychotherapies. Financial coverage of psychotherapies would in particular enable access to treatment by people for whom the financial barrier would have prevented access to this treatment. Furthermore, reimbursing sessions with non-medical psychotherapists could also improve conditions of care-provision by mental health professionals. Finally, this model could be replicated in other countries where the health system is sufficiently comparable to that prevailing in France. IMPLICATIONS FOR FUTURE RESEARCH: An in-depth study is required to detail cost and benefit of providing insurance coverage for psychotherapies for the different protagonists involved in this funding, and its effects.

Factors associated with use of psychiatrists and nonpsychiatrist providers by ESEMeD respondents in six European countries.

OBJECTIVE: This study analyzed use of services from psychiatrists and other mental health professionals (psychologists, psychotherapists, counselors, and social workers) in six European countries. METHODS: Data were from respondents (N=8,796) to the European Study of the Epidemiology of Mental Disorders (ESEMeD), a cross-sectional survey (2001-2003) of a representative sample of noninstitutionalized adults in Belgium, France, Germany, Italy, the Netherlands, and Spain that was conducted via computer-assisted interviews with the Composite International Diagnostic Interview, version 3.0. RESULTS: Twenty-three percent of respondents reported lifetime use of any professional for mental health problems, and 60% consulted a mental health provider. Among these, 56% used a psychiatrist and 68% used a nonpsychiatrist provider. Factors associated with use of psychiatrists only were being retired or unemployed, having 12 or fewer years of education, living in France or Spain, having a severe disorder, and using psychotropic medication. Factors associated with use of nonpsychiatrist providers only were living in the Netherlands or Germany, never being married, and having an anxiety disorder. CONCLUSIONS: The findings suggest that there is no simple model of associations between mental health care system and patterns of service use. System characteristics, such as practitioner-population ratios, levels of practitioner availability, and gatekeeping and reimbursement policies, affect patterns of use of mental health providers. Recent British and Australian plans could be used as models for better allocation of services in some ESEMeD countries.

Religious advisors' role in mental health care in the European Study of the Epidemiology of Mental Disorders survey.

OBJECTIVE: To study the role of religious advisors in mental health problems in six European countries and to compare it to data from the USA. METHODS: Data were derived from the European Study of the Epidemiology of Mental Disorders (ESEMeD) study, a cross-sectional study, conducted in Belgium, France, Germany, Italy, the Netherlands and Spain. 21,425 individuals, 18 and older, were interviewed with the Composite International Diagnostic Interview 3.0. Findings were compared to the National Comorbidity Survey (NCS) and replication of the NCS (NCS-R) in the US. RESULTS: In ESEMeD, 0.6% of individuals (0.3% exclusively) sought help from religious advisors concerning mental health problems during the previous year, compared to 2.6% in NCS and 3.4% (for human services) in NCS-R in the US. Among those using any form of service, 6.9% consulted religious advisors (12.2% in Germany to 2.1% in Spain) compared to 18.8% in the US. Being younger (less than 25 years old), being older (more than 64) and religiosity are associated with the use of religious advisors, whereas being a student is associated with a lower probability. CONCLUSIONS: Seeking help from religious advisors for mental health problems varies dramatically among ESEMeD countries. Except for Germany, organised religion in the ESEMeD countries could not be considered as an alternative.

Prevalence, risk factors, and use of health care in depression: a survey in a large region of France between 1991 and 2005.

OBJECTIVE: To compare the prevalence, risk factors, and use of care for depression between 2 periods, concerning changes in social factors and health care provision. METHOD: We compared data from 2 surveys carried out in a large urbanized French region (Ile-de-France) 15 years apart (1991, n = 1192; 2005, n = 5308), using comparable methodology and tools. RESULTS: The overall prevalence of depression has slightly increased over this period. In contrast, the tendency of people who claim they feel depressed has dramatically increased. At-risk populations have also changed during this period. The proportion of people consulting a psychiatrist for depression has not changed, while general practitioner (GP) consultations have decreased and psychologist consultations have increased 3-fold. Psychotropic use by people who are depressed has decreased significantly. CONCLUSION: The trend toward increased depressive symptoms does not correspond to an increase in depressed disorders. In a well-staffed urbanized French region, psychologists are playing a growing role in managing depression at the expense of GPs, when the use of a psychiatrist remains unchanged; decreased use of psychotropic drugs may be a consequence.

Factors associated with use of psychotherapy.

CONTEXT: Psychotherapies are recommended in manuals of good practice. There is however little epidemiological data assessing access to this type of treatment, and in particular the combined role of the offer and socio-demographic characteristics. The present research aims to contribute data on the profiles of a sample of individuals who underwent psychotherapy in France, and on the respective impact of various factors such as mental health status, socio-demographic characteristics, life events and the care offer, focusing on a specific population for whom the mode of financial cover for this type of care is governed by a complementary health insurance (MGEN). METHODS: Between June 1999 and March 2000 a survey using a self-administered questionnaire was conducted on a sample of MGEN-insured individuals. Ten thousand individuals aged between 20 and 60 were selected randomly, received a questionnaire, and up to three recalls in case of non-response. The overall response rate was 66.5%. The questionnaire comprised 261 questions enabling data collection concerning the main socio-demographic, professional and mental health variables. RESULTS: In this population aged from 20 to 60, lifetime prevalence of recourse to psychotherapy was 11.8%. The main factor associated with use of psychotherapy is the severity of the clinical condition (assessed in terms of comorbidity). Certain traumatic events experienced in childhood are also related. The effect of socio-demographic variables varies according to severity, although it was noted that being female, having high educational status, and being single were consistently related to wider use of psychotherapy. The analysis also evidenced the importance of the density of the care offer. CONCLUSION: Our results suggest that the use of psychotherapy, within a well-informed population with high quality insurance cover, is related primarily to clinical condition rather than to socio-demographic status, especially in people with high levels of comorbidity, although the effect of educational status remains. However, this study only looked at mere use of psychotherapy, without determining the suitability of the treatment provided. It is indeed possible, and even probable, that variables such as educational status, income, or care offer may have a link with resorting to the right type of care, in terms of both relevance and adequate duration.