Programme de soins psychiatriques : Etude de l'expérience de jeunes patients par une méthode qualitative: Psychiatric care program: A qualitative study of the experience of young patients.

OBJECTIVE: Ambulatory care without consent is widely used, but it is controversial, and its effectiveness has not yet been proven. The patient experience remains largely unstudied in France, particularly that of young patients, yet their adherence to care in the early stages of the disease is complex and has an impact on their prognoses. The aim of this study is to investigate the experience of young patients undergoing a program of care (POC) in order to suggest ways of optimizing their care and to enrich the debate on the use of POCs. METHOD: Semi-structured interviews were conducted with 11 patients between ages 20 and 32, who were either undergoing a POC or had done so in the previous 5 years, followed by a semi-pragmatic phenomenological analysis of the resulting transcripts. RESULTS: (1) The outpatient experience with restraints is contradictory, ranging from deprivation and intrusion to support and protection. (2) The POC is portrayed as a framework for developing awareness of disorders and acceptance of care. (3) Patients report a lack of information about care with restraints, even to the point of being unaware of its existence. Patient-psychiatrist interactions within the POC are complicated by the restraints, but remain perceived as a care relationship. (4) They report constraints in their daily lives in connection to the POC, which can complicate professional involvement. CONCLUSION: The results support the importance of nurturing the therapeutic relationship within the POC and involving patients more in their care, starting with better information. They support the use of POCs as a temporary tool to be combined with work on adherence to treatment and support for social and professional reintegration. SPECIALTY: Psychiatry.

OBJECTIF: Les dispositifs de soins ambulatoires sans consentement sont largement utilisés, mais ils sont controversés et leur efficacité n'est pas prouvée à ce jour. L'expérience des patients concernés reste très peu étudiée en France, et notamment celui des jeunes patients, or leur adhésion aux soins en début de maladie est complexe et a un impact sur le pronostic futur. L'objectif est d'étudier l'expérience de jeunes patients suivis en programme de soins (PDS) afin de proposer des perspectives pour optimiser leur prise en charge et d'enrichir la réflexion sur l'utilisation des PDS. MÉTHODE: Des entretiens semi-directifs ont été réalisés auprès de 11 patients de 20 à 32 ans suivis en PDS ou l'ayant été dans les 5 dernières années, puis une analyse phénoménologique de type sémio-pragmatique a été réalisée sur les verbatims obtenus. RÉSULTATS: (1) L'expérience de la contrainte en ambulatoire est contrastée avec un vécu de privation de libertés et d'intrusion, mais aussi de soutien et de protection. (2) Le PDS est représenté comme un cadre permettant l'évolution de la conscience des troubles et de l'acceptation des soins. (3) Les patients rapportent un manque d'information sur les modalités de soins sous contrainte, pouvant aller jusqu'à la méconnaissance de l'existence de cette mesure. Les interactions patient-psychiatre au sein du PDS sont complexifiées par la contrainte mais restent perçues comme une relation de soin. (4) Ils rapportent des contraintes dans la vie quotidienne liées au PDS et qui peuvent compliquer l'insertion professionnelle. CONCLUSION: Les résultats soutiennent l'importance de soigner la relation thérapeutique au sein du PDS et d'impliquer davantage le patient dans sa prise en charge, en commençant par une meilleure information. Ils soutiennent une utilisation du PDS comme un outil temporaire à associer à un travail sur l'adhésion aux soins et à un accompagnement à la réinsertion sociale et professionnelle. SPÉCIALITÉ: Psychiatrie.

[Failure to draw up medical certificates increase judiciary releases]. / La moindre argumentation des certificats médicaux accroît le risque de mainlevée.

OBJECTIVES: In France, a systematic control of compulsory psychiatric admissions has existed since the enactment of the law of July 5th 2011. The Court of Cassation clarified that the liberty and custody judges (JLD) cannot supersede the medical opinion described in the medical certificates. In 2015, the JLD ordered the release of 8.4 % of all compulsory psychiatric admissions. The goal was to compare the quality of medical certificates derived from judicial release based on medical grounds with non-released witnesses from the cohort of compulsory psychiatric admissions ordered in the Groupe Hospitalier Universitaire Paris Psychiatrie & Neurosciences (GHU-Paris) between November 1, 2017 and October 31, 2018. METHODS: We included as cases all the medical certificates derived from judicial release based exclusively on medical grounds from the release cohort of the GHU-Paris from November 1, 2017 to October 31, 2018, concerning the systematic control 12 days after compulsory psychiatric admissions. A witness whose compulsory care had been maintained was matched according to the same judge, place and date of hearing, mode of compulsory care and site of hospitalization. Each certificate was analyzed according to a reading grid relating to the good decisions in matters of compulsory admission and medical certificates' redaction. An overall score, based on the description of the clinical and symptomatic evolution, the level of discernment, the capacity of consent and the mode of compulsory care was awarded to each certificate. RESULTS: Seventeen release files were included in the comparative study. Globally, the clinical progression, psychiatric symptoms, level of consciousness and ability to consent did not differ in the two groups. The grade of quality of certificate was lower in case of withdrawal (2.92±1.08 VS 3.28±0.88, P=0.026). Psychiatric symptoms in "justifiable notice" (the last medical certificate prior to the judicial hearing) were less specified in case of withdrawal (58.8 % VS 94.1 %, P=0.015). Not describing any symptoms led to a 12.51 risk of withdrawal (95 % CI=[1.16; 135.19], P=0.038). Even with witness certificate, clinical progression was noticed in only 85.3 % of cases, in 89.3 % of psychiatric symptoms, in 68.0 % of level of consciousness and 80.0 % for the ability to consent. CONCLUSIONS: Judiciary releases of compulsory psychiatric admissions exclusively based on medical grounds are not arbitrarily decided by the JLD but are based on a failure to draw up medical certificates. Doctors must comply with a careful drafting of all medical certificates: description of symptoms, clinical course, level of consciousness and ability to consent. It is necessary to be attentive to judiciary releases based on medical grounds to evaluate and improve medical practices concerning the drafting of medical certificates.

[Involuntary psychiatric care for incarcerated people: a descriptive study of 73 consecutive judge-ordered discharges from psychiatric hospitalisation in France]. / Soins psychiatriques sans consentement pour les personnes détenues : une étude descriptive de 73 mainlevées consécutives en unité hospitalière spécialement aménagée.

INTRODUCTION: The procedure of involuntary psychiatric hospitalization has been recently modified in France. Indeed, since 2011, a liberty and custody judge is appointed for each measure, to guarantee the rights of psychiatric inpatients and to prevent abusive hospitalizations. As a result, if procedural errors are noted, the liberty and custody judge may order the immediate ending of the psychiatric hospitalization. To date, only two studies described the reasons for judiciary discharge from involuntary psychiatric hospitalizations, but no study has been conducted in forensic psychiatric units for incarcerated people. The objective of the current study was to describe the main reasons judges use to decide on the irregularity of the hospitalization (against the opinion of psychiatrists) for detained patients, and to compare these reasons with those for patients in the community psychiatric unit. METHODS: We included all the discharges ordered between 2011 and 2018 in two units of the same hospital: a forensic psychiatric unit for incarcerated people and a community involuntary psychiatric unit. We extracted sociodemographic characteristics and judiciary information such as date of discharge, resason fordischarge, presence of the patient at the hearing. We analyzed the judge-ordered discharge rate (corresponding to the number of discharges divided by the number of involuntary psychiatric hospitalizations) for each year. Then, we examined the reason of discharge for each measure. RESULTS: One hundred and forty-seven discharges were analyzed: 73 in the psychiatric forensic unit and 73 in the community psychiatric unit. Rates of discharges were 6.7% and 8.8% for the forensic unit and the general psychiatric unit, respectively. Several reasons for the discharges were common for the two units (failure to inform the patient, lack of physical examination), but others were specific to the forensic unit, such as the impossibility for the patients to communicate with their lawyer, or the lack of immediate dangerousness for the person or for the others. CONCLUSION: This study highlights the specific aspects of involuntary psychiatric hospitalizations for people in prison in France. Future studies are needed to assess the impact of these judge-ordered discharge on patient's mental health, particularly for incarcerated patients.

[Evaluation of the use of care programs provided for under the law of 5 July 2011]. / Évaluation du recours au programme de soins prévu par la loi du 5 juillet 2011.

OBJECTIVES: The law of 5 July 2011 introduced the possibility of outpatient care without consent in the context of care programs (CP). Despite major ethical and legal issues and frequent recourse in France, few studies are available on the use of this mechanism. An in-depth review of practices involving a large sample of CP was essential. The main objective of this study was to look at their content, the clinical profile of the patients involved, and the progress of these CP. METHODS: We carried out a retrospective, observational study, including all the CP set up between January 1st, 2016 and December 31st, 2018 in the Sarthe department. Data strictly related to the CP (content, justification, duration, patient compliance, re-hospitalizations, etc.), and patient-related variables (socio-demographic characteristics, diagnosis, antecedents, etc.) were studied. RESULTS: We studied 559 CP, 70 % of which (n=391) in the context of "care by decision of the hospital director", with a wide disparity of recourse by psychiatric sector. One third of the hospitalizations without consent ended with a CP. They involved men (68.5 %, n=383), with a psychotic disorder (77.8 %, n=435), with a history of hospitalization (90 %, n=503), and with poor adherence to care (83.2 %, n=465). Cannabis use accounted for 41.3 % (n=231) of cases. Certificates initiating CP did not have a clear justification (34.6 %, n=251) or state a goal of adherence to treatment (16.5 %, n=120). The content of the different CP was homogeneous: 65.6% of medical consultations and 47.6 % with a nurse, 100 % mentioned treatment used. Their average duration was 3.4 months. Even though the CP were followed (69.9 %, n=391), 52.8% (n=295) ended with reintegration, mainly justified by symptomatic relapse (34.8 %, n=147), and new CP were put in place almost systematically (90.6 %, n=260). However, reintegrations were shorter than first-time admissions (26 vs. 95 days). When a decision was lifted (n=174), it was based on the criteria of clinical stability (35.7 %, n=120) and compliance with the CP (27.6 %, n=93). Half of hospitalizations in "care at the decision of the State representative" ended with a CP. These CP were longer (4.5 months) and with a higher rate of reintegration (62.2 %) than for those in "care at the decision of the hospital director". There was no significant difference of CP compliance according to the mode of psychiatric care. CONCLUSIONS: Our study allows a precise vision of patients concerned by CP: men with risk factors for psychiatric dangerousness, with a severe clinical profile. It also found a high rate of re-hospitalization despite good adherence with the CP which is in line with a device allowing the work of an alliance to care and interventions at the beginning of relapse. CP have poorly personalized content and are poorly justified by psychiatrists although it is a freedom-restricting measure, highlighting the need for increased awareness amongst psychiatrists of the legal framework of their practice regarding care without consent.

[Descriptive study of the releases pronounced by the liberty and detention judge at groupe hospitalier universitaire Paris psychiatrie & neurosciences from November 2017 to October 2018]. / Étude descriptive des mainlevées prononcées par le juge des libertés et de la détention au groupe hospitalier universitaire Paris psychiatrie & neurosciences du 1er novembre 2017 au 31 octobre 2018.

OBJECTIVE: In France, a systematic control of compulsory psychiatric admissions has existed since the enactment of the law of 5 July 2011. In 2015, the judge of freedoms and detention ordered the withdrawal of 8.4 % of the compulsory psychiatric admissions. The aim of the study is to describe the grounds for judiciary withdrawals of compulsory admissions ordered in the groupe hospitalier universitaire paris psychiatrie & neurosciences (GHU-Paris) between November 1, 2017 and October 31, 2018. METHODS: All of the withdrawal decisions adjudged during the mentioned period in the GHU-Paris were analysed following a specific framework. The main analysis deals with the classification of the "administrative", "medical", and "mixed" grounds. The secondary analysis looks at the fundamental facts affecting the judge of freedoms and detention's decision. RESULTS: Of the 127 orders decided by 21 judges of freedoms and detention analysed in this study, the majority were part of the systematic control of compulsory psychiatric admissions (74.8 %) and were made through a referral procedure by the director's hospital (69.3 %). The main reasons for withdrawal decisions were "mixed" (52.9 %), among which were described: failure to respect time limit (20.2 %), failure to inform the patient (11.6 %), third party's proceeding (8.7 %) and lack of documents (8.7 %). "Medical" grounds account for 31.8 % of all grounds. More precisely, failure to respect the required elements for involuntary admissions in psychiatric services was the greatest subcategory (29.5 %). "Other" grounds represented 15.8 %. No "administrative" ground was found. Judges ordered 69.3 % withdrawals within 24 hours to allow community treatment orders to be put into place. In the centre hospitalier Sainte-Anne, 70.8 % of the 24 appeals quashed the first decision by the judge of freedoms and detention. CONCLUSION: Several reasons justify withdrawals of compulsory psychiatric admissions. Scrupulously respecting procedures and drafting psychiatric certificates might decrease the number of withdrawals.

[Involuntary hospitalization: A survey of liberty and custody judges]. / Soins psychiatriques sans consentement : une enquête auprès des juges des libertés et de la détention.

The procedure of involuntary hospitalization in France has been recently modified by the law of 5 July 2011. Since that time, a liberty and custody judge has been appointed to guarantee the rights of psychiatric inpatients and to prevent abusive hospitalizations. Currently, for one involuntary hospitalization in ten a release is decided by the liberty and custody judge although psychiatrists consider that psychiatric care is necessary. In order to improve our understanding of the role of liberty and custody judges, and how they make their decisions, we conducted a qualitative survey of liberty and custody judges in the Tribunal de Grande Instance of Lille. Three judges were questioned, based on a semi-structured interview. Judges' responses have highlighted the need for psychiatrists to strictly respect the legal procedures and to accurately describe the clinical signs and symptoms that justify the procedure of involuntary hospitalization in the medical certificates. The intervention of liberty and custody judges for patients with psychiatric disorders represents a breakthrough for patients' rights in France, reflecting that they are considered as citizens, with the same rights as others. Nonetheless, this new mission needs a progressive learning, based on mutual exchanges with doctors and caregivers.

[Involuntary psychiatric care for inmates in France: Only for "dangerous" patients?] / Les soins psychiatriques sans consentement en milieu pénitentiaire sont-ils réservés aux patients « dangereux ¼ ?

The unités hospitalières spécialement aménagées (UHSA) are full-time inpatient psychiatric units for inmates in France. Their creation has been associated with several advances in access to psychiatric care for inmates in recent years. However, there is still only one means of involuntary hospitalization for prisoners in France: care by decision of a representative of the state (les soins sur décision d'un représentant de l'état [SDRE]). Interestingly, for SDRE to be recognized as legal by the French judge, the patient must be "a danger to himself or to the others". Thus, there is a major difference with involuntary hospitalization outside the prison, and there are specific criteria for involuntary psychiatric hospitalization for inmates in France. This situation questions the general framework of involuntary psychiatric care and is very inconsistent with French law. Indeed, the goal of the loi no 94-43 du 18 janvier 1994 relating to public health and social protection is to ensure equivalent care for all patients, incarcerated or not.