International Review of Psychiatry, August 2012; 24(4): 363368

The organization of psychiatric care in France: Current aspects and future challenges

DENIS LEGUAY1 & PATRICE BOYER2

1Psychiatre

des Hpitaux, Angers, France, and 2Department of Neurosciences and Psychiatry, Universit Paris 7, Paris, France

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Abstract In the last four decades, psychiatric care in France has led to the development of catchment area-based service provision. Within each geographical area teams are now responsible for psychiatric care both at outpatient and inpatient levels. However, nancial and economic constraints have led to a reduction in beds and stafng levels. The numbers of psychiatrists in private practice has remained more or less the same over the years due to steady demand and other factors. As in many other western European countries, de-institutionalization has been a major driver in the evolution of psychiatric care delivery in France. This is linked with several developments, including the introduction of more efcient pharmaceutical drugs which have reduced the likelihood of relapse. Other factors which have inuenced this include the progressive de-stigmatization of psychiatric disorders and policy changes leading to signicant bed reduction. All of these factors are inter-linked and have inuenced psychiatric care delivery. In this paper we provide an overview of the current state of psychiatric care and its delivery in France.

Introduction In 1945 all the French scientic organizations linked to psychiatric practice met during a national conference and agreed on a general policy to restructure psychiatric care in France (Ayme, 1995). The two keywords which were considered as the leading messages to conduct this restructuring were humanization and de-institutionalization. A clear mission was assigned to the public health system which, ever since then, has been in charge of ensuring the prevention of mental health problems, the continuity of care and the implementation of walk-in clinics. It is on the same basis that in the early 1970s the secteur psychiatrique (psychiatric sector or psychiatric catchment) was created (Loi 851468, 1986). The secteur or sector was dened as a precise geographical catchment area for which a single, comprehensive team took responsibility for mental healthcare delivery in the geographical area. Therefore, all the patients belonging to the same sector were followed by the same multi-professional team, composed of physicians, psychologists, nurses and social workers. The same team was responsible for the prevention, for outpatient and inpatient care and for the follow-up. The

organization of the different sectors was extended to the whole French territory from 1975 to 1990 both in adult and in child and adolescent psychiatry. This system still constitutes the main basis for psychiatric care in France (Leguay 2002). In parallel to the implementation of the public sector, private practice in psychiatry has undergone a very signicant development since 1970. The main reason for this has been the separation of neurology and psychiatry as medical specialities after May 1968. Until 1968, a limited number of neuro-psychiatrists were following academic degree courses before shifting to private practice. After 1970, the number of psychiatrists trained in different French universities dramatically increased, resulting in the setting up of more and more private practices. Most of these private psychiatrists received a psychodynamic training which explains why the main orientation of private ambulatory care was psychoanalytically linked in this period. Contemporaneous with the leading roles played by the public health and the private ambulatory care systems, private hospitals have existed since the 19th century. These private hospitals have been maintained but currently their geographical location is rather

Correspondence: Patrice Boyer, European Psychiatric Association (EPA) President, CMME, 100 rue de la Sant, 75014 Paris, France. Tel: 33 1 53804941. E-mail: phmboyer@gmail.com (Received 14 June 2012 ; accepted 14 June 2012 ) ISSN 09540261 print/ISSN 13691627 online 2012 Institute of Psychiatry DOI: 10.3109/09540261.2012.703953

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D. Leguay & P. Boyer disability (handicap), thus offering the possibility for patients to be taken in charge by specic social structures (Loi 2005-102, 2005). Private practice The number of physicians having a private practice in psychiatry has been stable since the year 2000. The current gure is 9 private psychiatrists for 100,000 inhabitants (compared to 11 psychiatrists in the public sector for 100,000 inhabitants). The geographical distribution of this type of practice is extremely heterogeneous (the highest density being recorded in the Parisian area and in the southeast of France, the wealthy part of France). A total of 2.5% of the French population are treated in private practice (Alonso et al., 2004). The global number of these private specialists will probably decrease over the next 10 years (20%) before increasing afterwards (Conseil National de lOrdre des Mdecins, 2011). It must be remembered that by the nature of private practice and the condition, the prole of patients consulting a private psychiatrist is rather different from the prole of patients treated in a public institution. Patients are younger, currently employed, suffering relatively milder disorders and eager to benet from a rapid change in their mental status. The real coverage for reimbursement of the care provided in private practice is rather variable; in theory it is around 70% (the social security rate) but everything depends on the honoraria charged by the physician (highly variable) and on the coverage provided by other insurance systems (mutuelles). Private hospitals The activity of this branch has also remained pretty stable over the last decades (25% of psychiatric patients hospitalized over one year have been hospitalized in private hospitals, which represents 20% of the total number of psychiatric beds). Only patients who give their consent (i.e. voluntary patients) may be hospitalized in private hospitals.

heterogeneous (they are predominantly located in the south-west and south-east of France as well in the Parisian area). The last partners for the delivery of psychiatric care in France include different non-prot associations which are mainly orientated towards specic specialist care after patients have been discharged from hospital.

The current evolution of psychiatric care in France

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The recent evolution of psychiatric care is probably (and unfortunately) better explained by economic and budget restrictions and nancial reasons rather than by the evolution of techniques and treatments.

The public health system A total of 2.7% of the general population aged above 20 are treated through the psychiatric public health system which is, as a consequence, the main provider in terms of therapeutic services. The two most frequent groups of disorders treated in the sector are psychotic disorders (30% of active cases) and severe mood disorders (30% of active cases). It must be remembered that the medical care provided by the public health system for this type of pathology is free of charge for patients and their families. Over the two last decades, the number of patients referred to the public health system has enormously increased ( 90%). During the same period of time, paradoxically the total nursing staff has been reduced ( 10%). The number of inpatient beds has also been reduced to a ratio of 60 beds for 100,000 inhabitants (a reduction of 60% over 15 years) (Coldefy, 2007). Of course the reduction in the number of beds is justied by the de-institutionalization process which started half a century ago; by now the number of beds is more or less stable since it would not be reasonable to reduce the beds further. The proportion of patients followed by the sector over a year and for which hospitalization is necessary is around 15%. Among them, 18% correspond to non-voluntary hospitalizations. Since the capacity in term of beds is not sufcient and the non-voluntary hospitalizations are mandatory, a signicant amount of urgent cases are transferred to the ambulatory ward. Another solution to compensate for this shortage in treatment capacities is to refer some difcult cases to medico-social services which are sufciently advanced (Charzat, 2002). In this respect the French parliament passed a law in 2005 recognizing psychiatric disorders as being responsible for social

Question raised by the current organization of psychiatric care in France As has been previously mentioned and similar to what has happened in many other European countries (to different degrees), de-institutionalization has been the main trend in the evolution of psychiatric care in France. There are many reasons for this tendency. The rst and perhaps the most signicant reason is probably linked to the introduction of more efcient therapeutic drugs. These

Psychiatric care in France medications made relapses less likely and less frequent (leading from the age of asylum to the age of small inpatient units. The rst neuroleptic ever, chlorpromazine, was created and developed in France and successfully prescribed to patients with psychosis by Delay and Deniker at the Sainte Anne Hospital in Paris (Deniker 2002)). But another important consequence of de-institutionalization includes progressive de-stigmatization of psychiatric patients, for which society recognizes the status of normal citizens. This, combined with pressure from patient and carer organizations, and advocacy and consumers groups, has also inuenced move from asylums to community care. Quite remarkably, the peak of the de-institutionalization movement has corresponded to a time where a claim has been made for reducing health and medical costs. Finally (and partly thanks to the reduction in the number of beds and staff), expenditure linked to psychiatric care has increased half as fast as the costs due to other medical conditions. Since the global cost for treatments has increased, one can say that the amount of money available to treat psychiatric conditions has decreased. In France all the pressure for the deinstitutionalization process has been supported by the public sector (Goffman, 1979). In 1986 new public rules of procedures were adopted to transfer towards dispensary care, outreach teams and ambulatory follow-up the funding previously dedicated to hospitalizations. Of course there was not only a theoretical perspective behind such a decision, but a practical one as well: switching from inpatient to outpatient care allowed for a signicant reduction in stafng. In principle, the idea was good, but in fact there has been no assessment of the nature and of the importance of the means requested to switch from one type of care to the other. No technique was proposed to proceed to such an assessment and the major goals in term of public health were never clearly formulated nor announced. As a result, a global political decision was taken, xing the rules for a general direction everyone had to follow, without taking into account what the local situation was and what the technical and human resources available on site were (WHO, 2001). The outcome has produced an extremely heterogeneous situation with a high variability in the access to care. Today, whether psychiatric patients are living in the Parisian area, in a medium-sized city or in a rural area, the quality of care they will receive still remains highly variable (Kovess, 2001). In summary, the sector policy responsible for delivery of mental healthcare is a major factor in the de-institutionalization process in France, but several aspects can be criticized. Care provided by the sector

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As noted above there are advantages and disadvantages in this approach. Some of the disadvantages are described below. Lack of homogeneity The most striking example for lack of homogeneity is the very variable standard of care (if any) which is available for a given pathology depending on the sector where a patient is treated. There may be variability in access to specialists within the team or even in the constitution of the team. Of course, there is a general agreement on the efcacy of the main psychotropic drugs and of the necessity to provide psychotherapeutic support to the patient. But once again, depending on the sector team, the main course of treatment will be quite different: psychoanalytically orientated, CBT orientated, socially orientated, institutionally orientated, for example. Limited systematic evaluation of the impact of the different treatments has been conducted, even for the most chronic and disabling cases. The head psychiatrist in each sector has a direct responsibility for the delivery of care provided by the team to a given population. Certainly too great a freedom is offered in the absence of any assessment of the therapeutic orientations chosen. In some cases there is an inordinate delay in translating research and evidence-based data into clinical practice. Often teams believe very strongly in their own therapeutic methods specically developed by them, thus blocking the introduction of other methods widely accepted and evidence from elsewhere. Continuity of care and adequate means Another aspect of the sector policy which can be criticized is the systematic (and necessary) priority to provide emergency care in crisis situations. Of course emergency cases have to be prioritized; however, this may lead to constant pressures to deal with emergencies at the expense of other types of care, but principally at the expense of better continuing and ongoing care for patients with other conditions. As a result, the continuity of care often consists of minimal support, either referring the patient to a day hospital or giving appointments at an outpatient clinic (dispensaire) with closer focus on routine prescription rather than psychotherapy or combination of therapies. Under these circumstances psychoeducation delivered to the patient or the family is too often lacking, as are in-depth clinical, psychological or neuropsychological explorations, implementation of strategy of prevention against relapse,

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D. Leguay & P. Boyer Care provided in private psychiatry practice As mentioned earlier, the number of psychiatrists in private practice dramatically increased in the 1970s and the1980s. Due to problems linked to the (lack of) national policy in term of continuous medical education, the type of practice of most of these psychiatrists has remained the same over the years. Hence, certain old fashioned attitudes and practices from the 1970s have been maintained, principally related to psychodynamic theories. In fact, in many cases the evolution of practice (when it occurred) did not come from psychiatrists themselves but from their clients. Patients are now extremely well informed about the different pathologies and different theories, and about the available treatments and responses. Mental health problems are in a way de-stigmatized by the media (if not by society itself) since many articles are dedicated to this topic. There is much less taboo than in the past when a patient consults a psychiatrist (Giordana et al., 2010). For all these reasons, private practice remains numerically important but has to be challenged regarding some of these aspects. The most problematic issue linked to private practice is the unbalanced distribution of private practices from a geographical perspective. The density is the highest in the richest regions, and the reverse is true as well. As a consequence, total health costs are increasing where the density is the highest, but poorer areas are signicantly lacking physicians. Up to now any attempt to solve this question by a centralized decision has failed. Another issue which will have to be addressed urgently by the profession as well as other stakeholders is the participation of private psychiatrists in the care of more severe cases. Usually the patients who attend private practices are generally mild or moderate cases. As a consequence, private psychiatrists are not involved in the process of compulsory hospitalizations.

choice of new therapeutic methods and cognitive remediation. Societal aspects Over the years the sector has more and more often been asked to answer (and to solve) all types of difculties occurring in the medico-social eld as well. The problem is that in France the vast majority of psychiatrists are not trained to deliver support and assistance to disabled people. Unlike some other European countries (as in the UK for example), social psychiatry is not extensively taught during the specialization process. Hence a clear lack of competency exists in this domain. In France the problems related to disability depend on the competency of different political bodies which deal with social inequalities. All matters linked to disability have to be considered under the current legal rules in term of insurance policies, and it can be said that the policy of care and the policy of cure are hardly convergent in France. Another major psychosocial aspect of psychiatry, not directly linked to disability, is related to follow-up, concept of recovery, and the social re-integration of patients presenting chronic and severe conditions. Regarding these patients, in France as in many other countries, concerns have been raised in relation to safety issues for society. Risk to others has taken on a major impetus. Media and politicians have debated on law and order, and security concerns have been increasing since isolated cases of murders or crimes have been reported. In July 2011 a specic law was voted in by the French parliament stipulating more stringent control of care delivered to patients who represent a threat to public order (Loi 2011803, 2011). The core measures of the law are twofold: the general frame of the psychiatric care delivered to the patient is to be placed under the control of a judge (instead of an administrative ofcer); and the discharge of a patient after a compulsory hospitalization will be closely controlled and monitored as well. It is too early to assess the real impact of this law. From the perspective of everyday practice, the law of course slows down the different steps of the process of hospitalization against a patients will (hospitalization without consent represents 20% of all psychiatric hospitalizations in France). Slowing down the discharge process of course leads to overcrowding in the inpatient units. At the same time, it is also apparent that the saturation of these units has already been the case over the last 5 years: after a period of transfer to ambulatory care the demand for inpatient care has progressively increased.

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Perspectives The mission of the sector and the re-organization of care As has been mentioned, the mission devoted to the public health system and the sector is extremely large and perhaps over-demanding. The sector is in charge of the full range of care, from early detection and diagnosis to crisis intervention, the decision whether to hospitalize, follow-up after hospital discharge, ambulatory care, and resolution of societal problems. This diversity of tasks results in a lack of specialization, yet special skills may be needed to meet more specic needs. New techniques

Psychiatric care in France for assessment or treatment are not well known and not introduced in the armamentarium of therapies (particularly in the rehabilitation eld) (Leguay et al., 2008). On the positive side, however, a consensus seems to have emerged to organize the healthcare system stage by stage. The rst stage would correspond to the standard care delivered by the sector (which will be responsible for ensuring the continuity of the treatment). The second stage would correspond to the collaboration between different sectors in the case of specic needs required by the treatment (e.g. access to family, specic social aspects of the case). The third stage would consist in referring some patients to expert centres more specialized in difcult cases and in the treatment of specic conditions such as psychotic or bipolar disorders, drug and alcohol addiction, or post-traumatic stress (this last stage corresponds in a way to what tertiary care is in English-speaking countries). Of course, to avoid overlap and duplication, the three levels of interventions would have to be carefully harmonized. Family and consumers associations Another recent hot topic which has arisen in France as in other European countries is the role and importance to be given to families, consumers associations and advocacy groups in the organization of the healthcare system and choice of the most appropriate treatments. The level of awareness and of information of these different associations is increasing and they want their opinion and advice to be taken into consideration by the health authority, both in setting standards and the access to care. Quite recently a very tense debate took place in France regarding the types of treatment which were proposed for autistic children (Circulaire DGAS, 2005; Hochmann, 2009). Family associations have challenged the routine habits of some centres where most recent developments evidenced by the literature in this eld have not been incorporated into their treatment techniques. Whatever ones personal opinion is in this respect, the role of these associations will have to be clearly recognized and a consensus will have to be found to work as harmoniously as possible for the sake of patients (Roelandt & Desmons, 2002). The problem of suicide in France Another huge problem in France is linked to the high suicide rate reported in recent years. Interestingly, the mental health profession does not consider this as a specic problem requiring specialized centres or the development of new techniques adapted to this kind of risk.

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Usually suicide is regarded as a consequence of the primary mental disorder the patient is suffering from (e.g. depression, schizophrenia). The most recent data in the domain of research on suicide are not yet translated into clinical practice. Concomitantly, prevention programmes decided at a political level may not focus on general societal considerations or on the detection of specic components of the suicidal behaviour. Mental health versus psychiatry? Finally, in France as in other countries, any debate regarding the choice or standardization of psychiatric care cannot be separated any longer from a more general discussion regarding the boundaries of an adequate mental health policy. When the politique de secteur was created 50 years ago, its clear mission was to offer society the most efcient way to take charge and to cure the mental disorders which could be encountered in the general population. The sector was envisioned as the best possible therapeutic answer to many different mental problems, but the frame for it retained a broadly medical approach even though applied to a full multidisciplinary team. Now professionals are requested to face and solve problems arising in a much larger domain and of a greater diversity: social exclusion, vulnerability, antisocial behaviour, conduct disorders and conducts at risk, professional stress, for example. One can wonder: do the possible answers to these problems still belong to the eld of psychiatry? In fact, whatever their personal opinions are, psychiatrists will be asked to propose new types of interventions even if these interventions sometimes are not directly linked to usual medical practice. Of course there is a major risk behind such requests: a psychiatrist is a physician as well as a citizen, and the different measures they could potentially recommend have to remain entirely ethical from a medical perspective. Increasingly, the media and society at large require psychiatrists to give their advice to enable policymakers to take what are supposed to be the right decisions. The psychiatrist seems to be permanently in the position of an expert. This expertise is probably part of their necessary psychiatric skills. But ination of the skills is fraught with difculties. Being an expert supposes a vast preliminary training (thousands of hours) whereas becoming a super expert will require super training. Conclusion The organization of psychiatric care in France has known signicant transformation over the last two

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Coldefy, M. (2007). Mental Health Care. The use of statistical methods [La prise en charge de la Sant Mentale Recueil dtudes statistiques]. Paris: La Documentation Franaise p. 316. Conseil National de lOrdre des Mdecins (2011). Atlas de la dmographie mdicale en France. Situation au1er janvier 2011. Deniker P. A little bit of history. Encphale, 2002, 28, Suppl 2. Giordana, J.Y. (ed). (2010). La stigmatisation en sant mentale: Rapport au Congrs de Psychiatrie et de Neurologie de Langue Franaise, ouvrage collaboratif. Paris: Masson. Goffman, E. (1979). Asiles tudes sur la condition sociale des malades mentaux et autres reclus, 1961; traduction de Liliane et Claude Lain, prsentation, index et notes de Robert Castel. Paris: ditions de Minuit. Le Sens Commun[Asylums Studies on the Social Situation of Mental Patients and Other Reclusives, 1961; translation of Claude and Liliane Laine, presentation, indexes and notes by Robert Castel, The Common Sense, 1979]. Hochmann, J. (2009). La Bataille de lautisme Rexions sur un phnomne social contemporain. Psychiatrie Sciences Humaines Neurosciences, 7, 99111. Kovess, V. (2001). Planication et valuation des besoins en sant mentale. Paris: Flammarion. Leguay, D. (2002). Le systme de soins psychiatriques franais. Paris: MF Editions. Leguay, D., Giraud-Baro, E., Lievre, B., Dubuis, J., Cochet, A., Bantman, P., Vidon, G. (2008). Le Manifeste de Reh@b: Propositions pour une meilleure prise en charge des personnes prsentant des troubles psychiatriques chroniques et invalidants LInformation Psychiatrique, 84, 885893. Loi 851468 (1986). Loi 851468 du 31 dcembre 1985 relative la sectorisation psychiatrique. Journal Ofciel, 1 January. Loi 2005-102 (2005). Loi 2005-102 pour lgalit des droits et des chances, la participation et la citoyennet des personnes handicapes du 11 fvrier 2005. Journal Ofciel, 12 February. Loi 2011-803 (2011). Loi 2011-803 du 5 juillet 2011 relative aux droits et la protection des personnes faisant lobjet de soins psychiatriques et aux modalits de leur prise en charge. Journal Ofciel, 6 July. Roelandt, J.L. & Desmons, P. (2002). Manuel de psychiatrie citoyenne: Lavenir dune disillusion. In Press, p. 227. WHO. (2001). Rapport sur la Sant dans le Monde. La Sant Mentale, nouvelle conception, nouveaux espoirs [The World Health Report 2001 Mental Health: New Understanding, New Hope]. Geneva: World Health Organization.

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decades. Originally de-institutionalization was the priority and the politique de secteur was chosen as the best way to provide the community directly with the full range of care needed by patients. But now the challenges have changed. The diversity of problems the psychiatric profession has to deal with is much larger. Psychological difculties, conduct disorders or social disability, for example, are seen as within the domain of psychiatric expertise. Collaboration with consumers and family associations also forms part of the professional commitment. As a consequence, the way psychiatrist are educated and trained in France will have to change accordingly. Declaration of interest: The authors report no conicts of interest. The authors alone are responsible for the content and writing of the paper. References
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