Mental health and use of care in people receiving a French social benefit.

BACKGROUND: This paper presents and epidemiological survey of 300 adults randomly sampled among the Parisian population and 207 randomly sampled recipients of a social benefit. The RMI (Revenu Minimal d'Insertion) provides a regular minimal income to any person with resources below a certain level. It is not targeted at people with mental health problems. METHODS: The subjects were evaluated by trained interviewers using collateral information provided by an informant, together with CIDIS, a simplified version of the CIDI, covering: somatisation, panic attack, phobias, generalised anxiety, major depression and alcohol and illegal drug abuse (DSM-III-R and ICD-10 classifications). RESULTS: The response rate was 79% for the Parisian sample and 75% for the RMI recipients. As expected, the sociodemographic composition of the two groups adjusted for age differed considerably: RMI recipients were likely to be unemployed and single or divorced. The collateral information showed that psychoses of all types were more frequent among RMI recipients (4.2% vs 1.2%, P < 0.02). There were large differences in rates for substance abuse and dependence, antisocial personality and lifetime depressive disorders, but no difference for mental deficiency. This corresponded partly with the direct CIDIS measure: male RMI recipients suffered significantly more from severe depression than male Parisian controls: 16.7% compared to 3.4% (P < 0.01 lifetime) and from drug and alcohol abuse or dependency disorders. Depressed RMI recipients made less use of available medical care for their depression than Parisians controls, mainly because RMI recipients did not consult psychiatrists, whereas controls did (21%, P < 0.0001). On average, the duration of depressive episodes is longer in RMI recipients, especially in women. CONCLUSION: The high rate of psychiatric disorders and poor access to resources in RMI recipients have implications for the health system. Care would be improved if social workers administering the benefit were better trained to recognise psychiatric problems, and able to link their clients with (particularly) primary care services.

[Epidemiology and prevention of mental disorders]. / Epidémiologie et prévention des maladies mentales.

From a bibliographic analysis and personal experiences, the authors present the advantages of the epidemiologic method in psychiatry. They point out its specificity and the methodological difficulties. Since the psychiatric practices are being deeply transformed, it becomes essential to know precisely the importance and the distribution of mental diseases in the population. It is not possible to image changing a care system trend without knowing the real needs of the population. The descriptive epidemiologic method contributes to this. The aim of analytic epidemiology is ever more important since it allows to spot the circumstances in which mental diseases appear and are developed, and to elaborate etiological hypotheses. Finally, this favors preventive approaches where evaluative epidemiology permits to measure the validity and effectiveness of programs which, like those elaborated for other social calamities (transmissible diseases, degenerative diseases), take place for studies in the field of mental health disorders.

[Planning in mental health--is it possible?]. / La planification en Santé Mentale est-elle possible?

The author opens the subject by questioning "why" and "how" to plan for mental health. Planification is a public health process. This process made modern countries able to develop health care policies in accordance to scientific progress. This allowed to stop the transmission of communicable diseases. Mental health disorders are one of the 4 public health priorities along with cardio-vascular diseases, cancers an consequences of accidents. New care methods have to be found in order to be adapted to recent needs. In many countries, mental health care have been and still are on the way to be modified. These major modifications will be illustrated by the French "sectorisation" which will be replaced in the context of complete reconversion of the French mental health care system. Two research streams will be proposed: research focused on the health care system which will enlight the different systems, their characteristics, activities and adequation; epidemiological studies in order to measure population needs in term of mental health, to clarify how mental health disorders appear and what sort of care are used by the persons. To illustrate these themas, the author will present his own experience. For more than 25 years he was operating on complex private mental health care system using the resources of an epidemiological unit in order to plan the development of this care system.

[A comparative study of 2 epidemiologic surveys in the Governorship of Sousse and the XV sector of Yvelines]. / Etude comparative de deux enquêtes épidémiologiques dans le Gouvernorat de Sousse et le XVe secteur des Yvelines.

The authors report two epidemiologic surveys using the same methodology, in two areas, one in Tunisia (Governorship of Sousse), the other one in France (XVth Secteur des Yvelines). They define a prevalence rate and an annual incidence rate, in different socio-economic contexts and in inequally equipped areas.

[The place of the patient or the misfortune of the institution]. / Le lieu du malade ou les infortunes de l'institution.

Changes in psychiatric practices derive from noticeable revision of conceptual framework and from the presence of different resources available to treat mental health problems. After an absolute priority given to the psychiatric hospital which in hand of an able doctor like Esquirol was certainly a splendid instrument of care, has followed the "Sector concept" (catchment area) which ideally insists on preventive and therapeutic measures directed toward the sick or presumably sick individual. But such evolutions are seldom linear and vicious genius tends to slow if not to reverse the process. The author retraces here the evolution of a psychiatric care system managed by himself for 25 years. Originally created by Sivadon in the context of relative freedom due to appurtenance to the private sector, this experience has been developed through addition of a variety of therapeutic structures to end up with a comprehensive System of social psychiatric deserving a catchment area. The author gives us his insights on the slowly made modifications to the functioning of this structure. He confirms the value of the catchment area framework but in the same time underlines his risks.

[Evaluation of day hospital care. Improvement factors and chronicity factors]. / Evaluation des soins en hôpital de jour. Facteurs d'amélioration et facteurs de chronicisation.

From a long term study, the authors analyse the becoming of a 337 psychiatric patients cohort, treated in a day hospital. They examine particularly the correlations between the results (individual and institutional), the primary therapeutic objective and the means employed to reach it. The factor analysis of correspondence (Benzecri's method) permitted them to point out and classify some groups related to the therapeutic projects and their destiny. The relation between the length of stay (cost indicator), the means employed (mean indicator) and the results obtained (result indicator), requires a very thorough analysis to evaluate the possible determinants of health economy studies.

[Epidemiology and space of the therapeutic project]. / L'épidémiologie et l'espace du projet thérapeutique.

The author suggests an analysis of the evolution of psychiatry referring to space concepts, according to three stages. In the first one, the topographical space is represented by the asylum and the nosography, which both bound a closed field. The second stage represents the dynamical space of therapeutic institution which refers to the psycho-analytical and sociological concepts. The third stage opens a space of meaning; it refers to the concept of sector, to the process of deinstitutionalization and to the epidemiological field; it tries to surround some projects linked with the notions of mental health and prevention.

[A French experiment: a law for alcoholics presumed to be dangerous]. / Une expérience française: la loi sur les alcooliques présumés dangereux.

In France the complexity of the problems of alcoholism lie in its magnitude as well as its socio-economic implications. Countermeasures are conducted on essentially four levels: (i) social and educational; (ii) economic; (iii) repressive; (iv) health measures; all of which are embodied in the law of April 15th, 1954 concerning 'alcoholics presumably dangerous to others'. After a historical introduction the authors delineate the ante-delinquent character of the 1954 law and compare it to similar 'ante delictum' laws elsewhere. They describe the various modalities of its application and analyze its concept and actual application under positive as well as negative aspects. In an era of widely advocated, though not always sufficiently financed and endorsed, preventive approaches it appears worthwhile reflecting on a law which is opposed in principle by some and is difficult to apply because of limited resources, but has the merit of existing and allowing for an analysis of the reality.

[Instrumental analysis of day hospitals]. / Une analyse instrumentale des hôpitaux de jour.

The authors, taking the opportunity of an epidemiological study, submit the results of 12 day hospitals functioning, having a similar administrative structure, receiving an homogeneous train of clients but distributed on different points of the national territory and having a different functional organization. They draw conclusions from it, on the day hospital definition, the interest of defining scientific evaluation systems, for a better assessment of the therapeutic functioning, the place and importance of this type of medical service for the evolution of actions in the field of mental health.

[Psychiatric epidemiology: demographic study and characterization and prevalence rate of mental diseases]. / Epidémiologie psychiatrique: étude démographique et caractérisation d'un taux de prévalence des maladies mentales.

The authors report an experience on the assessment of mental illness prevalence rate in the socio-professional population of four French provinces. This analysis, preceded by a demographic study of the considered population, will be extended by an incidence of mental disorders research relative to constitute a cohort of patients which 3 years follow-up study will allowed to make a cost analysis (cost-effectiveness) of the chosen therapeutic ways and means.