Mental Health and Service Use of Migrants in Contact with the Public Psychiatry System in Paris.

BACKGROUND: Migrants, and particularly asylum seekers, are at increased risk of psychiatric disorders in comparison with natives. At the same time, inequalities in access to mental health care are observed. METHODS: In order to evaluate whether the Parisian public psychiatric system is optimally structured to meet the needs of this population, we examined data on mental health and service use considering three different levels: the global system treatment level, a psychiatric reception center, and mobile teams specializing in access to psychiatric care for asylum seekers. RESULTS: We found higher treatment rates among migrants than among natives (p < 0.001) but inequalities in pathways to care: more mandatory admissions (OR = 1.36, 95% CI: 1.02-1.80) and fewer specialized consultations (OR = 0.56, 95% CI: 0.38-0.81). We observed a mismatch between increased need and provision of care among migrants without stable housing or seeking asylum. CONCLUSIONS: Inequalities in the provision of care for migrants are observed in the Parisian public psychiatric system, particularly for those experiencing poor social and economic conditions. There is a need to facilitate access to mental health care and develop more tailored interventions to reduce discontinuity of care.

Mental Healthcare Utilization among Homeless People in the Greater Paris Area.

The healthcare utilization of homeless people is generally considered insufficient, and studies often suffer from methodological bias (institutionalized vs. street samples). To adapt public health policies in France, epidemiological data on this population are scarce. The objective of this study was to analyze the use of psychiatric care by homeless people with mental health problems in the Greater Paris area and to define the factors influencing this use. The data were from the SAMENTA survey performed in 2009 with a representative random street sample of 859 homeless people from the Greater Paris area. The survey studied the use of psychiatric care (lifelong use, current follow-up, discontinuation of follow-up and treatment) and factors potentially associated with this use for people with a diagnosis of a psychotic, mood or anxiety disorder, with the diagnosis established with an original survey device. Because of our complex sampling design, we describe data for only a weighted estimated prevalence, weighted estimation of the number of people in the population (N) and unweighted total subgroup studied in the survey (n). Among 840 homeless people with useable data, 377 (N = 9762) had a psychiatric disorder. The use of whole-life care for these people may seem high, estimated at 68.7%, but few people were followed up for their disorders (18.2%); individuals with a psychotic disorder were more frequently followed up (36.5%) than others were (p < 0.05). Among those followed up (n = 86, N = 1760), 63.0% were taking medication. Access to care for these people seemed preserved, but the maintenance of care seemed problematic; indeed, among people with a lifelong whole use of care (n= 232, N = 6705), 72.3% could be considered to have discontinued care. The factors that improved lifetime health service utilization or follow-up were socio-demographic (age < 42 years, more educated), social (with social security coverage, not living in a hotel), and medical (psychotic disorder, personality disorder, suicide risk, somatic chronic illness, perception of mental suffering). Improving the care of homeless people with psychiatric disorders requires improving access to care for those isolated from the health system (in particular those living in hotels) and to guarantee continuity of care, by adapting the organization of the care system and promoting social rehabilitation.

[Homelessness: psychological and behavioral issues]. / SDF: aspect psychopathologique et comportement.

Risk factors lead to social exclusion and their accumulation can lead to homelessness. This inevitably contributes to a progressive increase in psychological distress or aggravates a pre-existing mental illness. Over the years, homeless people, who are never happy, develop various survival strategies and mental defenses that can sometimes prove effective. Other individuals who are less"adapted" to living in the street may suffer from both mental and physical collapse. Proactive programs designed to facilitate access to healthcare and welfare have been created in order to offer solutions designed to enable homeless people to leave the street, through access to medical care, accommodation and civil rights. The psychiatric sector has been slow to adapt to the needs of this population, although several teams specializing in mental illness and precariousness have been created These teams explore every possible avenue to help homeless people with mental health issues to recover a psychological balance that allows them to choose a recovery pathway and thus to regain a dignified lifestyle.

[Legal empowerment and mental health: the legal subject in hospitals]. / Accès au droit et santé mentale : quand les hôpitaux prennent soin du sujet de droit.

A social experiment and pilot project funded by the French Directorate General of Social Cohesion aimed at providing legal aid services ("legal empowerment and mental health") has been conducted since 2009 in three healthcare institutions in Paris (France): the Centre Hospitalier Sainte-Anne, the Groupe Public de Santé Perray-Vaucluse, and the Hôpital Tenon (psychotraumatology unit). Lasting until 2012 and piloted by the NGO Droits d'Urgence, the initiative aims to promote the legal empowerment of socially excluded people suffering from psychiatric or mental disorders and to facilitate access to care. The initiative operates on two levels, providing legal support to vulnerable people and offering legal expertise and advice to medical and social staff. An ad-hoc intervention approach was designed to ensure the implementation of the initiative based on several combined tools: legal aid, technical committees, awareness-raising activities, and pooling of legal resources and information. Developed across the three institutions, this integrated and subsidiary initiative improves our understanding of the complex circumstances of disempowered people ? who are often faced with overlapping social, medical, administrative and legal difficulties ? and helps to take into account their vulnerabilities. The cross-professional and cross-boundary system promoted by this initiative involves medical staff, social workers and lawyers around patients viewed as both actors and legal subjects.