1. TheFrenchpublichealthframework:amodelofintegrated comprehensivesystemLesecteur F.PETITJEAN

2. Sectorisa?on Establishmentofgeographicalcatchmentareaswithdedicatedmentalhealthstaprovidingservicestoallpa?entslivinginthearea FondamentalelementintheplanningofcommunityservicesinmostWesterneuropeancountriessincethe1980s 3. Theprinciples Con?nuityofcarebyateamofprofessionals(nurses,psychologists,psychiatrists,socialworkers..) Treatmentistobeprovidedasearlyaspossible Geographical,culturalandsocialproximity Goingfromthementalhospitaltothecommunity Integratepreven?on,treatmentandandrehabilita?on Hence:twodierentmeanings(geographicalandorganiza?onofcare) 4. Abitofhistory AdolfMeyer(1915)ar?culatestheconceptofmentalhealthservicescloselyiden?edwithacommunity Reemphasizedasabasicpremiseofdeins&tu&onaliza&onwithresponsabilityofcaretransferredfromlargestateins?tu?onstolocalcommunity-basedorganiza?onsaccountablefortheprovisionofservices Firstadministra?vetext(circulaire)inFrancein1960 5. S.JohnsonandG.Thornicro[(1993) Progressivelyfrom1959to1985 Nona?onaldecision,butinstalledbyhealthdistricts 63%ofcases:oneteam 10%ofcases:dis?nc?onbetweenhospitalandcommunityteams Tyrer(1985,1989)andHanssoninSweden(1987)showaneectonthenumberandthelengthofhospitalstaysaswellasthenumberofcompulsoryadmissions 6. MentalHealthDistrict(A.Meyer1915) Centremdicopsychologique CommunityMentalHealthCentres(USA) MentalHealthRessourcesCentres(UK) SocialPsychiatryCentres(Allemagne)ServizidiDiagnosieCura(Italie) 7. LesecteurinFrance Sectorsformentalhealthserviceprovisionweresetupinthe1960sand1970s Amentalhealthactpassedin1838hadledtotheconstruc?onoflargementalins?tu?ons(asylums)thoughoutthecountry Majorroleofthehistoricalcontext:a[erWWII,agroupofpsychiatristspioneeredamovementcri?caloftheasylums Con?nuityofthispolicysince1960,withvariouslegisla?onsconrmingsectorsasthebasisofthepublicmentalhealthsystem 8. 1968 : Psychiatry is separated from neurology1960 - 1985 : A Model predominantly based on a psycho-social approach The Bio Part is given less Importance 1970-1985 : a Sharp increase in the number ofpsychiatrists (1970 : 3000, 1997 : 12000) 9. -Psychiatric sectorization (Dec 31, 1985 Law) -Same source of funding for inpatient and outpatient services (December 30 and 31, 1985 Laws) -The rights and protection of individuals hospitalized for mental illness (June 27, 1990 Law) -Patients rights. Quality of health care system (March 4, 2002 Law) -New issues: HPST law ( 2009 ), Couty report ( 2008 ) 10. Data 63millioninhabitantsinFrance 815generalpsychiatrysectors(adults) 56100inhabitantspersector(over20yofage) 80%ofpsychiatricac?vityinhospitals Approx.1151000individualstreatedbypublicmentalhealthservices(mean1387persector,a62%increasesince1989). 26/1000personsincontactwithmentalhealthservices 54%ofwomen Pa?entsaged25-44represent43% 11. Globalcaseload 12. Caseloadinpart?meservices 13. Personnel/Caseloads 14. Healtheconomics 10%ofGNP Mentalillness,thirdcategorybehindCVdiseaseanddiges?ve(10,9%oftotalhealthexpenditure) Psychiatrichospitaliza?onacountsfor15,5%oftotalhospitalcosts,thehighestpropor?onforanyillness 15. Numberofpsychiatrists/dpartement(nonprivate) 16. Hospitalbeds 98%ofsectorshavebeds(meannumber:54) 43173publicadultpsychiatricbedsin2000 Agradualdecreaseovertheyears Nowamajorissueinlargeci?es:ndingahospitalbedforanacutelyillpa?ent 17. MEANNUMBEROFBEDS:55 MEANNUMBEROFOUTPATIENTPLACES:26 18. Meanlengthofhospitalstay 19. Souce:MinistryofHealthReports 20. Abalancedapproach? Bothcommunityandhospitalservicesarenecessaryinallareas Gradua?onaccordingtothelevelofressources(low,mediumorhigh) StudiesbyG.Thornicro[andM.Tansella(2004),byM.ColdefyinFrance(2010) 21. Schizophrenia 22. Diagnosis/gender 23. Epidemiologicaldatafor schizophrenia 1%prevalence 26%ofpa?entstreated(pointprevalence)inageneralpsychiatrysectorsin2003(LeFuretal.) 230000pa?ents,75%oftheminnonprivatestructures(Rouillon,1992) 24. Diagnosis/ageinfull?mehospitalisa?onDREES2003 25. CompulsoryadmissionsDREES2003 26. ASTUDYOF270PATIENTSWITHSCHIZOPHRENIATREATEDIN20 SECTORS Clinicalandsocio-demographiccharacteris?cs 270pa?entswithschizophrenia(DSMIIIR) Male Meanage34.5y.o. 2/3 Female Meanage35.4y.o. 1/3Meandura?onofillness13y Rehospitalisa?onrateduring24monthsfollowup AtM24:42%treatedinadayhospitaloradaycarecenter VIDONetcoll1993 AtM24:96%havestablehousing 27. SERVICESFORPATIENTSWITHSCHIZOPHRENIAASTUDYIN4PSYCHIATRICSECTORSKOVESS,DUBUISetal,Clinicalanddemographic1993characteris?cs .167pa?entswithschizophrenia(ICD10) .Randomlyrecruitedinthecaseloadsof4sectors .MeanAge:37y.o. .Meanageatrstpsychiatriccontact22yo .70%Male .13%nonshelteredemployment .85%Perceivedsomeformofsocialbenet (socialsecuritypensionorAAH). .42%treatedindayhospitalatinclusion Followupat12monthQOL(BakerandIntagliata)improvedat M12 28. Evidencebasedtreatment:the useofclinicalguidelines ACT,psychoeduca?on,cogni?ve remedia?on 29. Asser.veCommunitytreatment FirstdescribedbySTEINandTESTin1980 Numerouscontrolledstudies(BURNSetcol.2008) Adaptedinanumberofdierentcountries:USA,UK,Italie Hasproveditsecacyinanumberofdimensions:numberofhospitaladmissions,qualityoflife,clinicalsymptoms. Increasestheremissionrate(Bak,VanOsetcol.2007) Par?cularlyforhomelesspa?ents?(Burns,2006) Ispartofmostguidelines(PORT,NICE2009,McEvoy,Bollinietal.2008,APA,2009). 30. STEINandTESTMODEL CommunityOutreach MobilityandFlexibility MostServicesprovided directly(notbrokeredout) 24HourCoverage Caseloadssharedacrossclinicians Lowpa?enttostaRa?o(10:1) Con?nuityofcare Timeunlimited 31. PsychosisInforma.onProjectDaysinHospitalABer1yearand2years.*Mean39vsmean78P