“If your mother signs this paper, we will lay you down and tie you up. » Engraved in the memory of Sybille Dequero, this sentence was addressed to her son upon his arrival in the psychiatric emergency room. “Obviously, he got scared and wanted to go home! »she remembers.
Sybille's son, now 28, suffers from bipolar disorder, and she has no shortage of stories about the hospital. She talks about the time he was sent home due to a lack of psychiatric beds. The next day, he swallowed a box of pills in an attempt to end his life. Or this other crisis during which they traveled as best they could through the hospitals of Paris: Sainte-Anne, Bichat, Fernand-Widal, all were full.
“Summer is a time that I particularly dread. Because I know there will be fewer people in the hospitalbreathes the one who has taken her son there since he was 17 years old. It's not a place where you want to take your loved one. This is not reassuring. »
More and more patients, fewer and fewer places
The story of this “caregiver”, which has since been told in the theater, is symptomatic of a sector in great suffering. Since the 1980s, two thirds of public psychiatric hospital beds have been closed as a result of the “ambulatory shift” – the policy intended to reduce the number of nights spent in hospital.
Stays are shortened by referral to other structures, which are themselves saturated: in 2023, waiting times for half of the medical-psychological centers (CMP) ranged from one to four months for adults and up to one year for children. Sybille Dequero and her son therefore oscillate between emergency hospitalizations, which are too short, and appointments with liberal psychiatrists, when they find them.
In the 1980s, there were 800,000 psychiatric patients. Today, there are 2.8 million. Compared to places in hospitals, the equation becomes particularly shaky.
One in four people are affected by psychological disorders during their life in Europe, a figure that is constantly increasing
According to Magali Coldefy, researcher specializing in psychiatry at the Institute for Research and Documentation in Health Economics (Irdes), the increase in the number of patients can also be explained because “We enter the hospital door more easily than before, for example for autistic disorders. But the length of hospitalization has decreased”. One in four people are affected by psychological disorders during their life in Europe, according to the WHO, a figure that is constantly increasing.
On the one hand, the population is aging, and 14% of people over 60 live with a mental disorder. On the other hand, the Covid crisis has worsened discomfort, particularly among young people, among whom disorders have exploded: in 2023, nearly one in three high school girls will have had suicidal thoughts, according to Public Health France.
Lack of political will
The government seems to be reacting and is increasing its announcements on mental health. In 2023, the “My psychiatrist” system will be put in place to allow reimbursements for liberal consultations for mild disorders, supplemented by a toll-free suicide prevention number, as well as first aid training in mental health.
On October 19, Michel Barnier, then Prime Minister, even announced that mental health would be made a major national cause for the year 2025. This label, allocated for example to mentoring in 2023 or to sport in 2024, allows associations to disseminate free messages on public radio and TV channels, but is not necessarily accompanied by a budgetary increase.
The budget allocated to psychiatry is partly absorbed by hospitalization, which requires more and more resources
Since the start of the pandemic, seven Ministers of Health have succeeded one another, leaving their share of disappointments after each visit. The budget allocated to psychiatry, the largest expenditure item for Social Security at 24.6 billion in 2023, is partly absorbed by hospitalization, which requires more and more resources.
On strike in October 2024, public hospitals judged that the 3.5% increase in the budget proposed in the finance bill would be almost absorbed by inflation and the increase in employer contributions.
Maeva Musso, president of the association of young psychiatrists and addictologists (AJPJA), campaigned for the establishment of this great national cause. Aware that this will not resolve the hospital crisis, she believes that this announcement could at least lift the taboo on mental health:
“Mental disorders are very stigmatized and so is the profession. Currently, there is no public mental health policy, unlike other countries. However, we should have a policy that is much more preventive than curative. »
Same observation for the president of the National Union of Families and Friends of Sick and/or Mentally Disabled People (Unafam), Emmanuelle Rémond: “We're tired of tearing down the walls! ». According to her, the general population should be trained to recognize weak signals to avoid going as far as hospitalization:
“When you can no longer get up in the morning, or you are going a thousand miles an hour, you need to consult. This is a public health issue. »
Prevention could be established further upstream, like other European countries, according to Nöel Pommepuy, head of the child psychiatry center at EPS Ville-Evrard in Seine-Saint-Denis: “For example, working on empathy from kindergarten and preventing bullying, rather than curing it once it's too late. »
-Prevention rather than cure, the message seems clear to avoid hospitalizations. And when these are necessary, it is possible to reform the practice of hospital psychiatry.
Make the environment more attractive for patients…
The first hospitalizations are essential, because they often signify the patients' divorce from psychiatry. “A young person who has had a seizure arrives urgently at the hospital, in a brutal moment, is generally tied up. The family will be very marked, because the diagnosis is sometimes announced violently, sometimes not at all, due to lack of time”, note Noël Pommepuy.
The patient's mother Sybille Dequero affirms, she was never asked how she was throughout the journey with her son: “ We don't include the family, we feel left out, even guilty. »
For the child psychiatrist, city policies should also invest massively in support, from the first crises, “ on education, employment, on activities centered on the life project, taking treatment”.
This proactive policy would make it possible to avoid chronically ill and wandering patients, and to relieve congestion in services, while ensuring patient adherence to care. IRDES researcher Magali Coldefy agrees:
“Recognizing that the patient can be a partner in care, giving them the means to manage their disorder, creating advance directives with them to follow in the event of a crisis, are methods that have proven themselves. »
The available time of caregivers has been drastically reduced, compromising the bond with the patient in a profession based on relationships.
According to the researcher, for public hospitals, the question is less about the budget than about the available time of caregivers. This has been drastically reduced with the application of the 35-hour week and the increase in the administrative burden weighing on civil servants, compromising the link with the patient in a profession that is nevertheless strongly based on relationships.
However, she tempers: “Some hospitals have more staff and don't perform better. It is also and above all a problem of philosophy of care. »
Same observation for Maeva Musso of the AJPJA, who delivers the first recommendations resulting from the #choisirpsychiatrie survey, relating to the attractiveness of the sector and carried out among 3,396 professionals or future professionals: tend towards an end to restraints and isolation, avoiding the overprescription of medications, centering care around recovery, the patient and their family… These practices, coupled with destigmatization of mental health, could once again attract caregivers in a cruelly deserted area.
…as for caregivers
In public hospitals, there is a shortage of speech therapists, psychomotor therapists, nurses and especially psychiatrists. In medical school, psychiatry is one of the least chosen specialties – 67 intern positions remained vacant in 2023. And future psychiatrists, put off by working conditions, are increasingly heading towards the liberal sector or towards private clinics, which are gaining ground.
The textbook cases follow one another. At the Edouard-Toulouse psychiatric hospital, in the northern districts of Marseille, a doctor left during the summer of 2024 and an entire unit will close in 2025, depriving an entire district of care.
The unions denounce a “failure to assist a person in danger” for the general population and for patients
The unions denounce a real “failure to assist a person in danger” for the general population and for patients, in services where one can be “three caregivers for thirty patients”, while the head of the establishment deplores the great difficulty in recruiting doctors.
In Ariège, a rural department particularly affected by medical deserts, the only psychiatric hospital has been operating understaffed for several years. But the promulgation of the RIST law of May 2023, which regulates the salary of temporary workers in the public sector, precipitated the departure to the private sector of more than half of the team, most of them hired on a temporary basis, leaving psychiatric emergencies bloodless .
For Noël Pommepuy, these desertions also relate to a “public service crisis” resulting from political choices. He also has no shortage of “courageous” ideas to resolve this crisis in psychiatry. For example, nationalize temporary work with a pool of doctors and a capped salary, create an intermediate profession between the psychiatrist and the nurse, revalue salary scales, or even establish an obligation of care in the final year of psychology.
For the associations of young psychiatrists AJPJA, Affep and ANEMF, the challenge is to “ change the way we think about care [en faveur d’] a modern, humanist, progressive, courageous and questioning psychiatry.” A more humane psychiatry which would once again make young doctors want to get involved, patients and their families to be supported, and the general population to be in better health.
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