The modernization of psychiatry must be a public health priority for France.
The Covid-19 epidemic has shown up the fragility of the French healthcare system. The lockdowns and the measures restricting personal freedom have created considerable psycho-social damage, particularly in young people, and this has underlined the fact that psychiatry in France has been neglected. This blindspot in heathcare policy must be remedied urgently because, whereas the first wave of the pandemic in 2020 affected hospital care and the second wave in 2021 was economic and social because of the inevitable rise in bankruptcies and unemployment, the third wave will be psychiatric. Since the spring of 2020, the incidence of mental disorders has doubled in France, notably affecting 29% of young people between the ages of 15 and 24. Worse still, one in five French people have thought of committing suicide.
For psychiatry as well as for our healthcare system, the Covid-19 crisis has been not so much disruptive as a revelatory factor and an accelerant. Before the epidemic, one out of every five French people suffered from sort of mental disorder, but only 40*% to 60% of them are receiving treatment. On average, it takes eight to 10 years to detect a disorder after the first symptoms appear. And there is a systematic lack of care for people in highly precarious situations, e.g. homeless people, immigrants and prison inmates.
The consequences of this failure are very serious for the nation. In public health terms, patients’ lifespans are being reduced by 10 to 20 years, particularly because of suicide (10,000 deaths and 220,000 attempts every year).
Insufficient prevention and care have led to the state’s use of disproportionate measures – placing restrictions on personal freedom, isolating or restraining – and violating patients’ dignity.
Psychiatry in France has fallen victim to the fear that mental illness instills, to the stigmatization of sufferers and their entourage, and to the erroneous conviction that such disorders cannot be treated successfully, although there is a 67% recovery rate in people suffering from depression.
Primarily, the problem is the chronic insufficiency of care, its mediocre quality, the widely varying quality of treatment offered, and huge regional differences.
Psychiatry only accounts for 2.4% of university professors and for 5.8% of students, and both doctors and nurses receive inadequate training.
This situation is unacceptable not only in the light of the Covid-19 epidemic, but also regarding the major challenges facing 21st century medicine: ageing populations, the knowledge-based economy, and the place held by the brain. The situation is paradoxical, given France’s role in the beginnings and development of psychiatry: Philippe Pinel’s invention of it in 1791, Jean-Martin Charcot’s work on the nervous system, Henri Laborit’s discovery of the first anti-psychotic and anti-anxiety drugs, Esquirol’s creation of specialized institutions throughout France in the 19th century… Just as oncology has become a great national cause, so should psychiatry; it should be the subject of a radical rethink, in six main areas.
Firstly, sufferers and their entourage should not be stigmatized: public opinion must be educated so as to change the image of mental illness and insist on the fact that it can be prevented and treated. Secondly, training must be improved; psychiatry should be better integrated into the medical curriculum and specialized carers should be trained, particularly with regard to the treatment of children and teenagers. Thirdly, prevention should be systematized, particularly concerning young people. Fourthly, treatment should be reorganized and centered on decompartmentalization and cooperation between psychiatry, community medicine, nurses and psychologists, as well as cooperation with the patients’ family and friends, who are often ignored or viewed with suspicion. Fifthly, finance must be flexible and not within a fixed overall budget that makes it impossible for institutions and practices to move forward, and puts a complete stop to any innovation. Finally, there must be investment in innovation and in both public and private research. In France, public expenditure on mental health accounts for less than 4% of the budget for medical research, as compared to 7% in the UK and 16% in the USA, whilst the return on investment, estimated at 37%, is one of the highest in the medical field.
Modernizing psychiatry in France is not merely a priority for public healthcare, it is also essential for strengthening the nation’s resilience in face of the crises specific to the 21st century. We must replace the three-pronged principle of “ignore, relegate and neutralize” by a new trio: “prevent, treat and cure.”
(Column published in Le Figaro, 1st March 2021)