3 QUESTIONS TO... : MAY 2015

1/ Why did you choose to analyze schizophrenia rather than another mental disorder?

We were interested in enriching the knowledge of the population affected by schizophrenic disorders and care provided in French health care facilities for multiple reasons. First of all, schizophrenia, by the precocity and complexity of its manifestations, severity and often chronic course, is one of the ten diseases that causes the most disability according to the World Health Organization (WHO).
Schizophrenia is a major cause of social withdrawal and precariousness and has a heavy impact: indeed, patients' life expectancy is on average ten years less than in the general population. This disease affects in France 1-2% of the adult population, approximately 400,000 people. The treatment of patients require a wide range of care modalities ranging from full-time hospitalisation to various forms of part-time and outpatient care and monitoring, and the severity of the disorder makes it the first disease in terms of activity in health care facilities. A quarter of the total number of hospital days in establishments with inpatient psychiatric care accreditation are allocated to these patients. Schizophrenia is also one of the most severe disorders in terms of the suffering it causes for both the patients and their families but also in terms of its cost for society. It occupies the first rank of mental illnesses from the perspective of its cost, estimated at 1.1% of national health expenditures (Charrier et al., 2013). Furthermore, schizophrenia and persons concerned are subject to a strong stigmatization in society, creating a significant barrier to improving the quality of life of people. To enhance awareness of that population and its modalities of care helps to reduce the associated stigmatization, often based on a misunderstanding of the disease.

2/ What did the the database Medical Information System for Psychiatry (Rim-P) allow you to study?

Based on data supplied by the Medical Information System for Psychiatry (Rim-P), the study aims to describe, in a new way, the national population treated for schizophrenic disorders in health facilities and the variability of care modalities.
The disease, as the use of hospitalisation, occur earlier for men than for women. The treatment of patients with schizophrenic disorders is characterized by a higher intensity and diversity of care, whether outpatient or hospital, than what was observed for other psychiatric disorders. Patients frequently mobilize all full-time modalities of care, part-time and ambulatory, developed as part of the policy of deinstitutionalization of psychiatric care. Despite the importance of ambulatory use for these patients, hospitalisations are more common than in the general population and often relatively long.
Although the proportion of patients suffering from schizophrenic disorders is similar in public, private, multidisciplinary or monodisciplinary facilities, the modalities of care provided vary from one facility to another. These differences are notably related to the different activity structures according to mission and status as well as the types of population admitted. Patients suffering from schizophrenic disorders are in the vast majority (83%) treated in public hospitals (specialised and multi-disciplinary), with non-profit private facilities (Espic) and for-profit private facilities admitting respectively 12 and 5% of patients diagnosed. In public and non-profit private establishments, 28 and 25% of hospital days are allocated to the treatment of schizophrenia. In the private for-profit sector, it only represents 12% of hospital days. The length of stay varies considerably according to type of health care facility and reception. It is lower in multidisciplinary public facilities (general hospitals and university hospitals) and in for-profit private hospitals with 75 and 78 days respectively. It reaches 85 days in specialised public hospitals and 97 days in non-profit private facilities. Within these broad categories, there are also significant variability in lengths of stay. Those fulfilling a public service mission present a greater heterogeneity in the length of hospital stays as part of them correspond to emergencies and crisis management whereas others correspond to longer care provision. In the private sector, the lengths of stay are more homogeneous than in the public sector due to the planned and non-emergency nature of care provision. Psychiatric readmission rates also vary widely and are lower in institutions with high ambulatory activity.

3/ What are the issues raised by the variability of care modalities for patients treated for schizophrenic disorders?

If it is now accepted that adapted care results in a durable remission in one third of cases for people suffering from schizophrenic disorders (Andreasen et al., 2005), it is currently admitted that the prognosis more especially depends on the quality of psychosocial support, access to health care and compliance with the proposed treatment regimens. There are notable differences in care provision according to type of health care facility. These differences call into question the equity of care for the patients concerned. The analysis here is limited to care provision in health facilities but also questions the longer-term evolution and its relationship with ambulatory care, medical-social and social sector.

Remission in Schizophrenia: Proposed Criteria and Rationale for Consensus.
Andreasen N.C., Carpenter W.T., Kane J.M. et al. (2005). American Journal of Psychiatry, 162, 441-9.

Le coût de la schizophrénie : revue de la littérature internationale.
Charrier C., Chevreul K., Durand-Zaleski I. (2013)., L'Encéphale, Volume 39, Supplement 1, Pages S49-S56.

Interview by Anne Evans

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