3 questions to… Clément Nestrigue, Magali Coldefy and Julien Mousquès on the occasion of the publication of Issues in Health Economics (228), June 2017: The Heterogeneity of Hospitalisation Admission for Depression is Linked to Prior Healthcare, in collaboration with Fabien Daniel (ISPED, IRDES) and Nadia Younès (University of Versailles Saint-Quentin, IRDES).

September 2017

1/ What are the main characteristics of health care modalities for people suffering from depression in France?

According to the European Health Interview Survey (EHIS-ESPS), the estimated prevalence of depression in France is 7%, or nearly 4 million people. Depression management is characterized by two main elements: on the one hand, a significant - albeit decreasing - proportion of patients suffering from depressive symptoms who do not seek care; on the other hand, a preponderant role of the general practitioner in the management of these frequent disorders.

According to the European Study of the Epidemiology of Mental Disorders (ESEMED), it is in France that the general practitioner least often refers his patients to a specialist professional (22%) compared to Germany (25%), Belgium (30%), Spain (40%), Italy (50%) and the Netherlands (55%). At the same time, the proportion of patients receiving medication prescribed by a general practitioner is among the highest (63%) in Europe.

Ambulatory care is also characterized by a small proportion of treatments considered adequate, as most treatments do not respect the minimum recommended duration of six months for antidepressant treatment or psychotherapy.

There are several factors that contribute to these dysfunctions: stigmatization associated with mental illness, difficulties in treatment compliance, lack of training of professionals and difficulty in accessing rapid specialist advice. Other examples include the lack of reimbursement for consultations with a psychologist or psychotherapist (non-physicians), delays in obtaining an appointment with psychiatrists, or the reluctance of patients or professionals to go to a specialized psychiatric facility.

2/ How does your study complement the knowledge about these modalities?

While the management of depression in ambulatory care is relatively well documented, few studies have attempted to analyze hospital management. Our study seeks to fill this gap. Hospitalization is recommended for severe forms of depression, high-risk suicidal situations, or because of a particular social context. In 2012-2013, 200,000 primary hospitalisations for a depressive episode were recorded in health care institutions, or 100,000 per year.

As the primary hospitalisations cover very disparate situations, we first described these hospital episodes through a typology in 9 classes, based on information concerning the characteristics of the individual (age, existence of psychiatric or somatic co-morbidities, or suicide attempt and severity of the depressive episode...) and his hospitalisation (nature of the hospital service, length of stay, type of health care facility - public or private, single or multi-disciplinary -, legal mode and entry mode).

Our analysis then focuses on contacts with general practitioners, the specialized outpatient system (liberal psychiatrists, medical psychological centres (CMPs, Centres médico-psychologiques)) and drug dispensing prior to this hospital episode. Finally, the link between these hospitalisations and the type of prior ambulatory care is studied in order to better characterize these hospital episodes and reposition them in the individuals’ health care pathway.

3/ What are the main results?

Our results show that 1 in 10 primary hospitalized patients had no ambulatory follow-up in the six months preceding this hospital episode. For 6 out of 10 patients, the general practitioner was the only doctor consulted, regardless of the reason for consultation. 3 out of 10 inpatients consulted a psychiatrist and more than half of the patients had antidepressant treatment prior to hospitalisation.

The typology shows a great heterogeneity of the types of hospitalisation for depression and the fact that they are more often performed in a medical department than in psychiatry, with frequent admission by the emergency services. This suggests a link between the health care pathway prior to hospitalisation and the planned or unplanned nature of hospitalisation.

These "unplanned" hospitalisations seem to occur more frequently when the patient is not treated by any outpatient practitioner (general practitioner and psychiatrist) but also when the treatment does not involve psychiatrists. The intervention of a specialised professional seems to have an impact on the type of hospitalisation and on the drug therapy given to the person. These pathways are also associated with certain individual patient characteristics: young people and CMU beneficiaries are more frequently found in the profiles of patients who consult fewer specialists prior to hospitalisation and of unplanned hospitalisations.

The results of this study confirm the importance of coordination between general practitioners and psychiatrists in improving the management of mental disorders.

Interview by Anna Marek