3 questions to… Coralie Gandré, Delphine Moreau, Ibtissem Ben Dridi and Anna-Veera Seppänen, following the publication of the Issues in Health Economics (281), September 2023: "Barriers, Levers, and Contrasts in Complex Care Pathways: the Case of Cancer amongst People Living with a Severe Mental Illness", written in collaboration with the Canopée Consortium
The example of cancer is particularly relevant to study in people living with a severe mental illness (SMI) as it is one of their most common causes of death, just as for the general population, except that death occurs earlier for them and their mortality rate is twice as high. While this is often attributed to a higher incidence of cancer in these people, this has not been demonstrated in international literature, which generally shows an incidence rate similar to, or even lower than, that of the general population - even if biases of under-screening of cancers may exist. This led us to analyse the potential role of factors involved after the onset of cancer, during the care pathways, by using a dual qualitative and quantitative approach as part of a multidisciplinary research consortium.
We show that people with SMI have, on average, less access to recommended diagnostic tests, less timeliness between diagnosis and treatments, increased use of invasive treatments and less intensive treatment combinations, while such combinations have the potential to increase the odds of favourable outcomes and to reduce the odds of cancer recurrence. Less post-treatment follow-up was also found amongst people with SMI. These results were observed even in comparison with controls who had no pre-existing SMI, matched on age, local area (département) of residence, type of cancer at presentation and the year of its incidence, and after adjustment for other clinical and socio-economic characteristics, and place of treatment.
The qualitative approach showed that the differences identified in the care pathways, objectified in the quantitative approach, could be linked with adaptations to the specific circumstances of individuals and their choices, but also with preconceptions about the difficulties associated with mental illness and inadequate care organization, which could be improved by dedicated public policies.
Nevertheless, it is necessary to avoid any temptation to unduly homogenise the group of persons living with SMI, by underlining the heterogeneity of the situations experienced by persons living with such disorders, according to their available resources (social integration, stabilization of the mental disorder, presence of somatic care teams in psychiatry, presence of a type of organisation aimed at coordinating complex care pathways…).
These findings already point to potential solutions, by supporting the general follow-up of persons with SMI, going beyond the existing fragmentation of care. They could be based on recent developments that are underway in France - for example, the emergence of territorial networks for mental health (Projets territoriaux de santé mentale, PTSM) that aim to bring together all the actors involved in the care, including physical healthcare, of people living with a mental illness on the local level. They could also draw inspiration from foreign examples - based on the concept of "reverse integrated care", which aims to provide people with SMI with access to physical healthcare coordinated in mental health settings, taking into account that this is often their main entry point into the healthcare system.
The National Mental Health and Psychiatry Roadmap supports the development of multiprofessional primary care teams in specialized mental health facilities, but the scope of related measures remains limited. Moreover, the presence of psychiatrists or health professionals dedicated to complex situations in general care departments (or, in this case, in oncology) could also improve healthcare access for specific population groups, beyond those identified as having a mental disorder who are facing a combination of difficulties (physical or mental comorbidity, social isolation, precarity, depression in reaction to cancer, difficulties in treatment understanding, etc.). Finally, de-stigmatisation initiatives are essential: we show that, for some people with SMI, dealing with cancer enables the person to find a new social and more legitimate role, in contrast with prior experiences of stigmatisation associated with their mental illness - which says a lot about the difficulties they experience every day.