PROPOSALS OF THE FRENCH FEDERATION OF PSYCHIATRY

for the
GREEN PAPER
Improving the mental health of the population :
Towards a strategy on mental health for the European Union

The French Federation of Psychiatry (FFP), which gathers all the scientific societies of the discipline, is particularly concerned by the public consultation initiated by the European Commission in connection with mental health. That is the reason why the  FFP decided to take up this issue although French authorities did not ask it. 

Therefore, the FFP took part a public meeting organized by the House of Europe and organized a debate in its board and among its member-societies. After this internal consultation, the FFP submits here its remarks and proposals according to the questions asked in the Green Paper.  

1.	How relevant is the mental health of the population for the EU's strategic policy objectives, as detailed in section 1 ?

The FFP recommends to look very carefully for mental health indicators and suggests to define them in positive terms. These indicators must serve an organization improving mental health by better living conditions (i.e. educational, cultural and sanitary conditions). This presupposes to make access to social benefits easier and to take additional measures for the populations in  great need or facing difficulties to get welfare payments. 

The prevention, when it deviates from a positive vision for the search of indicators, must wonder about the negative and deleterious consequences of actions only focused on the eradication of the symptoms without considering their conditions of emergence.  

Mental health integrates sanitary and social policies in order to develop a prevention which takes into account the various factors contributing to its own preservation and preventing the outbreak of what would be the contrary of mental health, i.e. mental illnesses. A mental health policy includes primary, secondary and tertiary actions of prevention. Each of these three levels has to be considered for the individual, the family and the community. 

Primary prevention includes the assessment of the needs for care, the early prevention of  the disorders, the development of the answers to these needs and the conditions of access to medical treatments far beyond a non-specific social policy. 

Secondary and tertiary preventions cover the purposes of French community psychiatry. In this context, the mental health policy gives all its place to the approach of the mental disorders and of their consequences (handicaps, disabilities, social disadvantages). 

The FFP gives a lot of importance to the continuity between the various stages of mental health and to the articulations between that their respective actors and systems. 

The FFP wonders why no link is made between mental health, such as it is explained in the Green Paper, and psychiatry. 

The FFP gives the utmost importance to the continuity that must exist between mental health and psychiatry ; it requires that this issue appears in the text.

Primary prevention in mental health is more on the side of the social construction : prevention of social inequalities, involving the need for care and the accessibility to the health system. On the other side, secondary and tertiary preventions are strongly linked to the health system, the accessibility to the treatments (relying itself on the network of outpatient and inpatient equipments), with taking into account the social background. One and the other have to answer to the individual aspect and the population aspect. Continuity between these stages is not systematic but is an important issue that has to be considered.     

Prevention should not reduce the means given to the treatments which must be preserved and increased at the European level. 

2.	Would the development of a comprehensive EU-strategy on mental health add value to the existing and envisaged actions ans does section 5 propose adequate priorities ?

Prevention is to be promoted while preserving and improving a high quality and accessible care system. 

The FFP expects the term « mental ill health » not  to be maintained. The FFP thinks better to preserve the concept of mental health besides the concepts of mental illness and psychopathologic symptoms.  

The FFP favours a EU programme supporting clinical research in psychiatry.  

The FFP alerts the European Commission on the risk of abandonment of sufficient means dedicated to psychiatry by favouring prevention in the way of targeted programmes chosen under the pressure of current events or political lobbying without any obvious relevance of the need of the populations. 

Prevention is therefore to be promoted while supporting at the same time a high quality and accessible care system. 

The confrontation and the harmonization of some measures are a possible way as far as a specific approach remains possible within each Member-State. 

The FFP doesn't support the concept of « mental ill health » which is a source of confusion and of possible discrimination. 

Clinical research has to become a main line. 

3.	Are the initiatives proposed in sections 6 and 7 appropriate to support the coordination between Member-States, to promote the integration of the mental health in the health and non-health policies and stakeholder actions, and to better liaise research and policy on mental health aspects ? 

We think that the Green Paper doesn't consider the full scope of mental health programmes which should include in every State-Member a wilful policy to reduce social inequalities and focus on the improvement of the living and health conditions of the citizens. 

The FFP regrets that the concept of social link is never mentioned in the Green Paper for it is an essential determinant in the emergence of several disorders and sometime constitutive of them. The FFP requires that the treatment of the social link be taken up. Any social policy has to take into account this possibility of tying durable links. Such a policy should emphasize the importance of the neighbourhood, of public places to share activities, with the benevolent presence of the authorities and an easy access to psychological support. 

The FFP warns the European Commission against the transformation of symptoms into disorders under the frequent pressure of various lobbies, either moved by financial purposes or only looking for the acknowledgment of some entity. 

The FFP reminds that only a clinical approach during a face to face meeting with the patient enables the diagnosis of an illness. Other methods allow to detect some tendencies but not specific needs. 

The FFP wishes that violence as a behavioural expression is not  used as an indicator.

The FFP thinks that the choice of the techniques of treatment should not be specified in this  document. 

The FFP wishes that the persons suffering of severe and long term disorders not be forgotten in the recommendations. Rehabilitation and deinstitutionalization are emphasized and linked with freedom and dignity : these are ethical positions the FFP strongly supports. The FFP requires a great vigilance so that the desinstitutionalisation does not join a disappearance of the medical and social answers adapted to this group. Failing this, these populations would be deprived of the specific treatments they need and abandoned to social homes or to their families, if not rejected into the streets with the obvious risk of a very dangerous physical and mental degradation. The FFP requests that solidarity, source of structuring links between individuals, remain a main line in the recommendations. The FFP recommends to support a prevention and care policy : each of these two aspects should not be unlinked from the other. 

The future parents, children and teenagers are to be psychologically supported. Mental suffering being often characteristic in teenagers and young adults, the distinction between the normal one and the pathological one is very difficult to assess. This is why prevention presupposes the development of child-psychiatry. 

The FFP recommends to set an accessible and free care system, as well as programmes for the detection of disorders and programmes accompanying the individuals towards the appropriate treatments, particularly for teenagers and young adults. Formal links between governmental or non-governmental rehabilitation systems and the psychiatric care system should also be established.   

The FFP wishes that sanitary psychiatric answers be supported, elaborated and made appropriate for the populations of prisoners. Sufficient means must be given to fight against any discrimination in the access to the care. 

The FFP requests that a new paragraph be included in section 6 after 6-2. The title of this paragraph would be : « Improving access to psychiatric care by linking mental health and psychiatric care ».

The FFP requires that the necessity of sufficient means for the health system be mentioned.

About formation : Improving mental health in both aspects, prevention and treatment, relies on the training level of the people in charge of these fields., either medical or non-medical. This justifies a particular budgetary effort of the community, exchanges of information and circulation of the professionals in order to share their experience. The training of psychiatrists must be of high quality and relate to the whole extent of the field they have to assume : prevention, diagnosis, psychopathology (which integrates the formation to psychotherapy according to the programme elaborated by the FFP), ability to organize community care,  rehabilitation and research. 

The FFP recalls that the epidemiologic approach is a method to apprehend the requirements in mental health and the prevalence of mental illness. Nevertheless, the clinical expertise of the professionals involved in this field, relying on clinical assessments and the context of the patient’s characteristics, is equally essential and should not be forgotten in the analysis. The prevention in mental health requires a policy of reduction of the inequalities and improvement of the standard of living but also a processing of the social link. A high quality prevention should respect the continuity of care, which facilitates their access by a destigmatization of psychiatric illness and clarifies the various times from assistance to treatment, emphasizing their complementarity and not recommending to unlink the one from the other. 
The FFP requires an improvement of the access to the psychiatric care by facilitation of the articulation between mental health and psychiatric care. Sufficient means must be given to satisfy this. 

The FFP supports a policy aiming at developing psychiatry, including a specific answer for children, teenagers and older persons. The FFP is particularly worried by the lack of prevention and of care for the prisoners (as well as living conditions in prison). 

The formation of professionals in mental health requires means with a specific aspect allowing the attenuation of fears –  sometimes the rejection – of mentally ill persons.  

Paris, May 15th 2006