La Croix-L’Hebdo : What is the role of the national psychiatry commission that you chair?
Michel Lejoyeux: The commission has two ideas. The first is for this body to be as representative as possible of the psychiatric world. We do not do psychiatry alone, and not just between doctors. The commission therefore brings together academics, hospital practitioners, psychologists, nurses, administrators, unions, but also medico-social professions and, of course, representatives of families and patients. The plenary committee has 55 members. That’s a lot, but if we want to do reasonable, responsible psychiatry, that’s what is needed.
→ LARGE FORMAT. “Citizen psychiatry”, to treat differently
The second idea of the commission is to move forward on certain thematic axes with working groups. In particular, we have one on walk-in care and emergencies – we have progress to make in this area – ethics, links with families, psychiatry and medicine – the life expectancy of psychiatric patients is still well below the national average -, child psychiatry, adolescent psychiatry, elderly psychiatry, research and innovative treatments … We will then develop the foundations of these issues.
What do you expect from these days?
ML: Already, I’m glad they exist! This shows that psychiatry and mental health are not side subjects or taboos. I think there was, on that side, a Covid effect: we wondered how the French were doing. We put a focus on a dimension that often tends to be overlooked.
Cancer or a heart attack are ailments clearly identified by the general public. While sanity, it retains a fuzzy side, almost poetic, of the style “But, finally, aren’t we all a little crazy? “. You would never say that of a cancer patient! However, when we talk about the health of a country, the “mental health” dimension is important.
→ ARCHIVE. Psychiatry in crisis
It is said that psychiatry is a sector of medicine particularly in crisis …
ML: There are a lot of different psychiatries. We cannot make the same diagnosis and provide the same solutions everywhere. There is no “one” magic solution for both the management of autistic people and that of depression in the elderly. I believe that the first thing is to heal society from the denial of mental suffering.
Are patients treated in psychiatry “real” patients and can they be treated? To these two questions, I answer yes. It is therefore first of all a matter of fighting against the folkloric image from which mental illness still too widely suffers. This implies, for example, that psychiatric emergencies are as clean and tidy as any other emergency department.
→ EXPLANATION. Psychiatrists warn about the suicidal “contagion”
I also believe that we must reintegrate psychiatry into medicine: there has been a real revolution concerning antidepressants or psychotropic drugs, but it has been less spectacular than that concerning cancer treatments, for example. However, before the age of 40, suicide is the leading cause of death in France.
At the mental health center where we did our report, there has been zero contention over the past year. Doing without restraint seem possible and generalizable to you?
ML: I note all the same that the restraint is the only medical device on which the Constitutional Council has given its opinion. He didn’t do it on intubation, for example! Having said that, of course the restraint must be questionable. To consider it trivial would be very disturbing. But neither can it be crossed out with a stroke of the pen.
Avoiding it as much as possible is a laudable and sought-after goal, but if you asked me to implement this practice in my department by the end of the year, I would answer you that it is not tenable. This requires a major organizational change and more staff.
Is the “ambulatory shift”, aimed at shortening or even avoiding hospital stays in favor of structures and care close to the patient’s home, is it the solution?
ML: I don’t like that word “ambulatory shift”. Of course, I am for outpatient care, but there are an incompressible number of situations where hospitalization is required. With the outpatient shift, you also do away with severe cases in nature. Go take a walk this evening to the psychiatric emergencies of Bichat and tell them about the ambulatory shift! It seems important to me to remember that the hospital is the only place that is open to everyone, all the time.
Obviously, whenever outpatient is possible, it is preferable. But it isn’t all the time. There are a number of cases in which one cannot be dogmatic about the outpatient clinic. It also seems to me that this famous ambulatory shift made it possible to disguise the closure of a certain number of beds. Sometimes, at the end of care, we do not have beds for teenagers who have just attempted suicide. Now, this is what a discipline so tragically under-equipped with beds can give: suicidal young people in the street.
Lack of beds but also lack of applicants … Isn’t there also a problem of recruitment at the time of studies?
ML: Medical demography is a major subject. For decades, we have reduced the supply of health care in the hope of reducing health care costs. As for the attractiveness of psychiatry, it is effectively less than that of other medical disciplines. In France, we have a boarding school with a very biological, very medical dimension. I think that psychiatry will attract more students if it is anchored more in the medical field, that it does not close itself on a field which is purely “of the soul”.
However, when you have already done three years very focused on biology and you are told “you are going to behave”, students can feel a bit like changing jobs. You are right, psychiatry is in the last specialties chosen with occupational medicine: because they appear to be the least medical. However, to make better psychiatry, we need more internships!
How do you see the future of the discipline taking shape?
ML: The first thing: the heaviest sick cases will not go away. There is a hard core of serious patients that will always remain. And I believe this is an important message to send to those in power. The treatments may well be more refined, new methods emerge, this proportion of patients constitutes the present but also the future of psychiatry.
The second thing that the Covid brought to light in particular: psychiatry must better manage the notion of crisis. We know that in the future, the expression of mental illness will be more in the form of an explosion. Because the pressure increases, because this is the type of pathology for which we will consult as late as possible. Psychiatry must therefore organize itself to provide a structured response to this “crisis mode”.
Take neurologists with strokes: faced with this disease, they have been able to develop a chain of care and response that intervenes within the hour. We must do the same and not stay in the mantra. Finally, there is innovation: we have made and are making considerable progress in brain stimulation, sleep, pharmacological research and institutional arrangements. It therefore seems important to me to remember that we are a discipline which innovates but which also needs sectorization. But this is threatened …
Why is sectorization important?
ML: Because it allows everyone in France to have, depending on their place of residence, a place of consultation and hospitalization assigned to them. In our country, no one can be refused treatment. It is a cumbersome, expensive device, also less glamorous than the latest therapy in vogue, but sector psychiatry must be defended as a collective health good. It is a real republican achievement.