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Despite an increasing number of adults older than 60 years with psychiatric disorders, there are few studies on older patients in psychiatric emergencies and no European data. We aimed to describe the population of patients aged 60 years and older who presented to the main French psychiatric emergency centre and identify predictors of psychiatric hospitalization. This monocentric study included 300 consecutive patients aged 60 years and older. Patients presenting because of psychiatric emergencies were frequently female and lived autonomously. More than 40% had a history of at least one psychiatric hospitalization and 44% had consulted a psychiatrist in the previous 6 months. The most common reasons for consultation were depression, anxiety, sleep disorders and suicidal thoughts. Psychiatric disorders were mainly mood disorders; neurotic, stress-related and somatoform disorders; and schizophrenic, schizotypal and delusional disorders. Only 10% had a diagnosis of organic mental disorders. Overall, 39% of the patients were admitted to the psychiatric hospital. Factors predicting hospitalization were a history of psychiatric hospitalization, suicidal thoughts and a diagnosis of a mood disorder or schizophrenia/schizotypal/delusional disorder. In conclusion, among people aged 60 years and older who consulted for psychiatric emergencies, 39% had to be hospitalized in psychiatry and only psychiatric factors influenced the decision to hospitalize. Our study highlights the need for further studies of older people in psychiatric emergencies in Europe, to anticipate the needs of this specific population and adapt multidisciplinary mental health care., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Pham-Scottez, Gallarda, Calvez, Silva, Barruel, Dauriac-Le Masson, Lahaye, Perquier, Sarazin and Gourevitch.)

Objectives: In France, a systematic control of compulsory psychiatric admissions has existed since the enactment of the law of July 5th 2011. The Court of Cassation clarified that the liberty and custody judges (JLD) cannot supersede the medical opinion described in the medical certificates. In 2015, the JLD ordered the release of 8.4 % of all compulsory psychiatric admissions. The goal was to compare the quality of medical certificates derived from judicial release based on medical grounds with non-released witnesses from the cohort of compulsory psychiatric admissions ordered in the Groupe Hospitalier Universitaire Paris Psychiatrie & Neurosciences (GHU-Paris) between November 1, 2017 and October 31, 2018., Methods: We included as cases all the medical certificates derived from judicial release based exclusively on medical grounds from the release cohort of the GHU-Paris from November 1, 2017 to October 31, 2018, concerning the systematic control 12 days after compulsory psychiatric admissions. A witness whose compulsory care had been maintained was matched according to the same judge, place and date of hearing, mode of compulsory care and site of hospitalization. Each certificate was analyzed according to a reading grid relating to the good decisions in matters of compulsory admission and medical certificates' redaction. An overall score, based on the description of the clinical and symptomatic evolution, the level of discernment, the capacity of consent and the mode of compulsory care was awarded to each certificate., Results: Seventeen release files were included in the comparative study. Globally, the clinical progression, psychiatric symptoms, level of consciousness and ability to consent did not differ in the two groups. The grade of quality of certificate was lower in case of withdrawal (2.92±1.08 VS 3.28±0.88, P=0.026). Psychiatric symptoms in "justifiable notice" (the last medical certificate prior to the judicial hearing) were less specified in case of withdrawal (58.8 % VS 94.1 %, P=0.015). Not describing any symptoms led to a 12.51 risk of withdrawal (95 % CI=[1.16; 135.19], P=0.038). Even with witness certificate, clinical progression was noticed in only 85.3 % of cases, in 89.3 % of psychiatric symptoms, in 68.0 % of level of consciousness and 80.0 % for the ability to consent., Conclusions: Judiciary releases of compulsory psychiatric admissions exclusively based on medical grounds are not arbitrarily decided by the JLD but are based on a failure to draw up medical certificates. Doctors must comply with a careful drafting of all medical certificates: description of symptoms, clinical course, level of consciousness and ability to consent. It is necessary to be attentive to judiciary releases based on medical grounds to evaluate and improve medical practices concerning the drafting of medical certificates., (Copyright © 2022 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Context : Nurses are regularly confronted with suicidal people. Their involvement is essential in the detection and prevention of suicide risk.Objectives : Through a literature review, we wanted to highlight the role of the advanced practice nurse by conducting specific training to improve nursing skills in the management of people with suicidal thoughts.Method : Our literature review was carried out according to the PRISMA recommendation criteria from several databases.Results : The review showed an improvement in confidence, attitudes, and nursing skills in assessing suicide risk. However, no long-term change in practice was demonstrated.Discussion : In France, a national training program on suicide risk prevention is implemented at the regional level by the Regional Health Agencies. At the same time, since 2019, Psychiatry and Mental Health has been part of the training program for advanced practice nurses.Conclusion : The advanced practice nurse is a central player in supporting teams in increasing their skills, particularly when conducting specific training.

The French psychiatric health system is not properly organized for managing the sense of urgency felt in critical situations that occur upstream from psychiatric health services, in "inappropriate" locations (e.g. home, street, work.), particularly for patients who are unwilling to cooperate and receive health care. Emergency services, police departments, or psychiatric teams - who should take charge? Families are distraught. The authors draw the line to propose a comprehensive and coherent model. Pressing emergencies require the intervention of emergency services, who may, when necessary, receive remote counsel from psychiatric health professionals. Other situations require a quick but delayed access to specialized care, including at-home care. With this comprehensive model, the authors address both a pre-hospital emergency occurring out of a dedicated sanitary place, as well as access to care for patients who are unwilling or partly unwilling to receive health care., (Copyright © 2020 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Since France was put into lockdown on 17 March 2020 in an unprecedented step to attempt to limit the spread of coronavirus, there has been a sharp fall in the number of psychiatric emergency admissions despite the COVID-19 pandemic which has increased stress levels. The first part of this study shows the reorganisation and adaptation of mental health services to meet the needs in the psychiatric department. The second part is a brief analysis of patient flows to CPOA and the presentation of different hypotheses explaining these disruptions during lockdown. Finally, this study discusses the facts of three clinical cases during this period., (© 2020 Published by Elsevier Masson SAS.)

Background: Migrants, and particularly asylum seekers, are at increased risk of psychiatric disorders in comparison with natives. At the same time, inequalities in access to mental health care are observed., Methods: In order to evaluate whether the Parisian public psychiatric system is optimally structured to meet the needs of this population, we examined data on mental health and service use considering three different levels: the global system treatment level, a psychiatric reception center, and mobile teams specializing in access to psychiatric care for asylum seekers., Results: We found higher treatment rates among migrants than among natives ( p < 0.001) but inequalities in pathways to care: more mandatory admissions (OR = 1.36, 95% CI: 1.02-1.80) and fewer specialized consultations (OR = 0.56, 95% CI: 0.38-0.81). We observed a mismatch between increased need and provision of care among migrants without stable housing or seeking asylum., Conclusions: Inequalities in the provision of care for migrants are observed in the Parisian public psychiatric system, particularly for those experiencing poor social and economic conditions. There is a need to facilitate access to mental health care and develop more tailored interventions to reduce discontinuity of care.

Objective: In France, a systematic control of compulsory psychiatric admissions has existed since the enactment of the law of 5 July 2011. In 2015, the judge of freedoms and detention ordered the withdrawal of 8.4 % of the compulsory psychiatric admissions. The aim of the study is to describe the grounds for judiciary withdrawals of compulsory admissions ordered in the groupe hospitalier universitaire paris psychiatrie & neurosciences (GHU-Paris) between November 1, 2017 and October 31, 2018., Methods: All of the withdrawal decisions adjudged during the mentioned period in the GHU-Paris were analysed following a specific framework. The main analysis deals with the classification of the "administrative", "medical", and "mixed" grounds. The secondary analysis looks at the fundamental facts affecting the judge of freedoms and detention's decision., Results: Of the 127 orders decided by 21 judges of freedoms and detention analysed in this study, the majority were part of the systematic control of compulsory psychiatric admissions (74.8 %) and were made through a referral procedure by the director's hospital (69.3 %). The main reasons for withdrawal decisions were "mixed" (52.9 %), among which were described: failure to respect time limit (20.2 %), failure to inform the patient (11.6 %), third party's proceeding (8.7 %) and lack of documents (8.7 %). "Medical" grounds account for 31.8 % of all grounds. More precisely, failure to respect the required elements for involuntary admissions in psychiatric services was the greatest subcategory (29.5 %). "Other" grounds represented 15.8 %. No "administrative" ground was found. Judges ordered 69.3 % withdrawals within 24 hours to allow community treatment orders to be put into place. In the centre hospitalier Sainte-Anne, 70.8 % of the 24 appeals quashed the first decision by the judge of freedoms and detention., Conclusion: Several reasons justify withdrawals of compulsory psychiatric admissions. Scrupulously respecting procedures and drafting psychiatric certificates might decrease the number of withdrawals., (Copyright © 2020 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Background: The French mental health law, first enacted on July 5, 2011, introduced the possibility of psychiatric commitment in case of extreme urgency (imminent peril - ASPPI). The decision of involuntary admission can then be made by the hospital director based on a medical certificate, without the need of a third party request. This procedure was intended to be applied on an exceptional basis, but its use is steadily increasing against the other types of involuntary care. Our study aimed at comparing the characteristics of patients who had received an indication for involuntary admission due to imminent peril (ASPPI) or at the request of a third party (ASPDT/u) in a psychiatric emergency ward, according to sociodemographic and clinical characteristics and regarding the potential implication of a third party., Methods: An observational study was conducted among patients from the Centre Psychiatrique d'Orientation et d'Accueil (CPOA), located at Sainte-Anne hospital in Paris, from August 1st to 31st, 2016., Results: One hundred and fifty patients with an indication for involuntary commitment were included, 101 of whom for ASPDT/u (67 %) and 49 for ASPPI (33 %). For more than half of the patients from the ASPPI group, a third party had been identified with (39 %) or without (17 %) contact information. Compared to ASPDT/u patients, ASPPI individuals were more socially vulnerable, showed more negligence, and had a lower mean functioning score. The indication for ASPPI status was also associated with behavioural quirks, prior psychiatric hospitalization (especially as an ASPPI patient) and with the diagnosis of chronic psychosis instead of mood disorder., Conclusion: Our exploratory results help to better understand how the ASPPI procedure is used in psychiatric emergency wards six years after enactment of the law. They highlight the differences between ASPPI patients and ASPDT/u and raise ethical issues regarding involuntary psychiatric care., (Copyright © 2019 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Emergency psychiatric units are receiving more and more foreign unaccompanied minors: for many of these young people it is their first contact with psychiatric services. This context of crisis crystallises the administrative and legal paradoxes at work in the support of these youngsters. Coordination between emergency care, statutory bodies and community-based care enables stability to be established while the care project is being set up., (Copyright © 2019. Published by Elsevier Masson SAS.)

Governments and nonprofits routinely partner to launch place-based initiatives in distressed neighborhoods with the goal of stabilizing real estate markets, reclaiming vacant properties, abating public nuisances, and reducing crime. Public health impacts and outcomes are rarely the major policy drivers in the design and implementation of these neighborhood scale initiatives. In this article, we examine recent Health Impact Assessments in Baltimore, Maryland and Memphis, Tennessee to show how public health concepts, principles, and practices can be infused into existing and new programs and policies, and how public health programs can help to improve population health by addressing the upstream social determinants of health. We provide a portfolio of ideas and practices to bridge this classic divide of housing and health policy.

Background: On July 5, 2011, France introduced a law permitting the involuntary admission of patients considered to be in "imminent danger" into psychiatric care without the consent of the family. This is known as "admission en soins psychiatriques pour péril imminent"(ASPPI). ASPPI authorizes all physicians to hospitalize a patient without his or her consent nor the consent of a third party. This differs from previous measures as only one certificate is needed. The law also requires involuntarily admitted patients to present themselves before a judge specialized in Liberties and Detentions (juge des libertés et des détentions), 12 days following their admission. Although there has been an increase in the number of ASPPI admissions when compared to other types of involuntary admission, patients admitted by ASPPI have been hospitalized for a shorter time than others. Some authors, however, have pointed out that decision criteria are frequently interpreted in a loose manner by physicians. This study was conducted at Sainte Anne hospital in Paris., Objective: This study tried to determine if there were different clinical and non-clinical characteristics associated with the length of hospitalization under ASPPI., Methods: This study analyzed all administrative files for patients admitted under ASPPI from January 1, 2015 to December 31, 2015. These files contained the medical certificates and the court orders. The sample was split into two groups: patients hospitalized for a shorter stay and who did not present themselves to the judge and patients hospitalized for a longer stay and who did present themselves to the judge. The certificates were analyzed with a criteria grid, which includes clinical and non-clinical items. Clinical items were taken from the French High Authority of Health (Haute Autorité de Santé) 2005 recommendations. These include suicidal risk, risk to others, drug abuse, delusions or hallucinations, mood disorder and lack of selfcare. Non-clinical items include other information found in the certificate and sociodemographic information found in the administrative file., Results: Among the 250 certificates analyzed, 172 (68.8%) were associated with a long stay and 78 (31.2%) with a short stay. A bivariate analysis found no significant differences between the two groups for non-clinical characteristics and for drug abuse and mood disorder. When no suicidal risk was present, the stay was short in 21% of the certificates and long for 79%. When a suicidal risk was present the stay was short in 43% of the certificates and long for 57% (P=0.0002). When a risk to others was present the stay was short for 19% of the certificates and long for 81% (P=0.003). When delusions and hallucinations were present the stay was short in 15% of the certificates and long in 85 % (P=5×10e -14 ). When a lack of selfcare was present the stay was short in 10% of the certificates and long for 90% (P=0.01)., Conclusion: This study identified two types of situations linked with the length of hospitalization for patients under ASPPI. In one situation, associated with a longer stay, we found acute psychiatric disorders exhibited by more delusions, hallucinations, drug abuse, and lack of selfcare. In the second situation, associated with a shorter stay, this study found more episodic situations with suicidal risk. This study suggests that some involuntary admissions could be avoided if physicians could monitor episodic situations in appropriate structures. Moreover the criteria grid we used in this study should be validated to further analyze the quality of the certificates in order to lead to more precise recommendations., (Copyright © 2017 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Relevance of hospitalization in addictologic care. Curing drug addictions requires long-term, mostly ambulatory, care. Regardless, hospitalization may be pertinent in certain situations. In emergency situations, it is pertinent mainly for psychiatric or somatic considerations, as a result of complications or intricacies (hospitalization in a psychiatric unit, however, either free or compulsory, cannot be prescribed until an acute intoxication has subsided). As a pre-programmed medical decision, a stay in a sanitary or a medico-social setting may constitute a milestone in withdrawal or post-withdrawal care. Hospital stay may create distance from drugs or from the failing supporting environment, particularly when the patient's history includes specific debilitating past incidents, failures in ambulatory care, or post-withdrawal complications., Competing Interests: A.-K. Trebalag, N. Danon et R. Gourevitch déclarent n’avoir aucun lien d’intérêts. C. Lucet déclare avoir participé à des colloques pour Indivior et avoir été prise en charge lors de congrès par Lundbeck.

Objectives: Driven by the growth of high deductibles and price transparency initiatives, patients are being encouraged to search for prices before seeking care, yet few do so. To understand why this is the case, we interviewed individuals who were offered access to a widely used price transparency website through their employer., Study Design: Qualitative interviews., Methods: We interviewed individuals enrolled in a preferred provider organization product through their health plan about their experience using the price transparency tool (if they had done so), their past medical experiences, and their opinions on shopping for care. All interviews were transcribed and manually coded using a thematic coding guide., Results: In general, respondents expressed frustration with healthcare costs and had a positive opinion of the idea of price shopping in theory, but 2 sets of barriers limited their ability to do so in reality. The first was the salience of searching for price information. For example, respondents recognized that due to their health plan benefits design, they would not save money by switching to a lower-cost provider. Second, other factors were more important than price for respondents when choosing a provider, including quality and loyalty to current providers., Conclusions: We found a disconnect between respondents' enthusiasm for price shopping and their reported use of a price transparency tool to shop for care. However, many did find the tool useful for other purposes, including checking their claims history. Addressing the barriers to price shopping identified by respondents can help inform ongoing and future price transparency initiatives.

Changes in insurance coverage over time, or "churning," may have adverse consequences, but there has been little evidence on churning since implementation of the major coverage expansions in the Affordable Care Act (ACA) in 2014. We explored the frequency and implications of churning through surveying 3,011 low-income adults in Kentucky, which used a traditional expansion of Medicaid; Arkansas, which chose a "private option" expansion that enrolled beneficiaries in private Marketplace plans; and Texas, which opted not to expand. We also compared 2015 churning rates in these states to survey data from 2013, before the coverage expansions. Nearly 25 percent of respondents in 2015 changed coverage during the previous twelve months-a rate lower than some previous predictions. We did not find significantly different churning rates in the three states over time. Common causes of churning were job-related changes and loss of eligibility for Medicaid or Marketplace subsidies. Churning was associated with disruptions in physician care and medication adherence, increased emergency department use, and worsening self-reported quality of care and health status. Even churning without gaps in coverage had negative effects. Churning remains a challenge for many Americans, and policies are needed to reduce its frequency and mitigate its negative impacts., (Project HOPE—The People-to-People Health Foundation, Inc.)

Objective: To examine the criminological circumstances of homicide in a group of French murderers with and without major mental disorders (MMD) stratified by the perpetrator's gender., Methods: Sociodemographic, clinical, and criminological variables were collected from the psychiatric expert reports of 210 cases of homicide heard at the High Court of Angers, France. Murderers were categorized according to MMD diagnosis and gender., Results: Among 210 murderers, 17.6% (n = 37) had a MMD (20% of the female perpetrators). Logistic regression models showed that being a murderer with a MMD was associated with younger age (adjusted Odds Ratio OR = 1.03, P = 0.034), high school education (OR = 2.48, P = 0.036), previous use of psychiatric services (OR = 4.75, P = 0.003), alcohol intoxication (OR = 2.71, P = 0.027), and delusional state (OR = 3.96, P = 0.002) at the time of the homicide. Multiple correspondence analyses showed that female murderers with a MMD were more prone to have depression and to use drowning as a method than those without a MMD, and that male murderers with a MMD more often had a high school education and delusional beliefs at the time of the homicide than those without a MMD., Conclusion: Specific profiles of criminological circumstances of homicide could help to explore the risk of homicide in female and male patients with a MMD., (Copyright © 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

The risk/benefit ratio weighs up on the one hand the expected advantages and on the other the potential risks of a procedure. It is taken into consideration with every therapeutic decision, whether it concerns medication-based treatments, psychotherapy or any other type of treatment. The ethical dimension is a critical element which must be taken into account during team deliberations, whenever these are possible., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objective: Consensus that enhanced teamwork is necessary for efficient and effective primary care delivery is growing. We sought to identify how electronic health records (EHRs) facilitate and pose challenges to primary care teams as well as how practices are overcoming these challenges., Methods: Practices in this qualitative study were selected from those recognized as patient-centered medical homes via the National Committee for Quality Assurance 2011 tool, which included a section on practice teamwork. We interviewed 63 respondents, ranging from physicians to front-desk staff, from 27 primary care practices ranging in size, type, geography, and population size., Results: EHRs were found to facilitate communication and task delegation in primary care teams through instant messaging, task management software, and the ability to create evidence-based templates for symptom-specific data collection from patients by medical assistants and nurses (which can offload work from physicians). Areas where respondents felt that electronic medical record EHR functionalities were weakest and posed challenges to teamwork included the lack of integrated care manager software and care plans in EHRs, poor practice registry functionality and interoperability, and inadequate ease of tracking patient data in the EHR over time., Discussion: Practices developed solutions for some of the challenges they faced when attempting to use EHRs to support teamwork but wanted more permanent vendor and policy solutions for other challenges., Conclusions: EHR vendors in the United States need to work alongside practicing primary care teams to create more clinically useful EHRs that support dynamic care plans, integrated care management software, more functional and interoperable practice registries, and greater ease of data tracking over time., (© The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association.)

Background: There is emerging consensus that enhanced inter-professional teamwork is necessary for the effective and efficient delivery of primary care, but there is less practical information specific to primary care available to guide practices on how to better work as teams., Objective: The purpose of this study was to describe how primary care practices have overcome challenges to providing team-based primary care and the implications for care delivery and policy., Approach: Practices for this qualitative study were selected from those recognized as patient-centered medical homes (PCMHs) via the most recent National Committee for Quality Assurance PCMH tool, which included a domain on practice teamwork., Participants: Sixty-three respondents, ranging from physicians to front-desk staff, were interviewed from May through December of 2013. Practice respondents came from 27 primary care practices ranging in size, type, geography, and population served., Key Results: Practices emphasizing teamwork overcame common challenges through the incremental delegation of non-clinical tasks away from physicians. The roles of medical assistants and nurses are expanding to include template-guided information collection from patients prior to the physician office visit as well as many other tasks. The inclusion of staff input in care workflow redesign and the use of data to demonstrate how team care process changes improved patient care were helpful in gaining staff buy-in. Team "huddles" guided by pre-visit planning were reported to assist in role delegation, consistency of information collected from patients, and structured communication among team members. Nurse care managers were found to be important team members in working with patients and their physicians on care plan design and execution. Most practices had not participated in formal teamwork training, but respondents expressed a desire for training for key team members, particularly if they could access it on-site (e.g., via practice coaches or the Internet)., Conclusions: Participants who adopted new forms of delegation and care processes using teamwork approaches, and who were supported with resources, system support, and data feedback, reported improved provider satisfaction and productivity. There appears to be a need for more on-site teamwork training.