Anthony Mann, Delphine Capdevielle, Karen Ritchie, Jean-Philippe Boulenger, Joanna Norton, Isabelle Jaussent, Cindy Prudhomme, Michel David, Emmanuelle Rivoiron-Besset, Neuropsychiatrie : recherche épidémiologique et clinique (PSNREC), Université Montpellier 1 (UM1)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université de Montpellier (UM), Département de Médecine générale, Université Montpellier 1 (UM1)-Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier), Département de psychiatrie adulte, Centre Hospitalier Régional Universitaire [Montpellier] (CHRU Montpellier)-Hôpital La Colombière, Institute of Psychiatry, Institute of psychiatry, Queen Mary University of London (QMUL)-King‘s College London, The study was supported by a university hospital research grant from the Central Hospital, University of Montpellier, Montpellier, France., and Villebrun, Dominique
Since the middle of the last century, there has been a transition in almost all Western countries toward a policy of reduced periods of hospitalization for patients with severe mental illness. While initially not evidence based, a number of observational studies have suggested that patients returning to the community show better quality of life and have larger friendship networks, lower mortality rates, and reduced dependence on pharmacotherapies than those remaining in institutions.1 This policy assumes, however, that community care is well organized and places increasing burden in particular on primary caregivers. While there has been considerable research on community mental health care in general in preventing relapse, relatively little attention has been paid to the interface with general practitioners, although it is estimated that 25% of patients with psychosis lose all contact with mental health services and are followed and cared for entirely within general practice.2,3 Patients discharged from the hospital following a psychotic episode frequently discontinue medication and often have multiple pathologies as well as social and professional difficulties. Antipsychotic medication also has numerous side effects that require monitoring. Adequate medical follow-up therefore assumes not only knowledge of these disorders on the part of primary care practitioners, but also an efficient interface between hospital practitioners and primary caregivers at discharge. There are many studies on pathways to care in first-episode psychosis4–7 and general practitioner management of early psychosis.8–12 Few studies, however, have examined care pathways of specific patients13 and particularly the influence of length of hospital stay on postdischarge community care. In France, public psychiatric care is organized into sectors that cover well-defined geographical areas of approximately 70,000 inhabitants.14 Each sector is Clinical Points ♦There is a need for greater recognition of the role of the general practitioner in managing first-episode psychotic patients after hospital discharge, specifically for the management of psychiatric symptoms in the case of early discharge. ♦Communication between general practitioners and psychiatrists needs to be improved. responsible for providing inpatient and outpatient care. Care is largely hospital based, the amount provided at a community level being limited overall, although it varies widely from one sector to another depending on the care organization and internal policy. Psychiatrists have few guidelines and protocols to follow with managerial targets to meet, resulting in different care models working alongside. There are long appointment delays for consulting private psychiatrists, many of whom offer psychoanalytic therapy only.15–17 Although general practitioners are the main primary care providers, they are not actively integrated into the community mental health team and seldom receive referrals from psychiatric services. General practitioners work mainly alone with no ancillary staff and limited collaboration with specialists, especially hospital psychiatrists.18 Changes were introduced in 2004, with patients strongly encouraged to register with a general practitioner of their choice whose role it is to coordinate care and refer patients if necessary to specialists (all except ophthalmologists, gynecologists, pediatricians, and psychiatrists for those patients under 26 years old). Those who bypass general practitioner referral can be financially sanctioned with lower reimbursements.19,20 In France there is still considerable variation in length of stay; our previous findings (D.C., unpublished data, 2011) confirm this, with length of stay varying from 4 to 371 days for first-episode psychotic patients within the same hospital. Our results suggest that this variation is not determined by clinical differences in patients at admission but rather by changes in medication during hospitalization, symptomatology at discharge (less negative but more positive symptoms for short-stay patients), and ward policy (length of stay being significantly shorter in services where the head psychiatrist declared being in priori more in favor of shorter [≤30 days] than longer stays [>30 days]). With regard to care plans at discharge, one-third (32.5%) of patients with a short length of stay were “referred” to care by a private psychiatrist compared to 12.5% of long length of stay patients; the remaining patients received community care or day hospital care (52.5% and 15%, respectively, for short length of stay patients; 44.4% and 43.1%, respectively, for long length of stay patients). Length of stay may also have an impact on the role of the general practitioner in providing postdischarge care and on the collaboration between general practitioners and specialists. However, there are to our knowledge no studies specifically on this topic. Furthermore, findings on service use specific to one health care organization are difficult to extrapolate to other settings. The aim of the present study was thus to describe the role of the general practitioner in providing postdischarge care to patients with first-episode psychosis in terms of frequency and type of consultation and the extent of collaboration with hospital-based specialist services. We then sought to determine whether decreasing length of stay was accompanied by a modification in this role. Although community psychiatric care remains largely underdeveloped and hospital based in France,14 it was hypothesized that short-stay patients would be more likely to consult their general practitioner after discharge than long-stay patients, most of whom stay “within” the system.