Psychiatrie sous double contrainte, enjeux de la planification en santé mentale [Psychiatry under double bind, issue of the planification in mental health]

Given the important modifications of the "Loi sur l'Assurance maladie (LAMal)", this article gives a contribution to the hospital planification by identifying the main factors that have determined the current organisation of the psychiatric care network. We notice a gap between the orientations of these networks and the funding scheme forecast in the framework of the LAMal. In order to preserve the progressions of these last years and to avoid the negative effects of a too restrictive funding act for the assignment of the public psychiatry, the planification must result in a consensus between the state, the insurances and the multiple actors of the mental health. Otherwise, this will be done to the detriment of the activities of secondary prevention, of coordination in the network, of support to the natural helpers, and of intervention to the vulnerable populations.

Social and medical vulnerability factors of emergency department frequent users in a universal health insurance system.

OBJECTIVES: The objectives were to identify the social and medical factors associated with emergency department (ED) frequent use and to determine if frequent users were more likely to have a combination of these factors in a universal health insurance system. METHODS: This was a retrospective chart review case-control study comparing randomized samples of frequent users and nonfrequent users at the Lausanne University Hospital, Switzerland. The authors defined frequent users as patients with four or more ED visits within the previous 12 months. Adult patients who visited the ED between April 2008 and March 2009 (study period) were included, and patients leaving the ED without medical discharge were excluded. For each patient, the first ED electronic record within the study period was considered for data extraction. Along with basic demographics, variables of interest included social (employment or housing status) and medical (ED primary diagnosis) characteristics. Significant social and medical factors were used to construct a logistic regression model, to determine factors associated with frequent ED use. In addition, comparison of the combination of social and medical factors was examined. RESULTS: A total of 359 of 1,591 frequent and 360 of 34,263 nonfrequent users were selected. Frequent users accounted for less than a 20th of all ED patients (4.4%), but for 12.1% of all visits (5,813 of 48,117), with a maximum of 73 ED visits. No difference in terms of age or sex occurred, but more frequent users had a nationality other than Swiss or European (n = 117 [32.6%] vs. n = 83 [23.1%], p = 0.003). Adjusted multivariate analysis showed that social and specific medical vulnerability factors most increased the risk of frequent ED use: being under guardianship (adjusted odds ratio [OR] = 15.8; 95% confidence interval [CI] = 1.7 to 147.3), living closer to the ED (adjusted OR = 4.6; 95% CI = 2.8 to 7.6), being uninsured (adjusted OR = 2.5; 95% CI = 1.1 to 5.8), being unemployed or dependent on government welfare (adjusted OR = 2.1; 95% CI = 1.3 to 3.4), the number of psychiatric hospitalizations (adjusted OR = 4.6; 95% CI = 1.5 to 14.1), and the use of five or more clinical departments over 12 months (adjusted OR = 4.5; 95% CI = 2.5 to 8.1). Having two of four social factors increased the odds of frequent ED use (adjusted = OR 5.4; 95% CI = 2.9 to 9.9), and similar results were found for medical factors (adjusted OR = 7.9; 95% CI = 4.6 to 13.4). A combination of social and medical factors was markedly associated with ED frequent use, as frequent users were 10 times more likely to have three of them (on a total of eight factors; 95% CI = 5.1 to 19.6). CONCLUSIONS: Frequent users accounted for a moderate proportion of visits at the Lausanne ED. Social and medical vulnerability factors were associated with frequent ED use. In addition, frequent users were more likely to have both social and medical vulnerabilities than were other patients. Case management strategies might address the vulnerability factors of frequent users to prevent inequities in health care and related costs.

Le médecin face aux inégalités sociales de santé: quel pouvoir d'action [General practitioners facing social inequalities in health: which power to act?].

The link between social inequalities and health has been known for many years, as attested by Villermé's work on the "mental and physical status of the working class" (1840). We have more and more insight into the nature of this relationship, which embraces not only material deprivation, but also psychological mechanisms related to social and interpersonal problems. Defining our possible role as physicians to fight against these inequalities has become a public health priority. Instruments and leads, which are now available to help us in our daily practice, are presented here.

Carie du biberon: un caillou dans la chaussure de la santé [The impact of childhood caries].

The early childhood caries affect primary dentition before the eruption of the permanent teeth. It is set to extended use of a bottle containing fermentable carbohydrates. The early childhood caries is not only a dental disease: it is a social, cultural and behavioral condition that reflects the practices and beliefs around the child. Swiss data indicate that in aged 2 children, one of for could be affected by this devastating oral disease, mainly in vulnerable populations. The primary care physician has an important role in the screening of preschool children, in determining the risk level of the child for early childhood caries. Physicians can advise families, especially pregnant women, about preventive measures and behavior, leading to a dramatic drop of early childhood caries prevalence.

Predictors of death among patients who completed tuberculosis treatment: a population-based cohort study.

Background: Mortality among patients who complete tuberculosis (TB) treatment is still high among vulnerable populations. The objective of the study was to identify the probability of death and its predictive factors in a cohort of successfully treated TB patients. Methods: A population-based retrospective longitudinal study was performed in Barcelona, Spain. All patients who successfully completed TB treatment with culture-confirmation and available drug susceptibility testing between 1995 1997 were retrospectively followed-up until December 31, 2005 by the Barcelona TB Control Program. Socio-demographic, clinical, microbiological and treatment variables were examined. Mortality, TB Program and AIDS registries were reviewed. Kaplan-Meier and a Cox regression methods with time-dependent covariates were used for the survival analysis, calculating the hazard ratio (HR) with 95% confidence intervals (CI). Results: Among the 762 included patients, the median age was 36 years, 520 (68.2%) were male, 178 (23.4%) HIV-infected, and 208 (27.3%) were alcohol abusers. Of the 134 (17.6%) injecting drug users (IDU), 123 (91.8%) were HIV-infected. A total of 30 (3.9%) recurrences and 173 deaths (22.7%) occurred (mortality rate: 3.4/100 person-years of follow-up). The predictors of death were: age between 4160 years old (HR: 3.5; CI:2.15.7), age greater than 60 years (HR: 14.6; CI:8.924), alcohol abuse (HR: 1.7; CI:1.22.4) and HIV-infected IDU (HR: 7.9; CI:4.713.3). Conclusions: The mortality rate among TB patients who completed treatment is associated with vulnerable populations such as the elderly, alcohol abusers, and HIV-infected IDU. We therefore need to fight against poverty, and promote and develop interventions and social policies directed towards these populations to improve their survival.

Influence of socioeconomic factors on delays, management and outcome amongst patients with acute myocardial infarction undergoing primary percutaneous coronary intervention.

The outcome after primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI) is strongly affected by time delays. In this study, we sought to identify the impact of specific socioeconomic factors on time delays, subsequent STEMI management and outcomes in STEMI patients undergoing pPCI, who came from a well-defined region of the French part of Switzerland. A total of 402 consecutive patients undergoing pPCI for STEMI in a large tertiary hospital were retrospectively studied. Symptom-to-first-medical-contact time was analysed for the following socioeconomic factors: level of education, origin and marital status. Main exclusion criteria were: time delay beyond 12 hours, previous treatment with fibrinolytic agents or patients immediately referred for coronary artery bypass graft surgery. Therefore, 222 patients were finally included. At 1 year, there was no difference in mortality between the different socioeconomic groups. Furthermore, there was no difference in management characteristics between them. Symptom-to-first-medical-contact time was significantly longer for patients with a low level of education, Swiss citizens and unmarried patients, with median differences of 23 minutes, 18 minutes and 13 minutes, respectively (p <0.05). Nevertheless, no difference was found regarding in-hospital management and clinical outcome. This study demonstrates that symptom-to-first-medical-contact time is longer amongst people with a lower educational level, Swiss citizens and unmarried people. Because of the low mortality rate in general, these differences in delays did not affect clinical outcomes. Still, tertiary prevention measures should particularly focus on these vulnerable populations.

Le stigmate de la "folie": de la fatalité au rétablissement [Stigma of "madness" from fate to recovery].

Stigma is a "natural" social reaction, partly unconscious and automatic towards "different" and "vulnerable" populations. Suspicion of danger, unemployment, excluded from society, locked in hospital, assaulted or killed are the possible consequences of mental disorders' stigma. Despite advances in psychiatric treatments, the stigma of the "madness" remains a barrier to access to recovery. The stigmatization process is more complex than simple labeling, and leads to discrimination and loss of social power. Understanding the mechanisms of stigmatization can determine targets for effective interventions to fight stigma at the individual, institutional and political levels. The roles of patient and family associations, as well as the recovery model for the professionals, are essential. The aim of this article is to review the various aspects of mental disorders' stigma and to examine ways to cope with them.

Screening for latent tuberculosis infection among undocumented immigrants in Swiss healthcare centres; a descriptive exploratory study.

BACKGROUND: Migration is one of the major causes of tuberculosis in developed countries. Undocumented patients are usually not screened at the border and are not covered by a health insurance increasing their risk of developing the disease unnoticed. Urban health centres could help identify this population at risk. The objective of this study is to assess the prevalence of latent tuberculosis infection (LTBI) and adherence to preventive treatment in a population of undocumented immigrant patients. METHODS: All consecutive undocumented patients that visited two urban healthcare centres for vulnerable populations in Lausanne, Switzerland for the first time were offered tuberculosis screening with an interferon-gamma assay. Preventive treatment was offered if indicated. Adherence to treatment was evaluated monthly over a nine month period. RESULTS: Of the 161 participants, 131 (81.4%) agreed to screening and 125 had complete examinations. Twenty-four of the 125 patients (19.2%; CI95% 12.7;27.2) had positive interferon-gamma assay results, two of which had active tuberculosis. Only five patients with LTBI completed full preventive treatments. Five others initiated the treatment but did not follow through. CONCLUSION: Screening for tuberculosis infection in this hard-to-reach population is feasible in dedicated urban clinics, and the prevalence of LTBI is high in this vulnerable population. However, the low adherence to treatment is an important public health concern, and new strategies are needed to address this problem.

Predicting Non Return to Work after Orthopaedic Trauma: The Wallis Occupational Rehabilitation RisK (WORRK) Model.

BACKGROUND: Workers with persistent disabilities after orthopaedic trauma may need occupational rehabilitation. Despite various risk profiles for non-return-to-work (non-RTW), there is no available predictive model. Moreover, injured workers may have various origins (immigrant workers), which may either affect their return to work or their eligibility for research purposes. The aim of this study was to develop and validate a predictive model that estimates the likelihood of non-RTW after occupational rehabilitation using predictors which do not rely on the worker's background. METHODS: Prospective cohort study (3177 participants, native (51%) and immigrant workers (49%)) with two samples: a) Development sample with patients from 2004 to 2007 with Full and Reduced Models, b) External validation of the Reduced Model with patients from 2008 to March 2010. We collected patients' data and biopsychosocial complexity with an observer rated interview (INTERMED). Non-RTW was assessed two years after discharge from the rehabilitation. Discrimination was assessed by the area under the receiver operating curve (AUC) and calibration was evaluated with a calibration plot. The model was reduced with random forests. RESULTS: At 2 years, the non-RTW status was known for 2462 patients (77.5% of the total sample). The prevalence of non-RTW was 50%. The full model (36 items) and the reduced model (19 items) had acceptable discrimination performance (AUC 0.75, 95% CI 0.72 to 0.78 and 0.74, 95% CI 0.71 to 0.76, respectively) and good calibration. For the validation model, the discrimination performance was acceptable (AUC 0.73; 95% CI 0.70 to 0.77) and calibration was also adequate. CONCLUSIONS: Non-RTW may be predicted with a simple model constructed with variables independent of the patient's education and language fluency. This model is useful for all kinds of trauma in order to adjust for case mix and it is applicable to vulnerable populations like immigrant workers.

Précarité et déterminants sociaux de la santé: quel(s) rôle(s) pour le médecin de premier recours [Deprivation and social determinants of health: any role for the general practitioner?]

Social deprivation also exists in an industrialised country like Switzerland where there are many different social economic levels; social inequalities have increased in the past years having a major impact on social economic determinants of health. Being aware of these determinants and systematically identifying them in patients has become crucial for the general practitioner in order to improve the way s/he delivers care and interacts with more vulnerable populations. Because the general practitioner is often in contact with people of different socioeconomic levels, s/he is a key witness of social inequalities in health. S/he therefore has a responsibility to document them, to promote health, to prevent disease and be an advocate for the disadvantages in order to influence these social determinants of health.

Informing patients about limits to confidentiality: A qualitative study in prisons.

AIM: Confidentiality is important in healthcare practice, however, under certain circumstances, confidentiality is breached. In this paper, mental health professionals' (MHPs) practices related to informing imprisoned patients about confidentiality and its limits are presented. METHODS: Twenty-four MHPs working in Swiss prisons were interviewed. Data analysis involved qualitative thematic coding and was validated by discussing results with external experts and study participants. RESULTS: For expert evaluations and court-ordered therapies, participants informed patients that information revealed during these consultations is not bound by confidentiality rules. The practice of routinely informing patients about confidentiality and its limits became more complex in voluntary therapies, for which participants described four approaches and provided justifications in favour of or against their use. CONCLUSIONS: Further training and continued education are needed to improve physicians' ethical and legal knowledge about confidentiality disclosures. In order to promote ethical practices, it is important to understand and address existing motivations, attitudes and behaviours that impede appropriate patient information. Our study adds important new knowledge about the limits to confidentiality, particularly for providers working with vulnerable populations. Results from this study reflect typical ethical and practical dilemmas faced by and of interest to physicians working in forensic medicine and other related settings.

A Descriptive Study of Gambling Among Emerging Adult Males in French-Speaking Switzerland.

The aims were twofold: to examine the gambling habits of emerging adult males in the French-speaking regions of Switzerland and to what extent these habits predict problem gambling within this population. We also evaluated problem gambling rates and provided data concerning variables such as gambling location, level of information about problem gambling and awareness of treatment centers. 606 Swiss male conscripts, aged 18-22 years, completed a self-report questionnaire. This was administered during their army recruitment day in 2012. Problem gambling was assessed through the Problem Gambling Severity Index (PGSI) (Ferris and Wynne 2001). 78.5% of the respondents were lifetime gamblers, 56.1% were past-year gamblers. Four out of ten past-year gamblers played in private spaces and in back rooms. The PGSI indicated that 10.8% of past-year gamblers presented with moderate gambling problems, whilst 1.4% appeared to be problem gamblers. The majority of respondents had never received information about problem gambling. Moreover, they were unaware of the existence of treatment centers for problem gambling in their region. PGSI scores were significantly predicted by the variety of games played. Problem gambling rates among young men appear to be higher than those of the general Swiss population. This confirms that emerging adult males are a particularly vulnerable population with regards to gambling addiction. The implications of this are considered for youth gambling-prevention programs.

Characterizing the vulnerability of frequent emergency department users by applying a conceptual framework: a controlled, cross-sectional study.

BACKGROUND: Frequent emergency department (ED) users meet several of the criteria of vulnerability, but this needs to be further examined taking into consideration all vulnerability's different dimensions. This study aimed to characterize frequent ED users and to define risk factors of frequent ED use within a universal health care coverage system, applying a conceptual framework of vulnerability. METHODS: A controlled, cross-sectional study comparing frequent ED users to a control group of non-frequent users was conducted at the Lausanne University Hospital, Switzerland. Frequent users were defined as patients with five or more visits to the ED in the previous 12 months. The two groups were compared using validated scales for each one of the five dimensions of an innovative conceptual framework: socio-demographic characteristics; somatic, mental, and risk-behavior indicators; and use of health care services. Independent t-tests, Wilcoxon rank-sum tests, Pearson's Chi-squared test and Fisher's exact test were used for the comparison. To examine the -related to vulnerability- risk factors for being a frequent ED user, univariate and multivariate logistic regression models were used. RESULTS: We compared 226 frequent users and 173 controls. Frequent users had more vulnerabilities in all five dimensions of the conceptual framework. They were younger, and more often immigrants from low/middle-income countries or unemployed, had more somatic and psychiatric comorbidities, were more often tobacco users, and had more primary care physician (PCP) visits. The most significant frequent ED use risk factors were a history of more than three hospital admissions in the previous 12 months (adj OR:23.2, 95%CI = 9.1-59.2), the absence of a PCP (adj OR:8.4, 95%CI = 2.1-32.7), living less than 5 km from an ED (adj OR:4.4, 95%CI = 2.1-9.0), and household income lower than USD 2,800/month (adj OR:4.3, 95%CI = 2.0-9.2). CONCLUSIONS: Frequent ED users within a universal health coverage system form a highly vulnerable population, when taking into account all five dimensions of a conceptual framework of vulnerability. The predictive factors identified could be useful in the early detection of future frequent users, in order to address their specific needs and decrease vulnerability, a key priority for health care policy makers. Application of the conceptual framework in future research is warranted.

Soins aux mineurs non accompagnés (MNA): l'expérience lausannoise [Caring for unaccompanied minors: an experience from Lausanne].

La prise en charge médicale du mineur non accompagné est complexe et nécessite la mise en place d'un réseau biopsychosocial. A Lausanne, l'Unité multidisciplinaire de santé des adolescents (UMSA) joue un rôle préventif et curatif pour cette population extrêmement vulnérable. Une prise en charge psychologique rapide est souvent nécessaire en raison des événements de vie dramatiques auxquels la plupart de ces adolescents ont été confrontés. L'absence de projet d'avenir pour la majorité de ces adolescents reste une entrave majeure à leur développement et à leur santé mentale et physique. Medical treatment of an unaccompanied minor is made more complicated firstly by its connections with the politics of immigration and secondly by the difficulty in gaining recognition of the priority of the minor's interests. Enabling healthcare teams to travel and meet these particularly vulnerable youths makes medical care more accessible to them and facilitates an optimal bio-psycho-social treatment. For most of these adolescents it is their lack of plans for the future which remains the major obstacle to their development and mental and physical health.

The vulnerability of Brazilian female prisoners to HIV infection

The purpose of the present study was to determine the vulnerability of women in prison to HIV infection. The study was carried out from August to October 2000 in a São Paulo State Penitentiary, where 299 female prisoners were serving time. We interviewed and obtained a blood sample from 290 females who agreed to enter the study. Sera were tested for the presence of antibodies to HIV, hepatitis C virus (HCV) and syphilis and the odds ratio (OR) was calculated for variables related to HIV positivity on the basis of a questionnaire. The overall prevalence data were: 13.9% for HIV (37 of 267), 22.8% for syphilis (66 of 290), and 16.2% for HCV (47 of 290). Sexual partnership variables were significantly related to HIV infection. These included HIV-positive partners (OR = 7.36, P = 0.0001), casual partners (OR = 8.96, P = 0.009), injectable drug user partners (OR = 4.7, P = 0.0001), and history of sexually transmitted disease (OR = 2.07, P = 0.05). In addition, a relationship was detected between HIV infection and drug use (OR = 2.48, P = 0.04) and injectable drug use (OR = 4.2, P = 0.002). Even women with only one partner presented a significant OR for HIV infection (OR = 2.57, P = 0.009), reflecting their vulnerability due to their trust in their partner, who did not use a condom. Although the use of injectable substances is associated with HIV infection, our results point to sexual behavior as the most important component of HIV transmission in the female prisoner population.