FR:

Les systèmes sociosanitaire et de santé mentale au Québec ont été substantiellement transformés dans les dernières années. Au coeur des restructurations, les réformes ont visé la consolidation des soins primaires et une meilleure intégration du dispositif de soins, tendances centrales des réformes sur le plan international. Cet article résume les principaux axes de transformation des réformes du système sociosanitaire et de la santé mentale au Québec. Il présente aussi le rôle clé des omnipraticiens dans la prise en charge des troubles mentaux et les stratégies de coordination déployées. Les réformes visent principalement l’intensification du travail en réseau des omnipraticiens avec les intervenants psychosociaux et les psychiatres. L’article conclut sur l’importance d’optimiser le déploiement de réseaux intégrés de soins et de bonnes pratiques en santé mentale. Par ailleurs, les réformes devraient toujours être accompagnées de mesures et de stratégies d’implantation à juste titre aussi ambitieuses que les changements planifiés !

EN:

Objectives: The health and mental health systems in Quebec have recently been substantially transformed. At the heart of this restructuring, reforms aimed to strengthen primary care and to better integrate services, which are central trends internationally. This article summarizes Quebec’s primary health and mental health reforms. It also presents the key role of general practitioners in the treatment of mental health disorders and their coordination strategies with the mental health care resources in the province.

Methods: Numerous documents on the Quebec health and mental health reforms and the international literature on primary mental health care were consulted for this study. Information on general practitioner roles in mental health were based on administrative data from the Régie de l’assurance maladie du Québec (RAMQ) for all medical procedures performed in 2006. The data was compared with the results of a survey realized in the same year with 398 general practitioners in Quebec. Complementary qualitative data was collected through one hour interviews on a subsample of 60 of those general practitioners.

Results: The central aim of the Quebec healthcare reform was to improve services integration by implementing local healthcare networks. A population health approach and a hierarchical service provision were promoted. For a better access and continuity of care, family medicine groups and network clinics were also developed. The mental health reform (Action Plan in Mental Health, 2005-2010) was launched in this general context. It prioritized the consolidation of primary care and shared-care (i.e. increased networking between general practitioners and psychosocial workers and psychiatrists) by reinforcing the role of general practitioners in mental health, developing mental health interdisciplinary teams in primary care and adding a psychiatrist-respondent function in each Quebec local healthcare network. In mental health, general practitioners played a central role as the primary source of care and networking to other resources either primary or specialized health care services. Between 20-25% of visits to general practitioners are related to mental health problems. Nearly all general practitioners manage common mental disorders and believed themselves competent to do so; however, the reverse is true for the management of serious mental disorders. Mainly general practitioners practiced in silo without much relation with the mental health care resources. Numerous factors were found to influence the management of mental health problems: patients’ profiles (e.g. the complexity of mental health problems, concomitant disorders), individual characteristics of the general practitioners (e.g. informal network, training); professional culture (e.g. formal clinical mechanisms), the institutional setting (e.g. multidisciplinary or not) and organizations of services (e.g. policies).

Conclusion: Unfortunately, the Quebec health and mental health care reforms have not been fully implemented yet. Family medicine groups and networks clinics, primary mental health teams and psychiatrists-respondent are not optimally operational and therefore, are not having a significant outcome. Support mechanisms to help implement the reforms were not prioritized. Hindering factors should be identified and minimized to increase positive changes in the health and mental health systems. This article concludes on the importance of implementing continuums of care, especially local healthcare networks and best practices in mental health. Furthermore, strong strategies to support the implementation of changes should always accompany sweeping reforms.

FR:

Une réforme ne peut voir le jour et atteindre ses objectifs sans être soutenue de diverses façons. Au Québec, le Plan d’action en santé mentale 2005-2010 – La force des liens a introduit de nombreuses réformes de fond et de forme dans le réseau de services en santé mentale. Cet article voudra explorer quelles formes d’encadrement peuvent soutenir cette réforme et à quel point ces formes ont été exploitées ou devraient l’être. Il pourra ainsi soutenir la réflexion sur les moyens d’encadrement qu’il faudra utiliser pour soutenir le prochain plan d’action actuellement en rédaction au ministère de la Santé et des Services sociaux.

EN:

OBJECTIVE: In 2005, the Québec Ministry of Health launched a major reform of its Mental Health services. This reform aimed both the type of services (collaborative care; community care) and the structure (shift to primary care venues) in which these services where offered. Any major reform must be supported by different means. This article will review which means are best suited to do this and up to what point these where used to support the implementation of the reform. It will also help in preparing for the upcoming launch of the next Mental Health Plan of Action by the Québec Ministry of Health.

METHOD: The authors exchanged on several occasions on their observations and thoughts on the subject.

RESULTS: Any major health reform must be supported by different means. Some are related to legislation or government policies, but these alone are insufficient. Others means include academic and continuing development actions, service accreditation or certification and user participation in policy and implementation stages of service delivery.

CONCLUSION: If some means of support are easily invested, some are neglected. An effort should be made to use all available means to support the upcoming Plan of Action. User involvement seems particularly promising.

FR:

Cette étude examine les politiques de santé mentale énoncées au cours des quinze dernières années par les pays de l’OCDE et les provinces canadiennes afin d’en décrire les variations, d’identifier certaines configurations et d’en tirer des leçons pour le Québec. Vingt et une politiques sont analysées en faisant appel à un modèle conceptuel dérivé de la théorie de l’action sociale de Parsons. Les politiques varient en termes de différenciation (besoins et groupes priorisés, niveaux d’intervention, finalités, bases factuelles, niveaux de spécification), en termes d’intégration (mécanismes d’efficacité variable allant du fonctionnement en créneaux à l’intégration complète de certaines composantes) et en termes de gouvernance (théories de programme plus ou moins explicites ou fondées, importance variable donnée aux structures, aux processus et aux résultats, mécanismes d’imputabilité et de financement, systèmes d’information et gouvernance clinique variables). Cinq configurations sont identifiées : santé publique, professionnelle, technocratique structurelle, technocratique fonctionnelle et politique. La politique québécoise actuelle, correspondant à une configuration technocratique structurelle, pourrait être bonifiée par le renforcement de ses aspects de santé publique, professionnels et fonctionnels si les obstacles politiques pouvaient être surmontés.

EN:

Objectives. The objectives of this research are: 1) to provide a conceptual framework for analyzing mental health policies; 2) to compare mental health policies across a sample of OECD jurisdictions; 3) to describe configurations of mental health policies; 4) to identify practical implications for the Province of Quebec.

Methods. Design: This research is a comparative synthetic study of mental health policies. Sampling: The web sites of the Ministries of health of the thirty-four OECD countries and ten Canadian Provinces were searched for mental health policies proposed within the last fifteen years. Twenty one such policies (with an English or French version) were retrieved, covering thirteen OECD countries, six Canadian Provinces and the WHO. Analysis: Content analysis was performed based on the categories (differentiation, integration, governance) and sub-categories of the aforementioned conceptual framework. Eight policies that together cover the variations encountered between all policies were used to identify typical configurations.

Results. A conceptual framework derived from Parsons’ Theory of Social Action posits that social action systems must exhibit a level of internal differentiation that corresponds to the heterogeneity of their external environment and also a level of integration that allows them to remain coherent despite the complexity of their environment. Governance mechanisms help them maintain an equilibrium between differentiation and integration.

In terms of differentiation, mental health policies exhibit much variation between the needs and the groups that are prioritized (age, gender, ethnicity, culture, etc.), the types of interventions that are proposed (promotion, prevention, treatment, rehabilitation, etc.), the systemic levels at which interventions take place (society, government as a whole, health care system, organizations, programs, individuals), and the level of specification and scientific basis of proposed interventions.

In terms of integration, policies promote various mechanisms belonging to four general categories of increasing effectiveness from hierarchical separation of mandates, to exchange of information, to collaborative planning, and to complete structural integration and co-localisation of certain components (ex. dependence and mental health services).

In terms of governance, policies present program theories of varying explicitness and scientific bases, and with different emphases on structures, processes or outcomes. Management models also vary in terms of precision, accountability, financing mechanisms, information systems, and the importance of clinical governance and quality improvement.

Five configurations of mental health policies are identified (the public health, the professional, the structural technocratic, the functional technocratic, and the political), each comprising typical combinations of the preceding ingredients.

Conclusion. The current Quebec mental health policy belongs to the structural technocratic configuration. It specifies fragmented mental health structures with mild integration mechanisms. In the future, it should consider improving its public health aspects (inter-sector work on the determinants of mental health), professional aspects (emphasis on scientific evidence, clinical governance and quality), and functional aspects (integrated specialized community mental health and addiction services). But political factors may prevent it from doing so.

FR:

Les trois Instituts universitaires en santé mentale (IUSM Douglas, de Montréal et de Québec) et le Centre hospitalier universitaire de Sherbrooke ont déposé un mémoire au Forum national de consultation sur le prochain plan d’action en santé mentale (PASM) 2014-2020, organisé en janvier 2014 par le ministère de la Santé et des Services sociaux (MSSS). À titre d’acteurs-clés du réseau de la santé mentale, ils commentent chacun des éléments présentés dans le document de consultation.

Ils considèrent que les orientations proposées sont en continuité avec le PASM 2005-2010 et les thématiques présentées reflètent bien les enjeux actuels. Ils suggèrent des principes plus explicites quant à l’organisation de services souhaitée, soit l’exercice de la pleine citoyenneté, une organisation en réseaux intégrés de services, la performance, l’amélioration continue et l’innovation, ainsi qu’une vision globale et intégrée de la santé. La complexité des problématiques actuelles commande une offre de services souple, complémentaire et en continuité, particulièrement pour les jeunes, les autochtones et les personnes présentant des troubles concomitants. Ils insistent donc sur l’importance d’agir en prévention, d’offrir des programmes d’intervention précoce et de consolider le soutien offert aux omnipraticiens et aux professionnels de la première ligne. Ils rappellent cependant de ne pas négliger l’offre de services spécialisés en ambulatoire et en hospitalisation. Les services offerts dans la communauté doivent être structurés autour des niveaux de soutien variés, tels que le SIV et le SIM, mais aussi autour de programmations spécialisées disponibles dans les services de consultations externes des hôpitaux. Aussi, la consolidation des services surspécialisés, l’enseignement et la recherche sont à inclure dans le prochain plan d’action en santé mentale. Finalement, une perspective de santé globale doit dépasser le cadre du MSSS pour devenir un engagement gouvernemental interministériel, s’appuyant sur une vision de santé publique de la santé mentale qui examine les conditions de santé de la population et tient compte des déterminants sociaux. Ce plan sera la base d’un réel soutien à l’exercice de la pleine citoyenneté et à la lutte à la stigmatisation, en collaboration avec les personnes utilisatrices de services et leurs proches.

EN:

Goal: Quebec’s three mental health university institutes (DMHUI, IUSMM and the IUSMQ) and the Centre hospitalier universitaire de Sherbrooke submitted a statement to the provincial consultation forum on the 2014-2020 Mental Health Action Plan (MHAP), which was held in January 2014 and organized by the Ministère de la Santé et des Services sociaux (MSSS). This article presents these institutes’ main recommendations.

Method: Mental health university institutes deliver a wide and diverse range of services. They know about the challenges of organizing mental health services and are aware of national and international trends in the delivery of the best organizational and clinical practices in mental health. It is therefore as key stakeholders in the mental health care network that they commented on each component in the working paper.

Results: The proposed orientations are consistent with the 2005-2010 MHAP. The presented themes clearly reflect current issues, although the guidelines must be more explicit regarding the vision of how services will be organized in coming years. These institutes therefore suggest that the following principles be included: the full exercise of citizenship rights, the organization of services within integrated networks, performance, continuous improvement and innovation, as well as a global and integrated vision of health. The complexity of today’s problems requires flexibility, complementarity and continuity of services, particularly for youth, aboriginals, and people with concomitant disorders. These institutions therefore stress the importance of prevention, early intervention programs, and increased support for first-line general practitioners and health care professionals. They also emphasized that specialized inpatient and outpatient services should not be neglected. Community services must also be structured around various levels of support, such as ICM and ACT, as well as around specialized programs available in hospital outpatient clinics. The development and transfer of knowledge remain a central issue when it comes to improving the mental health of the general population. The consolidation of ultra-specialized services, teaching and research should be included in the next MHAP. Finally, a global health perspective must go beyond the MSSS framework to become a governmental and interministerial commitment based on a vision of public mental health that incorporates the health status of the general population and accounts for social determinants.

Conclusion: It is important to have a national plan that promotes a vision. This plan must be part of an interministerial action plan that truly supports the full exercise of citizenship rights and the fight against stigmatization in collaboration with people who use these services and their families.

FR:

Si l’importance grandissante de la santé mentale des jeunes fait consensus, de multiples questionnements émergent cependant quant aux spécificités de ce domaine, qui ne peut être conçu comme une extension des services adultes pour des groupes plus jeunes. Cet article aborde ces questionnements en croisant les savoirs provenant de la documentation et ceux qui émergent à la suite de l’implantation du Plan d’action en santé mentale au Québec.

Le Plan d’action en santé mentale a mis de l’avant la collaboration et le partenariat entre institutions et disciplines. Malgré des avancées significatives, des discontinuités peu favorables à une prise en charge écosystémique persistent. Un ensemble de recherches récentes suggère que les contextes organisationnels qui encadrent les services influencent à la fois la façon dont les interventions sont mises en place et leurs résultats cliniques. Une structure de gestion flexible qui engage les intervenants en favorisant une appropriation du pouvoir, tout en minimisant les sources de stress au travail et en facilitant la création de partenariats, semble nécessaire pour favoriser la concertation interdisciplinaire et intersectorielle. Celle-ci est essentielle à la mise en place de services en santé mentale jeunesse.

EN:

The importance of children and youth mental health is increasingly recognized. This rapidly developing field cannot be conceptualized as an extension of adult services to a younger age group and its developmental and organizational specificities are the object of debate. Reviewing recent literature in this domain and some preliminary information about the Quebec Mental Health Plan implementation, this paper addresses some of the questions which structure this debate in Quebec.

Quebec mental health plan has put at the forefront collaboration among disciplines and partnership among institutions. In spite of having produced significant improvement in the field, discontinuities in services, which interfere with an ecosystemic model of care, persist. Recent studies suggest that the organisational climate which surrounds youth mental health services has a direct impact on the quality of services and on youth health outcomes. A flexible management structure, which engages clinicians and health workers, favors empowerment, minimizes work stress and facilitates partnership, is needed to foster successful interdisciplinary and intersectorial collaboration. This collaboration is the cornerstone of youth mental health services.

FR:

Cet article a pour objectifs 1) de tracer l’historique et la place des organismes communautaires en santé mentale (OCSM) ainsi que leurs valeurs et pratiques spécifiques et 2) d’étudier l’impact du Plan d’action en santé mentale (PASM) 2005-2010 sur leur fonctionnement et leurs relations avec le réseau public. Les auteurs abordent la diversité des OSCM en fonction des dimensions suivantes : historique des OCSM au Québec, typologie, territoires couverts et financement, modalité de pratiques, et regroupement. L’étude montre que malgré la place qu’ils occupent dans la dispensation des services, les OCSM perçoivent un certain recul quant à la reconnaissance de leur expertise par le réseau public depuis la mise en place du PASM 2005-2010. Leurs critiques concernent surtout les questions de leur sous-financement, la crainte d’une perte de leur autonomie lors de la signature d’une entente de services ainsi que des lacunes sur le plan de la gouvernance et de la concertation. Un financement plus adéquat des OCSM, principalement pour les groupes d’entraide et les OCSM offrant de la réadaptation psychosociale, de l’intégration aux études et au travail, la reconnaissance de la nécessité d’une pluralité d’approches, ainsi que la reconstitution de tables de concertation ayant des pouvoirs décisionnels sont des outils pouvant permettre aux OCSM de jouer plus adéquatement leurs rôles.

EN:

Objectives: The objectives of this article are: 1) to trace the history and role of mental health community organizations (MHCO) in the Quebec mental health system as well as their specific values and practices; and 2) to examine the impact of the Quebec Mental Health Plan 2005-2010 on the functioning of community organizations and their relations with the public healthcare system. Methods: This article draws upon writings produced by the principal provincial and regional community organization associations in Québec, as well as results of previous studies related to inter-organizational relations among MHCO. Results: The Quebec community-based system consists of several successive generations of the MHCO, each constructed within a particular context. Before 1960, the Canadian Mental Health Association offered activities for promotion and prevention in mental health and participated in the development of several MHCO. The 1970s witnessed the formation of groups aimed at the protection of human rights and the first alternative resources. During the 1980s and 90s, a proliferation of MHCO followed upon their formal recognition by the Ministère de la Santé et des services sociaux (MSSS). These new organizations were established not so much in opposition, or as an alternative, to the public mental health system, but in complement with it. By 2012-13, there were 412 MCHO financed by the MSSS offering services to the population. Roughly half were located in the regions of Montreal, Montérégie and the Capitale Nationale. The MHCO are distinguished from public institutions by a number of characteristics: 1) treatment based not on diagnosis but on the overall situation of the person; 2) shared experience with peers; and 3) empowerment, inviting the person to become involved in decisions concerning his/her treatment and service use as well as decisions that concern the functioning of the organization; 4) establishment of more egalitarian relationships between service users and treating professionals; and 5) rootedness of the organization within the community. MCHO are grouped at the provincial level according to their functions, their ideological affinity, and or their particular mandate, but there is no national classification of community organizations as yet. The financing of community organizations remains a principal source of discontent. The MSSS has indicated that the overall financing of MCHO should correspond to at least 10% of global expenditures for mental health programming, whereas the actual budget is equivalent to only 8.8%. This underfunding obliges community organizations to reduce services despite demands for increased financial assistance, which runs the risk of provoking increased “revolving door” situations, and the utilization of emergency services in cases of service users transferred from hospitals to the Health Social Services Centers, who are in difficulty after losing contact with their service providers who would otherwise have provided follow-up. As well, MCHO fear the loss of their autonomy and of being reduced to the role of secondary services in signing these service agreements. The current reform would represent a step backward for MHCO in terms of recognition of their expertise. The former consultation structures have been dispossessed of any real power, decision making now being in the hands of the regional agency and directors of institutions. Numerous relocations of personnel have also lead to breaks in contact between MCHO and the public system, as these relationships were usually informal. Conclusions: A number of recommendations emanate from these findings that may permit MHCO to respond more adequately to the needs of the population served without calling into question their autonomy: 1) offer more adequate financing, particularly for self-help groups and organizations offering psychosocial rehabilitation, access to education and work reintegration; 2) allocate specific services exclusively to the community-based system in order to avoid duplication in services; 3) recognize a multiplicity of approaches; and 4) reconstruct appropriate decision making structures.

FR:

La refonte des lois professionnelles et la réorganisation des services en santé mentale ont eu une influence significative sur la pratique infirmière en santé mentale au Québec. De nombreuses infirmières ont fait preuve de leadership clinique et ont su adapter leurs services aux besoins de la population selon les nouveaux milieux de soins de proximité. Cependant, plusieurs sont d’avis que le rôle des infirmières n’est pas suffisamment connu et mis à profit pour contribuer de façon optimale à l’offre de services en santé mentale. Ainsi, cet article porte un regard critique sur la pratique infirmière en santé mentale au Québec et les conditions essentielles à son évolution. Il vise à : 1) décrire les tendances actuelles qui caractérisent l’évolution des rôles et la modernisation de la pratique infirmière en santé mentale au Québec ; 2) offrir un aperçu de l’évolution de la pratique infirmière avancée en santé mentale (PIA-SM) et de ses retombées sur la qualité des services ; 3) clarifier le concept de PIA et situer son évolution au Québec ; et 4) proposer diverses stratégies visant à optimiser le rôle des infirmières et leur complémentarité avec les autres professionnels dans l’offre de services en santé mentale. Les progrès en cours sont illustrés par des exemples de pratiques innovantes développées par des infirmières québécoises dans le contexte de la restructuration des services de santé. Les données quant à l’évolution de la PIA-SM aux États-Unis et en Australie indiquent qu’il existe encore de nombreux défis liés à l’implantation réussie de ce nouveau rôle. Toutefois, il se dégage, de la majorité des études, un consensus de plus en plus important quant à la contribution de la PIA-SM pour améliorer la qualité et l’accessibilité des soins en santé mentale. La réforme des services de santé mentale au Québec s’avère donc être un moment propice pour développer et soutenir la PIA-SM et en retirer les bénéfices attendus.

EN:

New professional legislation and reorganization of mental health services have had a significant influence on mental health nursing practice. Many nurses have demonstrated clinical leadership and have been able to adapt their services to the needs of the population specially in the primary health care setting. However, many believe that the role of nurses is not sufficiently known and optimally utilized in mental health services. In this article we take a critical look at the mental health nursing practice in Quebec and at the essential requirements for its development. This review aims to: 1) describe current trends in the changing roles and the modernization of mental health nursing practice in Quebec, 2) provide an overview of the development of advanced nursing practice and its impact on the quality of mental health services; 3) clarify the concept of advanced nursing practice and position its development in Quebec and 4) propose various strategies for optimizing the role of nurses and their complementarity with other professionals providing mental health services. This review presents innovative practices developed by nurses in the context of the restructuring of mental health services. For example, new nursing roles have been developed to improve the collaboration with general practitioners groups in primary care settings and facilitate the evaluation and monitoring of patient presenting medical and psychological problems. Another interesting innovation was set up by nurses in developing a new service to allow timely access to integrated care for patients with substance abuse and mental health problems. The various testimonies reported in this article illustrate the potential contribution of these nursing innovations in improving the mental health services in Quebec. Also, in few countries, the reform of mental health services has been a good time to recognize this potential. Thus, some countries have repositioned the role of mental health nurses and supported the development of new models of advanced practice in mental health. These developments have been particularly significant in the United States and Australia. In United States, during the 1990s, at least four models of advanced practice in mental health nursing have been developed leading to wide variations in the roles, education, job titles, scope of practice and legal authorizations. Consequently, a consensus model of uniform standards of practice, accreditation and education has been proposed. This LACE model (Licensure, Accreditation, Certification, Education) will be in effect in 2015. Australia has adopted a more systematic approach, unified and progressive to facilitate the development of advanced mental health nursing practice. Australia who, through their many publications, retains more attention since a clear definition of the role of the nurse practitioner in mental health and a legal framework has been adopted at the national level. The Australian experience and the finding from studies suggest that mental health nurse practitioners and nurses who are specialized in mental health have the potential to make a significant contribution to enhancing access to and quality of mental health care through flexible an innovative approaches. So there are more and more evidence and indications that Quebec should invest in enhancing the skills of mental health nurses through the development of advanced nursing practice and integration of this new model in primary care. In addition, researches, funded by the Canadian Services Research Foundation (CHSRF, 2010), shows that the contribution of advanced nursing practice has never been stronger and there is a broad consensus to its value for the Canadian health care system (Dicenso.et Lukosius-Briant, 2010). The implementation of advanced practice nursing role in mental health is part of best practices required to improve care and mental health services and should be taken into account in future Action Plan 2014-2020.

FR:

Cet article vise à résumer l’état des lieux quant au rôle des familles de personnes atteintes de troubles mentaux au sein du système de santé mentale au Québec. À cet effet, un rappel historique permet de mettre en perspective les différents rôles occupés par les familles, d’agent causal, tant au point de vue de la générique que des émotions exprimées, à prestataire de soins qui peut vivre du fardeau et finalement partenaire. Un modèle élaboré par la FFAPAMM et qui identifie trois rôles principaux permet de contextualiser le rôle actuel dans le système. Ce modèle, intitulé CAP, regroupe et décrit trois rôles des familles qui, s’ils sont tributaires du passé, continuent de se côtoyer à notre époque : celui de client, d’accompagnateur et finalement de partenaire. Des recommandations provenant d’un projet de recherche québécois et d’un rapport de la Commission de santé mentale du Canada permettront d’envisager un avenir où les besoins et les aspirations des familles seront pris en compte.

EN:

Purpose. This paper aims to summarize the current situation regarding the role of families of persons with mental disorders within the mental health system in Quebec.

Methods. We made a research in the most recent and pertinent papers or books regarding: 1) the history of the family involvement in the mental health system in Quebec; 2) the present situation of these families and the models that we can see and 3) identify in recent governmental or research documents recommendations regarding a greater empowerment of the families in the mental health system.

Results. The research provides a historical perspective to the roles occupied by families. First the family was described as a causal agent; the work of the psychoanalyst Freud described the family unit as a source of conflicts in the areas of affect and sexual dynamics, and which results in the appearance of psychiatric symptoms. Later, this view of a causal agent came both from the point of view of genetic and from expressed emotions. In the 70’s new perspectives such as general systems theory (von Bertalanffy, 1968), described the family as responsive to mental disorder of one of its members rather than a responsible agent. With the deinstitutionalization movement, the family was perceived as a source of solutions for persons with mental illness, but also as persons who can live some burden. This subject became well described and a several studies reported about adverse effects of caring for a person with mental disorder on the health, well-being and feeling of caregiver burden. In the 90’s, some government action plans called for the relationship between the family and the health system as a partnership. Also, families want to be involved in decisions about care and to be informed about the diagnosis and treatment options. ( Lefley et Wasow, 1993)

A new model developed by FFAPAMM that identifies three main roles enables to contextualize the current role in the current system. This model, called CAP lists and describes three roles of families that, if they are dependent on the past, continue to mingle in our time. These roles are:

Accompanist: the role imposed by being near a person with mental illness (Fradet, 2012). As an accompanist, the family needs to establish relationships with health professionals. Accompanists want to be considered by stakeholders and be respected in their desire to share information and participate in decisions.

Client: this is the role that derives from the accompanist when the caregiver receives care services for its psychological or physical problems related to the fact support a sick person.

Partner: it is relative to the involvement (or not) the role of family members in the organization of care. It is a role of participation and decision-making. In this context, we also speak of participation in the consultation mechanisms.

Recommendations from a Quebec research project and a report of the Commission on Mental Health of Canada will consider a future where the needs and aspirations of families will be taken into account in mental health general services, short term health care, community mental health services. There are also some guidelines regarding education for professionals about the needs of families and about changing politics.

Conclusion. There exists in all associations of families of person with mental disorders, training on topics such as how to behave towards different mental disorders or aggressiveness near reached. A project of the Douglas Institute has hired a family member to the emergency room to help families better manage this often difficult time and to facilitate communication with stakeholders. Another project called “Learning to come closer without aggression” has helped more than 200 family members undergo training inspired by the Omega approach, which helps them better manage their own behavior in situations of aggression with their loved one.

FR:

Le Plan d’action en santé mentale 2005-2010 (PASM) en appelait à une plus grande participation des personnes utilisatrices de services de santé mentale aux instances locales, régionales et nationales du réseau de la santé et des services sociaux du Québec. Cet article propose un regard rétrospectif sur cette participation en lien avec le PASM. Il emprunte diverses perspectives pour faire ressortir des convergences et des tendances en se basant sur des écrits gouvernementaux et sur des recherches en cours sur la participation des usagers à de telles instances. Au cours de la période couverte, la fonction de porte-parole assumée par les individus concernés s’est complexifiée, particulièrement avec l’évolution d’une parole s’exprimant à la première personne du singulier, puis à la première personne du pluriel. La notion de participation publique a ainsi pavé la voie à celle de participation citoyenne. Les conditions et modalités de participation pourraient cependant être mieux définies et plus prévisibles.

EN:

Context: Among the guiding principles of the Mental Health Action Plan 2005-2010 (MHAP) of the Quebec Ministère de la santé et des services sociaux (Health and Social Services) is the recognition that persons who use mental health services (consumers) can be active agents of their own individual and collective recovery journey. In accordance with this principle, the MHAP called for greater participation of consumers in local, regional and national decision-making bodies within the network of health and social services in Quebec.

Objective: The objectives of this article are to look back on the various forms of consumers’ participation in connection with the MHAP since its enactment, and to better understand the complexities of being spokespersons through the Actor Network Theory conceptual framework.

Method: A scientific literature review was conducted. Different angles of analysis were used to highlight convergences and trends based on official governmental publications and ongoing research on consumers’ participation in decision and policy making. It was thought that a vertical case study approach would offer an historical perspective going back to the early 1960s to discuss the foundations of an “ideology of participation.” Another way of assessing participation is through a horizontal approach that would compare the terms of participation implemented from one regional authority to the other, in order to cover most of the Quebec territory.

Results: The MHAP did not provide clear indicators of how to assess progress made with regards to greater consumer participation. In some regions of Quebec, this participation was coordinated by community organizations that designated their representatives. In other regions, local authorities included consumers on a more individual basis to give their opinion. As all were not at the same stage in their recovery process, some were in a position to speak using the “we,” while others still needed to express themselves using the “I.” In either case, their function as spokespersons proved to be a bi-directional function. In one direction, the spokesperson informed the governmental and institutional stakeholders about the expectations of consumers and about their daily life realities. In the other way, they were able to explain and make more intelligible the intricacies of the system with a lay language, which helped non specialists they encountered to remain informed partners, even though indirectly. As they shared their experience as spokespersons with their peers, their peers were able to get a clearer understanding of the progress made to effectively promote active and effective participation. The lack of clear expectations and dedicated means to support participation, induced discrepancies from one region to another, making it difficult, though, to assess progress made overall.

Conclusion: As the function of spokesperson got more professionalized with increased opportunities to participate in policy and decision-making, spokespersons spoke from an “us” rather than an “I” standpoint. The concept of public participation evolved to one of civic participation, with the possibility to transcend the “us” and “them” dichotomy, as members of a community are all citizens to one another. Still, the terms and conditions of participation could be better defined and more predictable for greater equity in terms of access to different levels of policy and decision-making.

FR:

Depuis 1992, quatre stratégies en santé mentale se sont succédé avec pour buts de promouvoir la santé mentale, d’augmenter la qualité des services et de forger une approche cohérente concernant la réforme du système de santé mentale dans tous les États et territoires australiens. Ces cycles systématiques de planification ont permis le passage d’un système dominé par les hôpitaux psychiatriques à un système de services dans la communauté. Les budgets en santé mentale se sont accrus, mais se sont réduits avant de s’accroître avec un ambitieux programme d’accès équitable à la psychothérapie, fondé sur un paiement à l’acte des psychologues après une référence des médecins de famille. Plus récemment, le développement de services pour les jeunes psychotiques a soulevé des craintes d’abandon des patients plus âgés et de réduction des budgets, d’autant plus qu’avec un excès de mortalité de ces derniers, la discrimination des services n’est pas résolue. Il demeure une disparité pour les peuples autochtones. La création récente d’une commission de la santé mentale marque un rôle accru de la participation des usagers et familles, de même qu’une surveillance indépendante continue de la performance du système de santé mentale australien.

EN:

Canada is 1.5 times the size of Australia. Australia’s population of 20 million is located principally on the east coast. Like Canada, the Australia has a federal system of Government with 5 States and two territories. Each State and territory has its own legislation on mental health. The federal (Commonwealth) Government is responsible for health care planning. In addition, the federal Government subsidizes an insurance program (Medicare) that covers visits to specialists and family physicians, while provincial governments are involved in the provision of hospital care and community mental health services. The Commonwealth government also subsidises the cost of medication through the Pharmaceutical Benefits Scheme. These funds are supplemented by private health insurance. Mental health costs account for 6.5 per cent of all health care costs. Primary care treats the majority of common psychological disorders such as anxiety or depression, while specialist mental health services concentrate on those with severe mental illness. There have been 4 national mental health plans since 1992 with the long term aims of promoting mental health, increasing the quality and responsiveness of services, and creating a consistent approach to mental health service system reform among Australian states and territories. These systematic cycles of planning have first allowed a shift from psychiatric hospitals to community services, from reliance on psychiatric hospitals as pivotal to psychiatric care system. Community care budgets have increased, but overall have decreased with money not following patients; but recent deployment of federally funded through Medicare access to psychotherapy by psychologists for common mental disorders in primary care have increased overall budget. Concerns remain that shift to youth first onset psychosis clinics may come from older long-term psychotic patients, a form of discrimination whilst evidence amount of excess mortality by cardio-vascular diseases and cancers, and due to poverty, poor health prevention and primary health care for these patients. From a system perspective, Australia has been inspired by Canada and created in 2012 its own mental health commission with a similar leading role for patients and families, aboriginal people representatives, but also a surveillance of the system with its own yearly report, like the Quebec Health Commissioner 2012 mental health system performance report.

FR:

Les évolutions qui ont marqué les soins en santé mentale en Belgique ces dernières années montrent qu’un certain nombre de jalons importants sont d’ores et déjà posés vers la mise en place des soins orientés vers la communauté. Nous vivons, actuellement, en Belgique, un moment que l’on peut qualifier d’historique, tant la réforme qui est proposée est ambitieuse mais aussi complexe.

En effet, on parle d’une réforme globale des soins en santé mentale qui associe dans un même mouvement les compétences fédérales, régionales et communautaires.

Elle a pour but de transformer une partie de l’offrehospitalière en une offre de soins orientée dans lacommunauté par, notamment, la créationd’équipes mobiles qui prendront place dans le dispositifcommunautaire déjà existant.

Dans le même temps, nous développons l’approche opérationnelle du travail en réseau organisé autour des besoins des usagers et de leur entourage.

Dans cet article, nous proposons de décrire le contenu de cette réforme, ses mécanismes et ses acteurs. Nous présentons l’état d’avancement de la phase exploratoire en insistant sur des aspects positifs qui mettent en avant le caractère évolutif de notre démarche mais aussi des difficultés que nous rencontrons dans sa mise en place.

EN:

The developments in mental health care in Belgium over the last few years show that some major steps are already taken towards implementing community oriented care. In Belgium, we are going through a historic moment, as the proposed reform is ambitious but also complex. Indeed we talk here about a comprehensive mental health care reform which brings together federal, regional and community competencies.

It aims to transform part of hospital care into community oriented care by e.g. creating mobile teams in the existing community care mechanisms.

In the same time we are developing an operational approach to networking focusing on the needs of care users and of their families.

In this paper, we will describe the content of the reform, its mechanisms and all care professionals involved. We will also present the progress of the exploratory phase by stressing not only positive aspects that highlight the evolving nature of our approach, but also the difficulties we are facing in implementing it.

FR:

Objectifs : L’objectif de cette étude était, premièrement, de documenter les propriétés psychométriques d’une mesure du statut socioéconomique des personnes âgées et, deuxièmement, de documenter l’effet du statut socioéconomique sur l’association entre le besoin ressenti d’améliorer sa santé mentale et l’utilisation des services de médecine générale par les personnes âgées en tenant compte de l’effet de l’âge et du genre.

Méthode : Les données utilisées pour cette étude proviennent de l’étude ESA (Enquête sur la santé des aînés) sur la santé mentale et le vieillissement, réalisée en 2005-2008 auprès d’un échantillon probabiliste (n = 2811) de la population âgée de 65 ans et plus vivant à domicile au Québec.

Résultats : Nos résultats ont montré qu’un modèle de mesure du statut socioéconomique des personnes âgées, incluant une dimension individuelle (SSE_I) et contextuelle (SSE_C) de défavorisation, était plausible. La fiabilité de la mesure du statut socioéconomique utilisée dans le cadre du programme de recherche ESA était de ,92. Nos résultats ont montré que les femmes (b = -,43) ainsi que les personnes plus âgées (b = -,16) avaient un statut socioéconomique plus défavorisé. Cependant, nos résultats n’ont montré aucune association significative entre le statut socioéconomique, la perception du besoin d’améliorer sa santé mentale et l’utilisation des services de médecine générale chez les personnes âgées au Québec.

Nos résultats ne confirment pas l’idée avancée dans d’autres études selon lesquelles le statut socioéconomique a un effet sur l’utilisation des services de médecine générale par les personnes âgées et suggèrent que, dans un contexte où les services de santé sont donnés dans le cadre d’un programme d’assurance public, le statut socioéconomique n’influence pas l’accès aux services de médecine générale chez les personnes âgées.

EN:

Objectives: The objective of this study was, first, to document the psychometric characteristics of a measure of the older adults’ socioeconomic status and, secondly, to test the effect of the socioeconomic status on the association between the older adults perceived need to improve their mental health and their use of services in the general medical sector for psychological distress symptoms taking into account the effect of age and gender.

Method: Data used in this study come from the ESA study (Enquête sur la santé des ainés) on mental health and aging, conducted in 2005-2008 using a probabilistic sample (n=2811) of the older adult population aged 65 years and over living at home in Quebec.

Results: Our results showed that a measurement model of the older adults’ socioeconomic status including an individual-level (SES_I) and an area/contextual-level dimension of socioeconomic deprivation (SES_C) was plausible. The reliability of the SES index used in the ESA research program was .92. Our results showed that women (b=-.43) and older people (b=-.16) were more at risk to have a disadvantaged socioeconomic status. However, our results did not show evidence of a significant association between the older adults’ socioeconomic status, their perception of a need to improve their mental health and the use of medical services for psychological distress symptoms in the general medical sector in the older adult population in Quebec.

Conclusion: Our results do not support the idea suggested in other studies that socioeconomic status has an effect on the older adults use of services for psychological distress symptoms in the general medical sector and suggest that in a context where medical health services are provided under a public insurance programme context, the socioeconomic status does not influence access to services in the general medical sector in the older adult population.

FR:

Plusieurs études suggèrent que les professionnels de la santé entretiennent des attitudes négatives à l’égard des personnes présentant un trouble de personnalité limite (TPL). Cette recherche vise à évaluer les attitudes des omnipraticiens et des résidents en médecine familiale à l’endroit des personnes présentant ce trouble. Quarante résidents en médecine familiale et trente-cinq omnipraticiens ont été comparés à trente-neuf professionnels de la santé mentale à l’aide de l’Échelle d’attitudes à l’égard des personnes présentant un TPL (ÉA-TPL ; Bouchard, 2001). Les résultats démontrent que les omnipraticiens et les résidents en médecine familiale endosseraient des attitudes similaires à celles des professionnels de la santé mentale envers les personnes présentant ce trouble et que moins les cliniciens sont expérimentés, moins ils auraient tendance à présenter des attitudes positives à l’égard des personnes ayant un TPL.

EN:

Objectives. Several studies suggest that health professionals show negative attitudes towards people with Borderline Personality Disorder (BPD). Many publications have focused on the attitudes of nurses or other type of clinicians like social workers or psychologists. Few researches concern the attitudes of general physicians towards BPD even if they are the main professionals involved in the evaluation and treatment of these patients. Additionally, patients with BPD frequently consult general physicians and, because of the difficulties interacting with these patients, they do not always receive the treatments required by their condition. This research aims to assess the attitudes of general physicians and family medicine residents regarding patients presenting with this disorder.

Method. Forty family medicine residents and thirty-five general physicians were compared to thirty-nine mental health professionals using the Attitudes toward people with BPD Scale (ABPDS; Bouchard, 2001). This measure has two subscales labeled Comfort when interacting with someone who has BPD and Positives perceptions about BPD. The internal consistency of the scale as well as the two distinct factors are satisfactory. The participants also complete a socio-demographic questionnaire.

Means, t tests, ANOVAs and factorial ANOVAs are completed in order to compare the three groups on the ABPDS and explore the influence of variables such as sex, age, years of experience, and professional setting (urban or rural) on the results.

Results. The results show that general physicians have similar attitudes than mental health professionals towards people presenting with BPD and that family medicine residents present less positive attitude than the other two groups. In addition, clinicians with less experience tend to have less positive attitudes towards people with BPD and clinicians from urban settings seem to have more positive attitude. It was difficult to determinate which variables influence the results because the years of experience, the professional settings and the title of the participants are extremely related. The factorial ANOVAs show no interaction effect between these three variables.

Conclusion. Several studies show that health professionals present negative attitudes toward patients with BPD. This study reveals that general physicians and family medicine residents show respectively similar attitudes or less positive attitudes than other mental health professionals. These results underline the importance of providing specific training about BPD to family medicine residents. Because general physicians guide the evaluations and interventions concerning these patients and mental health professionals interact regularly with BPD, it will be helpful if all the clinicians receive more specific training regarding this disorder.

FR:

Les difficultés d’application des réformes législatives visant à réduire l’hospitalisation involontaire des personnes qui présentent un danger pour elles-mêmes ou pour autrui ont été soulevées dans de nombreux rapports, tant au Québec qu’ailleurs. Pour aplanir ces difficultés, un nouveau protocole de garde en établissement a été élaboré et implanté dans la région de l’Outaouais. La présente étude a pour but d’évaluer son implantation et ce faisant, établir le profil des personnes mises sous garde en établissement. Les résultats indiquent que la majorité de ces personnes sont aux prises avec des troubles mentaux graves et que les professionnels perçoivent positivement le nouveau protocole, sans toutefois faire le nécessaire pour consigner de façon rigoureuse les données dans les formulaires requis. Il est recommandé de non seulement informer les professionnels sur la procédure légale, mais aussi s’assurer que la structure organisationnelle est propice à son implantation.

EN:

Since the 1990s, legislative reforms have been undertaken in many Western countries to reduce involuntary hospitalization. Studies examining fluctuation rates before and after the legislative reform show a general trend toward an increase rather than a decrease in involuntary hospitalization rates (de Stefano & Ducci, 2008). In Quebec, many reports have shown that consent for psychiatric evaluation and hospitalisation for people who present an imminent danger to themselves or to others is difficult to obtain due to clinical, legal, and ethical considerations. To facilitate this process, a new protocol was developed and implemented following the training of 335 health workers and 85 medical doctors in 6 hospitals. Our study evaluated this protocol and established a profile of people who had been hospitalized against their will. Using a retrospective analysis, we examined the files of 179 patients who underwent a psychiatric evaluation process during an involuntary hospitalization. This file analysis allowed us to develop a better profile of these people and determine whether the required forms were present and how adequately they were filled out by the professionals. We also conducted a study with the professionals responsible for applying the new protocol to get a better idea of its characteristics (relative advantage, compatibility, simplicity, reversibility and observability) as well as the principles of consent and the obstacles to its implementation.

Our study showed that that half of the patients were diagnosed with schizophrenia or another psychosis. Fifty-four point two percent (54.2%) of the patients were males, 79% were single or separated and only 18,4% were working. At the time of their crisis situation, 30,7% were brought to the hospital by police officers and 19% were already hospitalized. The remaining patients were brought in by ambulance, family members or they came in by themselves. Professional opinion of the new protocol was positive however they did not rigorously enter the data required in the new forms. The new form was present in only 51% of files and when consent was given, it was only documented in 27% of the cases.

These results highlight the need to improve the documentation process given in the protocol. It would be very useful to establish strategies to obtain this consent in light of the specific characteristics that make up this subgroup of people who have been hospitalized against their will. Legislation alone is not enough to invoke a change in the involuntary hospitalisation rate. The clinical and organisational context must also be actively prepared to receive this new practice. In order to do this, evaluative research could contribute to improving the level of implementation and be of benefit to people in crisis and those with mental disorders.

FR:

L’un des quatre principaux chapitres du document de consultation proposé par le ministère de la Santé et des Services sociaux du Québec, en préparation du Forum national sur le Plan d’action en santé mentale 2014-2020, est consacré au plein exercice de la citoyenneté. Ce témoignage est le fruit d’un dialogue tenu entre la direction générale d’un institut universitaire en santé mentale québécois et d’un groupe de personnes utilisatrices de services qui prennent part au Projet citoyen au Centre de recherche de ce même institut. Les résultats préliminaires de la validation d’une nouvelle mesure de la citoyenneté ont été utilisés pour structurer et faire progresser ce dialogue. Cette étude de cas illustre une façon de trianguler des données issues d’une recherche participative et au sein de laquelle des personnes utilisatrices de services de santé mentale ont été des partenaires de recherche à part entière. Ces pairs assistants de recherche ont notamment assumé la collecte des données auprès de 178 autres personnes utilisatrices de services de santé mentale qui ont répondu à l’échelle de la citoyenneté. Ils ont aussi animé des groupes de discussion autour des résultats préliminaires, notamment pour donner des étiquettes aux domaines émergeant des premières analyses statistiques. Ils ont ensuite dialogué avec la directrice générale venue tremper dans le Projet citoyen, et ce témoignage reflète la teneur de ce dialogue.

EN:

Objective: One of the four main chapters of the consultation document proposed by the Québec Ministère de la santé et des services sociaux (Health and Social Services), in preparation for the National Forum on the Mental Health Action Plan 2014-2020, is dedicated to the full exercise of citizenship. This paper reports the dialogue that took place between the CEO of a university mental health institute and a group of service users, in order to participate in the consultation process regarding the full exercise of citizenship.

Method: Since May 2013, a dozen service users have gathered in the Projet citoyen at the Research Centre of Institut universitaire en santé mentale de Montréal (IUSMM). The Projet citoyen is a culturally adapted transposition, in Québec, of the Citizens Project that is in place in New Haven, Connecticut. One of the key components of both the Projet citoyen and the Citizens Project interventions is a group training regarding citizenship. Participants discuss what it means for them to be full citizens and they support each other in achieving personal or collective goals. To assess progress made in such matters, a new Citizenship Measurement has been developed by the Yale Program for Recovery & Community Health, and translated into French. This Mesure de la citoyenneté is in the process of being validated; peer research assistants conducted data collection by asking 178 people who use the mental health services of Quebec to complete the French Mesure de la citoyenneté. The preliminary results of a statistical analysis were used to structure the dialogue between the IUSMM CEO and the participants of the Projet citoyen.

Results: Three sub-scales emerged from preliminary statistical analysis (clusters). Colleagues of the Projet citoyen were invited, through a focus group conducted by one of them, to give evocative labels to these sub-scales. Regarding the first one, we felt that it was about asking ourselves what we can bring to others’ lives, wondering how we, as members of the community, can make a difference for a more inclusive civic cohabitation. The label “contribution to the community” was chosen. For the second sub-scale, personal and social spheres emerged as both being essential to the achievement of full citizenship. These spheres must be respected in complementarity. Hence we chose the label: “personal and social integrity.” Finally, the third sub-scale seemed to combine items that have the common elements of respecting human rights, respecting the person, and respecting the autonomy of the person. “Rights and freedom of choice” was chosen as a label for that sub-set. The IUSMM CEO immersed herself in the Projet citoyen and as her dialogue with the participants deepened around these features, a sense of mutual respect and friendliness got stronger. Participants were pleasantly surprised to see that an influential CEO can be sensitive and comfortable expressing this sensitivity, even with her emotions while interacting with service users as they are exercising their own citizenship as research colleagues.

Conclusion: This case study illustrates a way of triangulating qualitative and quantitative data sets generated from a participatory-action research project for which people who use mental health services have been active research partners throughout. A mobilizing effect was found among participants of the Projet citoyen who become multipliers once back in their respective communities and neighborhoods. This effect can also affect a senior manager. The ISUMM CEO was inspired to relay and communicate this innovative thinking on the full exercise of citizenship as a governmental priority in mental health. It could thus be recommended to implement and network some Projets citoyens in other educational, research and clinical settings. This would provide opportunities for service users to contribute to the community – here, the scientific community. It would exemplify respect for personal and social integrity by channeling the expression of the lived experience into an instrument of change. These Projets citoyens would advocate for the rights and freedom of choice of service users as partners, in action, of a citizenship-oriented mental health system.