0808Xavier Briffault is a social science researcher specialized in healthcare at the CNRS-CERMES3 and is involved in the Crazy App and Altotoc projects with the team led by Luc Mallet at the ICM. He recently wrote a book entitled “Mental health, public health”, published by Grenoble University Press. In his book, he develops a critical analysis of the public health program that aims at training parents on “best parenting practices” to prevent drug use by their children, and the various ways of improving mental health care through different strategies including placing the patient at the heart of healthcare and training practitioners. Current technological opportunities may pave the way for healthcare that meets patient needs more appropriately, with improved consideration of their specificities and environments.
WHY AND HOW IS MENTAL HEALTH CURRENTLY AN IMPORTANT TOPIC FOR PUBLIC HEALTH?
The first thing to consider is that mental health is one of the priorities announced by healthcare authorities, including the WHO, due to it being a factor of morbidity/mortality in industrialized countries. According to these authorities, depression is the 4th leading cause of morbidity/mortality in industrialized countries and will be the 2nd within the next 20 years. In every epidemiology study, mental health plays an important role in illness and directly contributes to mortality with suicide.
IS THE COST OF MENTAL HEALTH ALSO AN ISSUE?
The cost of psychiatric disorders, in the healthcare system, is indeed tremendous. This was already the case in the past, since mental health illness is nothing new, but the situation has evolved: infectious diseases have improved in prevention and care, and management of cardiovascular illnesses as well as cancer have improved as well. We are also becoming a society of services, going from an agricultural society to an industrial society, to an intellectual society where organizational, relational capacities as well as independence and being in charge of oneself has become much more important for individuals than in societies where workers and farmers were needed. In the past, different capabilities were required of individuals.
One hypothesis, simply put, is that mental inner life is a public issue. Where workers were previously required to be in good physical health, we now need workers in good mental health. Tuberculosis was the great catastrophe of the 19th century, and depression is the great catastrophe of the 20th century: it alters individual skills pertaining to initiative, independence, intellectual creation, and social interaction. Managing mental health and “maintenance” has become a public health issue.
The current economic system, qualified as “liberal”, is more individualistic than systems with strong government regulation and leads to higher requirements in terms of relational skills and skills for management of complex situation. These skills are exactly what individuals with various types of mental disorders are missing, including those with “common mental disorders” (depression and anxiety, for example). Serious mental health issues are no longer confined to “madness”. The development in the past 30 years of coaching, psychotherapy, and personal growth methods is a good illustration of how important self-performance management has become.
HOW ARE MENTAL DISORDERS DEALT WITH IN THE PUBLIC HEALTH ENVIRONMENT?
Risk factors are currently in the spotlight with early prevention, and dealing with problems before they appear. Drugs are an example of this, as they are increasingly considered as a mental health issue. To prevent drug use by future adults, certain programs consider it best to start educating children or even their parents, before they are born: research shows that certain parental factors influence drug use in descendants.
Public health programs rely on this approach by targeting specific issues and implementing training on best parenting practices to «teach parents how to be good parents, and teach kids how to be good kids».
According to some experimental results, this could have consequences on a decrease in substance abuse. However, the associated methodology is lacking in heft and efficacy is limited. Additionally, working with parents and children solely in the aim of lowering drug use, with more global actions on parenting, means ignoring consequences of these programs on other facets of life.
IN YOUR OPINION, HOW SHOULD PATIENT CARE CHANGE?
We need to look at the problem from a systemic point of view: mental health problems are bio-psycho-social, meaning that we need to have a synergistic approach to all the factors that contribute to the onset and persistence of mental health disorders. An integrated, not independent, approach is needed to consider the many interactions among factors.
Reality can no longer be divided into separate factors, just as prevention needs to go further than simple campaigns that have nearly no added value when it comes to real-life situations. What I recommend, in keeping with our recommendations at the Public Health Council and our actions with the National Mental Health Council, is paying greater attention to the geographical location where people spend the most time for their activities, where they actually live. We need to have everything needed in these areas to improve mental health: an appropriate physical environment, an enriching cultural environment, high-quality education, and ongoing education on mental health.
HOW CAN SCHOOL PLAY INTO IMPROVING MENTAL HEALTH?
There is so much we can do at school, including fighting against stigma: we often attempt to explain how important it is not to reject individuals who suffer from mental illness, because they aren’t responsible for their disorders. It’s a first step, but it isn’t enough. It can be complicated to interact with these individuals: to improve interactions, we need to develop operational skills, and in order to do that, we need to experience the disorder close up and get to understand it. The best possible solution is creating an “open” school, that welcomes children with various disorders. Of course, it implies material and human support with skilled adults, as well as educating children on mental health issues.
A health education program is currently being implemented at school: it needs to include mental health education, too!
BEYOND EDUCATION, WHAT ARE OTHER WAYS TO ACT ON MENTAL HEALTH?
There are many factors aside from education that impact mental health: urban environment, cultural environment, daily well-being, all of these are fundamental for good mental health. Social protection measures are also very important, to improve quality of life (transportation availability, daycare, schools, etc.) and reduce stress. Healthcare needs to be readily available as well.
WHAT ABOUT PRACTICIONER TRAINING?
General practitioners currently manage nearly all primary mental health problems. They have very little support and training, which is mainly medical, leading to a drug-centered approach. Most of the time, they are unable to manage the situation as a whole, especially factors pertaining to pre-existing disorders (personal history, environment, etc.).
This is a real problem, leading to our current situation with a lack of psychological healthcare. Neither psychologists nor psychiatrists are fully trained in psychotherapy in France, contrary to Canada and Switzerland. We need a true training program for psychotherapists, with a full curriculum. In my book, I explain that the perfect mental health expert should be a psychiatrist, psychologist, psychoanalyst, psychotherapist, linguist, and sociologist all in one…as well as a practitioner. We need to be able to understand the living environment, family dynamics, and the work environment all at once…
This brings us back to one of the major public health issues: we give practitioners simple instruments, applicable to everyone, however we are unable to develop training that would allow them to tailor and personalize patient care.
WHAT WOULD YOU SAY ARE FUTURE PERSPECTIVES TO IMPROVE MENTAL HEALTHCARE?
We are currently attempting to heighten the action potential of practitioners by using connected devices and mobile devices to enable long-distance contact with patients that would allow us to collect more data on each individual. We are currently working on a suicide prevention app with Margot Morgiève (CERMES3, ICM) that aims at collecting real-time data to monitor situations and suggest various modes of intervention.
If you remember only one thing from my book, it’s this: instead of generalizing, standardizing and decontextualizing patient care, we need to put them in context, make them local and tailored. Dividing everything into smaller parts, the basic scientific method to make sense of problems, is insufficient to implement useful action. We must also implement a terrain-based approach and methods capable of taking into account systemic phenomena and individual factors.
This is exactly what connected devices will enable. Up until now, appointments were short and rare due to equipment availability, and we were also missing the material support to carry out studies and collect patient information. Connected devices will allow us to follow the situation closely, with real-time information… for more precise action and tailored options.
Reference: Santé mentale, santé publique – Un pavé dans la mare des bonnes intentions. Xavier Briffault. Presses Universitaires de Grenoble, collection Points de vue. 2016.