Correspondence
www.lancet.com/psychiatry Vol 2 August 2015
Numbers of beds opened since the creation of UHSA
In her recent article in The Lancet Psychiatry, Colette Davidson rightly draws attention to the worrying situation of forensic psychiatry provision in France. 1 Indeed, the number of inmates with psychiatric disorders has increased alarmingly in France in the past decade,2 and we cannot agree more that prison is not the most appropriate place for people with severe mental health issues.1 However, most of the problems discussed are not only confined to the French prison service’s institutions, since the high prevalence of psychiatric disorders in prisons is also a worldwide issue.3 In Europe, forensic psychiatric provisions differ greatly across countries and several management disparities also seem to exist. Thus, we believe that cultural and historical differences need to be taken into account to understand the organisation and provision of care to prisoners in each individual country. In France, the dichotomy between the justice system and the health system is constitutional. The professional independence of caregivers from the judiciary system and medical confidentiality are fundamental values on which French psychiatric care facilities for prison inmates have been built (eg, Services Médico-Psychologiques Régionaux, which are fully managed by the Ministry of Health). Furthermore, major changes have taken place in recent years. For example, the creation, in 2010, of Unités d’Hospitalisation Spécialement Aménagées—full-time inpatient units for inmates—is starting to yield encouraging results since the suicide rate in French prisons, although still high, has fallen slightly (figure). These hospitals are sometimes attached to a university (as is the case in Lille), thereby
500
25
Number of beds Suicide rates per 10 000 inmates
450 400
20
350 300
15
250 200
10
150 100
5
Suicide rates per 10 000 inmates
France’s forensic psychiatry provision: the long and winding road
50 0
0 2010
2011
2012
2013
2014
2015
Year
Figure: Change in the suicide rates in French prisons (2010–15) compared with the number of beds opened since the creation of the UHSA in 2010 UHSA=Unités d’Hospitalisation Spécialement Aménagées. Data are from the French Ministry of Health and the French Ministry of Justice.
enabling the development of specific courses, conferences, and teaching. The attributes explained here also bear specific difficulties. The transparency and free-sharing of information between the justice system and the health system is strictly limited or almost nonexistent in France. Only the psychiatric expert commissioned by the justice system is released from medical confi dentiality to produce a report, which will eventually decide whether or not an individual is to be allowed access to care or face incarceration. Unfortunately, patients are very rarely judged to be not responsible for their crime because of their mental health status, and they are often condemned to wrongful prison sentences. Since the situation of patients with psychiatric disorders in prison is a global issue, we believe that forensic psychiatry practices have much to gain by sharing experiences and information through international networks and initiatives. For example, despite the several advantages mentioned by Davidson, the English forensic psychiatric services also raise various ethical obstacles, such as indeterminate detention justified by reference to public protection and an increased focus on risk prediction (illustrated by the implementation
of Dangerous and Severe Personality Disorder Units). 4 Finally, we believe that the existing trend towards over-specialisation in forensic psychiatry should not inadvertently lead to differentiated care for patients who have committed an offence or a crime (almost as if they were representative of a distinct group). Thereby, all psychiatrists should undergo a basic level of training in core forensic psychiatric principles, keeping in mind that the clinician’s role is not to enforce policy against acts of criminality but to provide care for patients.5
For the data on the impact of the UHSA on suicide rates in French prisons (2010–15) see www.sante.gouv.fr and www. justice.gouv.fr
We declare no competing interests.
*Thomas Fovet, Pierre Thomas, Catherine Adins, Ali Amad [email protected] Univ. Lille, CHU Lille, Pôle de Psychiatrie, F2RSM, Unité d’Hospitalisation Spécialement Aménagée (UHSA) Lille-Seclin, F-59000 Lille, France 1
2
3
4
5
Davidson C. France’s forensic psychiatry provision—is it up to scratch? Lancet Psychiatry 2015; 2: 385–87. Falissard B, Loze J-Y, Gasquet I, et al. Prevalence of mental disorders in French prisons for men. BMC Psychiatry 2006; 6: 33. Fazel S, Seewald K. Severe mental illness in 33,588 prisoners worldwide: systematic review and meta-regression analysis. Br J Psychiatry 2012; 200: 364–73. Buchanan A, Grounds A. Forensic psychiatry and public protection. Br J Psychiatry 2011; 198: 420–23. Fovet T, Geoffroy PA, Vaiva G, Adins C, Thomas P, Amad A. Individuals with bipolar disorder and their relationship with the criminal justice system: a critical review. Psychiatr Serv 2015; 66: 348–53.
e20
www.lancet.com/psychiatry Vol 2 August 2015
Numbers of beds opened since the creation of UHSA
In her recent article in The Lancet Psychiatry, Colette Davidson rightly draws attention to the worrying situation of forensic psychiatry provision in France. 1 Indeed, the number of inmates with psychiatric disorders has increased alarmingly in France in the past decade,2 and we cannot agree more that prison is not the most appropriate place for people with severe mental health issues.1 However, most of the problems discussed are not only confined to the French prison service’s institutions, since the high prevalence of psychiatric disorders in prisons is also a worldwide issue.3 In Europe, forensic psychiatric provisions differ greatly across countries and several management disparities also seem to exist. Thus, we believe that cultural and historical differences need to be taken into account to understand the organisation and provision of care to prisoners in each individual country. In France, the dichotomy between the justice system and the health system is constitutional. The professional independence of caregivers from the judiciary system and medical confidentiality are fundamental values on which French psychiatric care facilities for prison inmates have been built (eg, Services Médico-Psychologiques Régionaux, which are fully managed by the Ministry of Health). Furthermore, major changes have taken place in recent years. For example, the creation, in 2010, of Unités d’Hospitalisation Spécialement Aménagées—full-time inpatient units for inmates—is starting to yield encouraging results since the suicide rate in French prisons, although still high, has fallen slightly (figure). These hospitals are sometimes attached to a university (as is the case in Lille), thereby
500
25
Number of beds Suicide rates per 10 000 inmates
450 400
20
350 300
15
250 200
10
150 100
5
Suicide rates per 10 000 inmates
France’s forensic psychiatry provision: the long and winding road
50 0
0 2010
2011
2012
2013
2014
2015
Year
Figure: Change in the suicide rates in French prisons (2010–15) compared with the number of beds opened since the creation of the UHSA in 2010 UHSA=Unités d’Hospitalisation Spécialement Aménagées. Data are from the French Ministry of Health and the French Ministry of Justice.
enabling the development of specific courses, conferences, and teaching. The attributes explained here also bear specific difficulties. The transparency and free-sharing of information between the justice system and the health system is strictly limited or almost nonexistent in France. Only the psychiatric expert commissioned by the justice system is released from medical confi dentiality to produce a report, which will eventually decide whether or not an individual is to be allowed access to care or face incarceration. Unfortunately, patients are very rarely judged to be not responsible for their crime because of their mental health status, and they are often condemned to wrongful prison sentences. Since the situation of patients with psychiatric disorders in prison is a global issue, we believe that forensic psychiatry practices have much to gain by sharing experiences and information through international networks and initiatives. For example, despite the several advantages mentioned by Davidson, the English forensic psychiatric services also raise various ethical obstacles, such as indeterminate detention justified by reference to public protection and an increased focus on risk prediction (illustrated by the implementation
of Dangerous and Severe Personality Disorder Units). 4 Finally, we believe that the existing trend towards over-specialisation in forensic psychiatry should not inadvertently lead to differentiated care for patients who have committed an offence or a crime (almost as if they were representative of a distinct group). Thereby, all psychiatrists should undergo a basic level of training in core forensic psychiatric principles, keeping in mind that the clinician’s role is not to enforce policy against acts of criminality but to provide care for patients.5
For the data on the impact of the UHSA on suicide rates in French prisons (2010–15) see www.sante.gouv.fr and www. justice.gouv.fr
We declare no competing interests.
*Thomas Fovet, Pierre Thomas, Catherine Adins, Ali Amad [email protected] Univ. Lille, CHU Lille, Pôle de Psychiatrie, F2RSM, Unité d’Hospitalisation Spécialement Aménagée (UHSA) Lille-Seclin, F-59000 Lille, France 1
2
3
4
5
Davidson C. France’s forensic psychiatry provision—is it up to scratch? Lancet Psychiatry 2015; 2: 385–87. Falissard B, Loze J-Y, Gasquet I, et al. Prevalence of mental disorders in French prisons for men. BMC Psychiatry 2006; 6: 33. Fazel S, Seewald K. Severe mental illness in 33,588 prisoners worldwide: systematic review and meta-regression analysis. Br J Psychiatry 2012; 200: 364–73. Buchanan A, Grounds A. Forensic psychiatry and public protection. Br J Psychiatry 2011; 198: 420–23. Fovet T, Geoffroy PA, Vaiva G, Adins C, Thomas P, Amad A. Individuals with bipolar disorder and their relationship with the criminal justice system: a critical review. Psychiatr Serv 2015; 66: 348–53.
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