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The European Journal of Psychiatry

Print version ISSN 0213-6163

Eur. J. Psychiat. vol.21 n.1 Zaragoza Jan./Mar. 2007




General practitioners are bearing an increasing burden of the care of common mental disorders in France



Joanna Norton*; Michel David**; Jean-Philippe Boulenger*,***

* Inserm, U888, Montpellier, F-34093; Univ Montpellier I, Montpellier, F-34000
** Department of General Practice, Univ Montpellier I, Montpellier, F-34000
*** CHU Montpellier, Hop La Colombière / Department of Adult Psychiatry, Montpellier, F-34093. FRANCE

Address for correspondence




Introduction: In France, general practice is playing an increasing role in the management of common mental disorders. This is due to a variety of factors, among which the way general practice and specialised mental health services have evolved over time.
Methods: A description of the status quo in France, with a comparison between France, the UK and the Netherlands. A review of reasons for the present position.
Results: The general practitioner (GP) is often the only medical carer to be contacted in cases of psychological distress and over 80% of psychotropic medications are prescribed in this setting. Although most common forms of mental disorder can be managed at the primary care level, GPs need to be able to refer patients rapidly to specialised mental health services. Yet there are delays for consultations with both private and public psychiatrists along with difficulties in finding beds for full-time hospitalisation. The situation is predicted to get worse with the reduction in the number of psychiatrists and GPs forecasted for the coming years. 'Psychiatric sectorisation' has led to a substantial development of community mental health care services, yet this has not compensated fully for the reduction in full-time hospital beds. Furthermore, community mental health care services remain relatively isolated from other community health services with very limited exchanges with general practice.
Conclusion: GPs report an urgent need for training in mental health. Along with improving their ability to accurately detect and treat mental disorders, it is crucial also to improve communication between GPs and psychiatrists and increase shared case-management. Structural changes are also necessary to ensure a quicker and easier access to specialised mental health care services.

Key words: Primary health care, Mental health, Review, Training.


General practice in France is increasingly at the forefront for the management of common mental disorders (mainly anxiety and depression). This is due to a variety of factors linked mainly to the way general practice and psychiatry have evolved over time, a lack of coordinated care between generalist and specialist physicians and a of communication between general practice and community specialised mental health care. After describing the current situation of general practice as well as specialised psychiatric services, this paper will examine how general practice fits in to mental health care in France and the options the general practitioner (GP) has to choose from when managing mental illness.


French general practice

General practice in France contrasts to that in many other European countries. Firstly, France has one of the highest numbers of GPs per head of population1. Yet projections predict a 25% reduction in the number of GPs by 20252. As for all health care facilities in France, there are huge geographical disparities with a lack of physicians practicing in the rural areas and the North and a concentration of physicians in the Paris area and the Mediterranean urban zones3,5. This results from the freedom of choice to set up practice almost anywhere irrespective of the density of physicians in the area.

In France, GPs work as private practitioners on a fee for service basis with patients being paid back fully or partly by the state insurance system. GPs work mainly alone with no ancillary staff and with little contact with other GPs and specialists. Patients were until recently free to consult directly any GP or specialist (private or public) as often as wanted. Since July 2005, every citizen is encouraged to register with a specific physician (in 98% of cases a GP is chosen), responsible for coordinating care and referring patients to specialists6. This measure is hoped to reduce the amount of "shopping around" done by patients and overbooking of costly specialist services by patients with erroneously "self-diagnosed" disorders. Visits to most specialists without referral from the coordinating doctor are financially sanctioned.

Although direct visits to specialists have decreased dramatically7, this new legislation has substantially increased GPs' workload. Furthermore, patients being allowed to choose a GP or a specialist as coordinating physician and change at will, GPs have not been given a clear gate-keeping role restricting access to specialists as in the UK for example. They are regularly faced with the dilemma of complying with patients' demands which is in their interest and ethical considerations. The main differences between the organisation of general practice in France and in two contrasting European countries, the UK and the Netherlands, is shown in Table I.

In France, as elsewhere8, the GP is often the first and only medical professional to be contacted in the case of mental illness9. It is now widely acknowledged that GPs play a key role in the early identification of mental disorders and for severe cases in reducing the delay to appropriate treatment. Furthermore over 80% of all psychotropic medication prescriptions emanate from general practice10,11. Mental illness accounts for approximately one third of all health problems presented to the GP12,13 and is likely to increase hand in hand with the increase of common mental disorders in the general population.

Yet GPs report that they have very little time to deal with psychological problems which already account for longer consultation times14,15 than the 15 minute average16. Despite recent changes introducing additional fees for specific procedures17, the type of consultation and the corresponding amount of time required are not taken into account meaning a fixed rate is charged whatever the length of the consultation. GPs report a lack of initial training in mental health and over two-thirds of them state a need for continuous medical education training specifically in case-detection and psychotherapy18. Prescribing psychotropic medication often remains the only immediate solution. It is a safe "refuge" for GPs faced alone with complex clinical pictures and pushed to the limits of their medical competences19.

It is widely acknowledged that French GPs, as elsewhere, recognise approximately half of cases of psychiatric disorder among their patients12,13, as diagnosis is often made difficult by comorbid physical illness and patients presenting with somatic symptoms only. It has been shown that half of cases of major depression go unnoticed12 and less than half receive adequate treatment9. Improving GPs' ability to establishing accurate psychiatric diagnoses and offer adequate treatment is important11 just as is easy and rapid access to specialised care.


Specialised mental health care services

In France, there are a variety of different mental health services: the public hospital sector-offering inpatient beds in psychiatric hospitals and general hospitals, part-time (day or night) outpatient places, consultations and ambulatory mental health care - private and semi-private psychiatric clinics and private psychiatric practices.

In 2004, France reported 14,000 psychiatrists, that is 22 for 100,000 inhabitants, which is the highest density of psychiatrists in Europe20. 47% of psychiatrists are private. However, 49% of psychiatric establishments and 73% of psychiatric beds are in the public sector21. There are strong regional disparities with the highest density of psychiatrists found in urban centres (especially those with teaching hospitals) and in the southern part of the country. A large number of posts for psychiatrists in the state health system's hospitals lie vacant, especially in the rural areas and in northern France22.

Since the 1960s, state hospital services are organised into geographic 'sectors' each covering a population of approximately 70,000. The aim of this "politique de secteur" is to limit full-time hospitalisation and develop a variety of structures in the community such as out-of-hospital consultation and day care centres, therapeutic workshop centres and home-visits, as well as continuity of care with the same mental health care team23,24. It is also to develop coordinated mental health care involving primarily GPs. Although the extension of psychiatric hospital care into the community has been substantial, there are huge disparities between sectors in the transition from hospital care to ambulatory care leading to different specialised care models in different areas23. Table I shows the main differences between the organisation of specialised mental health care services in France and two contrasting European countries.

Since the 1990s, there have been further large reductions in the number of psychiatric hospital beds and in the mean duration of stay22,24, leading to frequent readmissions after discharge of patients not sufficiently stabilised. These cuts were meant to be compensated for by an even greater development of ambulatory care. Although this varies form one sector to another, it has overall been insufficient, with less than 10% of total mental health expenditure used on public sector community care3.


Forecasted reductions in the number of psychiatrists

Owing to the drastic reduction in the number of medical students since the 1980s (numerus clausus), the number of psychiatrists should decrease by nearly 40% over the next two decades. This should theoretically be sufficient to ensure France's mental health needs25 as it will be comparable to that of other European countries. However, there are already huge disparities in staff and bed resources from one sector to another and inequalities in access to care are likely to worsen, especially if private psychiatry remains unregulated with the possibility of setting up practice anywhere22. Moreover, a large number of private practitioners are principally practicing psychoanalytically orientated psychotherapy26.


The un-bridged gap between general practice and specialised mental health services

Let alone the time constraints of the fee-for-service system, French GPs are confronted with difficulties in accessing specialised care that have worsened with the above-mentioned changes.

The GPs in Verdoux et al's study report long yet similar delays for booking consultations with both public and private psychiatrists for patients with an early onset of schizophrenia. GPs obtained a consultation with a psychiatrist, whether private or public, in less than two weeks for only 40% of patients27. Delays can be expected to be even longer for less severe non-psychotic disorders and to increase in coming years with the forecasted drop in the number of psychiatrists.

The long appointment delay for consulting private psychiatrists can be explained partly by the fact that most patients are seen on a very frequent basis for psychoanalytical therapy only26,28. Private psychiatrists very rarely offer alternative therapies26. They see many patients with personal problems or sub-threshold symptoms only, leaving little time for new patients with definite psychiatric disorders28,29.

Despite similar consultation delays, GPs are more likely to refer patients with early onset schizophrenia to private psychiatrists27. It is likely that this applies even more so to patients with common disorders. Yet, private psychiatrists often charge rates beyond what is covered by the national health insurance, requiring patients with no additional private health insurance to pay the difference. When offering psychoanalytic therapy, the entire fee is often to be paid by the patient as part of the treatment process. Patients managed in the public 'sector' whether in full-time hospitalisation or ambulatory care tend to cumulate other medical and social problems: physical health problems, unemployment, marital problems and poor functioning. This 'patient environment' may no doubt make GPs reluctant to contact public sector psychiatrists for their patients29. GPs most often choose to manage patients in the early stages of mental disorder in general practice. The reluctance to refer them to a psychiatrist comes not only from the long consultation delay but from the complex procedure for booking a consultation. In order to actually be given an appointment it is often the GP who contacts the psychiatrist: for many GPs this involves ringing the psychiatrist and leaving a message on an answer phone (most private psychiatrists work alone with no secretary), being rung back by the psychiatrist, fixing the appointment and then contacting the patient again.

Advising a patient to visit a psychologist can sometimes avoid the stigma attached to seeing a psychiatrist and reduce the length of time necessary to convince the patient to consult. As is the case for private psychiatrists, psychologists offer mainly psychoanalytical therapy. However consultations are never refunded which explains in part why GP patient referral is limited27. French psychologists see mainly children and adolescents; the small proportion of adults consulting them tends to have perturbed personal and professional lives rather than clear-cut psychiatric disorders, coupled with a high level of education29.

Psychotherapies are offered at large in France as there is no convention regulating training and access to the profession (today anybody is entitled to offer psychotherapy). Increasing access to psychotherapies, by structuring the profession (setting official rules for being labelled as a 'psychotherapist') and examining how the costs could be covered by the national health insurance system, is currently under discussion30.

When requiring in-patient hospital care for a patient, both private clinics and public psychiatric hospitals pose problems. Private clinics often charge beyond what is covered by the national health insurance. Regarding hospital services, GPs are often confronted with difficulties in obtaining rapid full-time admission for a patient due to the reduction in hospital beds, a quicker "way in" being sometimes through the emergency services. Furthermore, a patient will preferentially be placed in the sector corresponding to his place of residence. As mentioned above, there are huge disparities between sectors in the offer and quality of care, as well as the theoretical approach to care. Although in theory the rules of 'sectorisation' do not apply to the patient who can choose to be treated by a team other than the one in charge of the catchment area22,24, it is well-known that the choice of the sector is very rarely left up to the patient24.

Public psychiatric care has remained relatively isolated with respect to other health care services. Firstly, there are very few psychiatric services in general hospitals and secondly, although the extension of psychiatric care out of the hospital into the community has been substantial, it remains relatively isolated from other community health care services. This has led to a lack of exchanges with other actors of the health care system24. GPs for example, report no or very infrequent contacts with their local mental health care teams although the vast majority know at least one private psychiatrist or psychiatrist of the sector's mental health care team27. Furthermore GPs report a lack of feedback from psychiatrists regarding the diagnosis and treatment of patients they have referred27,28. They also consider that irrespective of the diagnosis, the relationship with psychiatrists is difficult18, even more so than with other specialists28. Coordinated care and shared case-management will only be achievable if communication between GPs and psychiatrists is improved.



The current trends in medical demography and the lack of coordinated care between GPs and psychiatrists, means that GPs are likely to become increasingly isolated in the management of common mental disorders. The French authorities are well aware of the "time-bomb" related to mental illness which will be increasingly difficult to cope with given the reduction in offer of specialised mental health care31.

As is the case for all drug consumption, France has one of the highest psychotropic drug consumption levels in Europe32,34, with over three quarters of prescriptions emanating from general practice11. A recent report points to the need to increase GPs' ability to accurately identify cases of psychiatric disorder and offer adequate treatment11. Increasing access to psychotherapies has also been highlighted as a priority30. The central role of general practice in the management of mental illness is clearly recognised. Yet, let alone improving accurate GP case-identification and treatment, developing communication and shared case-management between GPs and psychiatrists with better access to specialised care is crucial for France to tackle this growing public health problem.



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 Address for correspondence:
Joanna Norton
Inserm U888, Hôpital La Colombière
Pavillon 42, 39 av. Charles Flahault
BP 34493, 34093 Montpellier Cedex 5 France
Tel : 0033 (4) 99614570 Fax : 0033 (4) 99614579
Norton Joanna :

Received 13 January 2007
Accepted 21 March 2007

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