|INTERNATIONAL PERSPECTIVE: REVIEW ARTICLE
|Year : 2014 | Volume
| Issue : 1 | Page : 10-18
Community mental health service: an experience from the East Lille, France
Jean Luc Roelandt1, Nicolas Daumerie2, Laurent Defromont3, Aude Caria2, Paula Bastow4, Jugal Kishore5
1 WHO Collaborating Centre for Research and Training in Mental Health (Lille, France), East Lille Services EPSM Lille Métropole, Lille, France
2 WHO Collaborating Centre for Research and Training in Mental Health (Lille, France), EPSM Lille Métropole, Lille, France
3 Department of Medical Information and Research, EPSM Lille Métropole, Lille, France
4 Department of Health, Care Services Improvement Partnership, United Kingdom
5 Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
|Date of Web Publication||3-Nov-2014|
Dr. Jugal Kishore
Department of Community Medicine, Maulana Azad Medical College, New Delhi - 110 002
Source of Support: None, Conflict of Interest: None
Over the past 30 years in the Eastern Lille Public Psychiatric sector, there had been progressive development of set up in community psychiatry. This innovative set up conforms to WHO recommendations. The essential priority is to avoid resorting to traditional hospitalisation, and integrating the entire health system into the city, via a network involving all interested partners: users, carers, families and elected representatives. The ambition of this socially inclusive service is to ensure the adaptation and non-exclusion of persons requiring mental health care and to tackle stigma and discrimination. It gives a new perception to psychiatry that is innovative and experimental, and observing human rights, i.e. citizen psychiatry. This experiment also provides lesson to India for effective implementation of its national mental health program.
Keywords: Community mental health, citizen psychiatry, France, India, Lille
|How to cite this article:|
Roelandt JL, Daumerie N, Defromont L, Caria A, Bastow P, Kishore J. Community mental health service: an experience from the East Lille, France. J Mental Health Hum Behav 2014;19:10-8
|How to cite this URL:|
Roelandt JL, Daumerie N, Defromont L, Caria A, Bastow P, Kishore J. Community mental health service: an experience from the East Lille, France. J Mental Health Hum Behav [serial online] 2014 [cited 2019 Jan 20];19:10-8. Available from: http://www.jmhhb.org/text.asp?2014/19/1/10/143884
| Introduction|| |
For 30 years, every effort has been made to integrate psychiatry into the field of medicine, and mental health into the health field. Mental health has become everyone's business: Psychiatry and social exclusion specialists and non-specialists are united in fight against mental disorders. Information about diseases and treatments, prevention and psychosocial rehabilitation are part of the patients' rights and society's duties. This mix of all sectors is termed as "citizen psychiatry" , based on the 'five principles', which were developed over time:
- Human and civic rights are inalienable. Psychiatric disorders can never invalidate them
- Justice and psychiatry, prison and hospital, imprisonment and care must no longer be confused
- Society, and therefore mental health services, has to adjust to patients' needs, not the other way round
- Citizen Psychiatry supersedes the strategy of French sectorization, in force since 1945, as it promotes the closure of medical and social exclusion places like asylums and large institutions
- Fight against stigmatization and discrimination is essential: raising the population's awareness in order to modify the prejudices of danger, misunderstanding and incurability against people with mental problems and facilitating access to care. 
The application of these principles to the functioning of a healthcare service implies changes in fundamental practice that can be summarized as follows:
- Change of paradigm: Psychiatric services should no longer have partners but be a partner
- Liaison of the psychiatry sector with mental health participants: users, families, towns' health and social leaders
- Coordination of responses to the population's needs in healthcare requires the involvement of local elected officials, in order to give coherence to a global and non segregated position, between health, social and cultural services
- Involvement and integration of users and families in healthcare and its management.
| Socio-Demographic Context of the Psychiatry Sector in East Lille|| |
The psychiatry sector of East Lille covers an area of 2653 hectares in the south-eastern area of the metropolis of Lille, i.e. 6 towns of the Eastern suburb, which has a population of 86,000 inhabitants living in the urban zone. Eastern Lille Suburbs comprises the following towns: Faches-Thumesnil, Hellemmes-Lille, Lesquin, Lezennes, Mons-en-Barœul and Ronchin.
The E.P.S.M (Former Psychiatric hospital of Armentières renamed Etablissement Public de Santé Mentale, Lille Métropole, i.e. Public Mental Health Institute Lille Métropole) Lille-Métropole, whose administrative headquarters are located in Armentières 25 km West of Lille, is in charge of the service administrative management. This area is close to the Nord-Pas-de-Calais region of France, in which 4.2% of the population is of foreign origin and has more unemployment (15.6% vs. a national average of 11.1%). Health statistics show an abnormally high death rate, the shortest life expectancy in France and an under resourced health system. The Nord-Pas-de-Calais region is, historically, having big asylums and 4 big hospitals located in around Lille, whose psychiatry units started to integrate themselves closer in to the community 10 years ago.
In 1998, the psychiatry service of Eastern Lille suburbs, Public Mental Health Institution, Lille Metropole (EPSM Lille Métropole) was promoted as a pilot site for community mental health by the mental health division of World Health Organisation (WHO). Since 2001, it has recognized the French WHO Collaborating Centre for Research and Training in Mental Health (WHOCCRTMH) for its community mental health program. WHOCCRTMH is one of the founding members of the International Mental Health Collaborating Network (IMHCN), created in 2001 in Birmingham, for the promotion of international cooperation in the field of pilot experiences in community mental health.
| Historical Background|| |
In 1977, there was shift in the management of mentally ill subjects in one of the sectors. The leadership decided to change the treatment modality in adult psychiatry sector. From the 6 units in the Mental Hospital at Armentières hosting over 300 chronic mentally ill people, about 60 "restless" people from the whole region and the Loos Lez Lille prison, were restricted to the regional units for compulsory treatment, and 15 tuberculosis patients.
To help the transformation, a private non-profile Medico-Psycho-Social Association (AMPS: Association Médico-Psycho-Sociale) was created early in 1977, which gathered all good will of that time to change the asylum system and to develop psychiatric sectorization. In conjunction with the hospital of Armentières, the AMPS gathered the elected officials of the 6 towns in the sector, care professionals, social partners and people interested in the implementation of the sectorization policy in East Lille. To begin with, it brought about the opening of the Maison Antonin Artaud (medico-psychological centre) and favored the free acquisition of the premises by the municipality of Hellemmes. It acted as the lever for all the subsequent development that was carried out.
The first mission of the AMPS was to raise the population's awareness about mental health issues and the importance of integrating people suffering from mental health problems into the City. Numerous meetings were organized in the neighbourhood. Then, research was carried out to study more precisely the stereotypes of "mental illness" and "madness" and the stigmatization of "mentally ill" or "mad" people. This research work, supported by the Nord-Pas-de-Calais Regional Council early in 1979, enabled the implementation of a policy of integration and public education. The project was able to develop common ground for psychiatry team and local artists, keeping as an objective of rooting out the negative image of madness and mental illnesses by the population in the towns of the sector. Several cultural and artistic programs were organized together by the psychiatry teams and municipal authorities.
In 1982, AGORA (Greek word for an open "place of assembly"), a centre of housing and deinstitutionalization, specializing in the rehabilitation of long term patients, was created. Its employees were paid by the AMPS. This experience initiated first contacts with social landlords, for the setting up of an associative and 'therapeutic flat', then for access to dispersed associative housing facilities.
These 30 years of common work within the association and with health and social authorities enabled the changes, and this constitutes the psychiatry sector of the Eastern suburb of Lille today. The change occurred in 2 essential steps:
- The first step (1975-1995) was the shift from the psychiatric hospital to the community, by the development of sectorization with the help of the global budget. In 1975, 98% of the budget was devoted to full-time hospitalisation (i.e. 300 beds in Armentières)
- The second step (1995-2006) consisted of decentralising and opening the psychiatry service by integrating team professionals in the health, social and cultural services of the towns. This integration increased the partners' participation (users, families, professionals and elected officials) in the decisions of the psychiatry service. The overall objective is that the psychiatry team goes out of its ghetto and thus professionals become "nice to know" by the population. Structures cannot be set up without the local elected officials' legal agreement. The overall philosophy is one of care and support. The practice is open and multi-faceted.
In 2009, 80% of professional staff was assigned to the city, while 20% remained assigned to full-time hospitalisation (26 beds, 9 are occupied in average). Today's care structures of the East Lille sector are, thus, spread within the cities, over a dozen different places, and always in contact with one another, which facilitates the patient's moves between each unit. These supported places are either rented most of the time or put at the disposal of patients by the towns, and are located closest to the treated population.
In 2010, following the positive development in France of the mental health local council (National Program 2008-2011) where the AMPS has been transformed into a mental health local council (MHLC) gathering the 6 municipalities of the eastern Lille mental health services territory. The MHLC provides a discussion platform for 6 towns' mayors, citizens, users of mental services, families, artists, cultural services, low income housing services, curators, social services, sanitary services, and psychiatric services.
Similarly, prevention and information education communication activities are planned with the involvement of all stakeholders.
| Caring Places: Accessibility and Continuity|| |
The psychiatric consultation centre "Maison Antonin Artaud" is located in a municipal house in Hellemmes. This place also hosts social receptions of the Unité Territoriale de Prévention et d'Aide Sociale d'Hellemmes (Territorial unit of prevention and social help/General Council) and the support service for gypsies.
The Van Belleghem medico-social centre is located in a Communal Centre of Social Action (in Faches-Thumesnil). This centre also hosts consultations for Maternal and Child Welfare, the Alfred Binet child psychiatry centre, sports medicine and social services. Psychiatric consultations are available within the Sports-Medical Centre located in the premises of the swimming pool in Ronchin. They are also available in the premises of the Territorial unit of prevention and social action of Hellemmes and Mons-en-Baroeul, which deals with elderly people and children (Maternal and Child Welfare) and is in charge of the follow-up of people in a precarious situation in the towns being served. Finally, they are available in the Medical House (Maison Médicale) of Mons-en-Baroeul, where one of the offices is rented to the sector team.
In all these places, consultations are offered. Besides psychiatrists of the sector, psychologists, psychomotility therapists and psychoanalysts offer diverse techniques such as psychoanalytic, cognitive-behavioural or systematic therapies.
Any person wishing to have a mental health care in that service, automatically see his/her general practitioner first, who provides an introductory liaison letter. These people are welcomed within 24 h by a nurse of the sector, who assesses the situation and the emergency level, according to the attending physician and the result of the nurse assessment. If need be, the user is seen on the very same day by a psychiatrist. For cases that are judged as non urgent, an interdisciplinary meeting is organized twice a week, in order to provide user with better guidance and care.
Services of inclusion and care activities integrated in the city
Centres of therapeutic activities are called services of inclusion and care activities integrated in the city. A devoted team organizes inclusion and care activities in all artistic, sport and cultural places in the 6 towns of the sector and in the Frontière$ centre.
Altogether, 48 different activities are offered per week, with 60% of them taking place in 21 places outside the service (association, social centre, maison folie, media library, retirement home, sports facilities, etc.).
In this system, activities are made upon medical prescription and reviewed regularly with users. They are all carried out in municipal structures, in conjunction with the local associative network, and are led by professional artists, sports professors (4 h of weekly time paid by the EPSM Lille-Métropole). These activities include Plastic arts workshop, aesthetics workshop, media library, sports, dance, music, singing and video activities, as well as psycho bodily activities (body awareness "vécu corporel", stimulation, aquarelax).
Also, a therapeutic workshop has been developed at the FRONTIERE$ Centre in Hellemmes. This artistic centre in the inner city is co-located with a contemporary art gallery, financially being supported by the Regional Direction of Cultural Action (Direction Régionale de l'Action Culturelle), which organizes monthly exhibitions. The planning is meant to be diverse, as it opens towards inhabitants' leisure and daily life. No matter where they take place, activities are above all designed as a springboard to support the users' integration into local life and to give them the tools to break their social isolation. These activities include the possibility to have one's meal in municipal restaurants or in a municipal room where meals are being delivered by a caterer.
The psychosocial rehabilitation teams (apartment service, activities service, work placement service), lead inclusion activities and are also in charge of home visits, scheduled nurse interviews, and socio-educative guidance in conjunction with the City's services. Whether at home or in a unit, the multidisciplinary team offers a personalized follow-up with adapted intensity and frequency, in conjunction with a psychiatrist in-charge. Over 500 patients benefit from this type of support every year.
The historic part of the local services, the Jérôme Bosh Clinic, a full-time in-patient unit, remains located in EPSM Lille-Métropole at Armentières. This in-patient service will be transferred to the Lille General Hospital in the near future. In these fully renovated premises, 20 patients can be hospitalised and benefitted from the intensive care program. In 2006, the mean occupancy was 10 beds out of 20 for a mean length of stay of 8 days. During hospitalization, besides medical, psychological, nurse and socio-educational interviews, the patient benefits from artistic therapeutic activities (plastic arts, video, and music) and from bodily support (psychomotility, hydrotherapy, relaxation, dietetics, and aesthetics). The unit is completely open (doors are not locked, a person at the entry is in charge of watching entries and exits), and whatever the kind of placement is, it could be compulsory by legal order or by a third person request or free will of user. Patients have access to the information applicable to them, including their medical treatment. They also attend meetings between carers and users, twice a week. There is a close articulation with the teams of the sector, which establishes first contact with the patient during hospitalization, to consider his/her discharge. Some hospitalized people are also taken to the FRONTIERE$ Centre, in order to benefit from therapeutic activities, and meals in the Concorde room (in a municipal town), with patients in day care.
| Alternatives to Hospitalization|| |
Therapeutic host family as an alternative to hospitalization
Therapeutic host families as an alternative to hospitalization were established in 2000 and there are currently 12 beds already available. In this case, the patient in an acute situation is sent to the family either directly, after a consultation, or secondarily after a hospitalization, for some days or some weeks. The instructions given to families are to host the person, not to cure him/her. A nurse and the social and medical team take care of support during home visits (management of treatment, link with therapeutic activities and consultations with the sector, in order to develop the individual project). Support is similar to that offered within the full-time hospitalization unit located in the hospital: medication, hydrotherapy and therapeutic activities carried out in the city in consultation centres and the towns' activity centres.
Families are paid up to 1036 euros per patient per month by the EPSM Lille-Métropole. They are an integral part of the psychiatry sector team. They provide attention and support which are important for patients. In family stays as an alternative to hospitalization, the average length of stay is 21 days. The host family in this way is therapeutic through the family dynamics complemented by the professional team and thus, enables personalised care of good quality.
Intensive care integrated in the city as an alternative to hospitalisation
This unit of 10 beds organizes reinforced follow-up of people who need it, during a repeatable period of 8 days. This follow-up takes into account the close circle of supporters and the patients' needs for a brief time, and for a reinforced follow-up (nurse interview, psychiatry, psychological consultations, relaxation, activities, etc.). This mode of intervention involves all carers (private nurses, general practitioner, local pharmacist, etc.) and all the person's de facto caregivers (family, friends, circle, etc.). It is the same team, along with the psychiatrist on call in the sector, which can be mobilized within 24 h for people in the need of the service. It responds to post emergency situations, in order to guarantee total continuity of care and guidance to the patients.
Reduction in stays and admissions for full time hospitalizations related to host families and development of home care treatment is given in [Table 1].
|Table 1: Paradigm shift from full time hospitalisation to home care treatment in Lille, France|
Click here to view
Inclusion and rehabilitation: "Dare to care"
The aim of the social inclusion program of WHO was to include and integrate care of mentally ill person within social groups and the regularization of the administrative, financial and social situation of the user. Mental health service at Lille has adopted WHO theme "Dare to Care" (WHO 2001) and other recommendations , by developing and combining these three components in order to reach the overall objective: housing; employment; leisure, arts and culture.
Access to associative apartments spread in the social fabric of the town is one of the major components of inclusion work. An "apartment committee" gathers the members of the Medico-Psycho-Social Association (AMPS: Association Médico-Psycho-Sociale), the representatives of public housing offices (HLM: Habitation ô Loyer Modéré), social landlords, caregivers, the representatives of users and family associations and trustees. This committee decides on the allocation of apartments located in the public housing stock. The president is a locally elected official. The AMPS covers the deposit; the patients cover the rent and the general expenses, with the help, if need be, of the trustee or the guardian and the team. The caring and socio-educational team is in charge of medical and socio-educational follow-ups. The therapeutic program comprises regular consultations with the psychiatrist in charge, the treatment taken, nurse interviews and schedules of therapeutic activities. Since the creation of the Committee, 150 apartments have been put at the disposal of patients, mostly as a co-tenancy of two or three people, with the presence of one student per apartment, who is hosted ex gratia to share the tenants' lives.
Currently, 57 apartments are supported by the "apartment committee" and 95 people, who accepted a contract of social inclusion and care, are being benefitted from this method of housing allocation. They are follow up by a specific mobile team, all days of the week i.e. 7 × 24 h.
Résidence André Breton
This associative and therapeutic residence is another form of access to accommodation, again within the framework of the public housing system. It is located in Faches Thumesnil and comprises six sheltered apartments and a large therapeutic apartment which hosts six people with severe handicap. The residence is completed by 5 social accommodation facilities entirely managed by the municipality. This accommodation is made possible by the constant presence of hospital staff (care assistants, health education assistants, education assistants and hospital service agents). Each patient is the tenant of his/her apartment. It is a genuine alternative to the concentration of the severely handicapped in specialised homes, which is a new form of handicap segregation. Assistance is given to the person who enables a good mix of the population, rather than segregation.
Housing to avoid very long term hospitalization
The Résidence Ambroise Paré, located in a block of low-rent accommodation, comprises two studios, one of which is occupied by a student, one 3-room apartment occupied by two users residents, and a 4-room apartment housing a student and 2 residents. This scheme is part of a social program of low rent accommodation approved by the municipality of Lille and social landlords.
The Résidence Samuel Beckett is a former centre for housing and social rehabilitation, for patients from the sector, settled here as a first step to change the service (discharge of patients who have stayed in hospital for a long time). This centre, which is owned by the municipality of Fâches Thumesnil, hosted the hospital day-activity and the regional centre for the setting up of basketball boards in the cities. Today, the structure, which is put at disposal by the EPSM Lille-Métropole, hosts:
- An apartment accommodating a therapeutic host family, providing an alternative to hospitalization, with a user host for a mean period of six months, that corresponds to the rehabilitation period. The family also insures supervision duties in exchange of free accommodation
- A second 5-room apartment, next to the first one, which is a therapeutic, associative, social and transitional hosting place, for patients who are medically stabilized and in transit for sheltered accommodation, a private or social apartment, a retirement home or any other accommodation facility. A student is also accommodated with the beneficiaries.
There is a housekeeper in the transitional apartment premises. The educational team is there during evenings and weekends. It observes and assesses the people's self-sufficiency and ability to live alone or in a shared apartment and to manage their daily life on their own. The sector nursing staff is in-charge of the visits and monitors therapeutic treatments.
Partnership with the centre d'adaptation à la vie active (centre for adaptation to working life)
The centre d'adaptation à la vie active (CAVA) located in Fâches-Thumesnil, is an association through the French law of 1901 (Association de Handicapés de Fâches Thumesnil: Association of disabled people of Fâches Thumesnil), which is a part of the field of inclusion through economic activities. Its purpose is to promote access to the job market for people with major difficulties of social and professional exclusion (recipients of minimal social income, long-term unemployed people). It has 20 places via a contrat d'Accompagnement dans l'Emploi (C.A.E.) (supervised work placement) or via a contrat d'avenir. The partnership with the sector leads to:
- The provision of 15 places within a specific setting, reserved for users referred to the centre by a sector psychiatrist. The aim is to "reboot" professional abilities (working patterns, professional relationships, team working, etc.). Patients are referred to the centre either directly or after an assessment by the occupational therapist of the therapeutic workshop in the Frontière$ Centre, which was set up within the CAVA premises during 2006
- The implementation of a socio-professional inclusion scheme for the disabled (DISPHP: Dispositif d'Insertion Socioprofessionnelle en direction des Personnes Handicapées), which offers applicants a personalized and tailored course of socio-professional inclusion. This comprises successive steps: First, in training centers, in order to define the person's professional level and to validate it through work experience. Then, according to identified abilities and needs, the person is referred to qualifying training, possibly to a sheltered environment or, for most people, to the ordinary environment, via a contrat d'accompagnement dans l'emploi (CAE) (supervised work placement), within municipalities, local communities or partner associations.
The establishment of vocational rehabilitation integrated in the city
Following a 3-year study carried out by a committee of experts, an experimental project was created, led by the municipality of Lezennes in the framework of the AMPS, composed of representatives of users and family associations, and associations of professionals in the field of economic inclusion. It is "integrated in the city" insofar as it is devoid of any production unit; all handicapped workers practise their professional activity within municipalities, local communities and partner associations, via the Work Centre. It enables people who are unable to integrate normally into the ordinary environment and who can however, find their place in conditions adjusted to their handicap.
In 2006, a new project to this scheme was added: "therapeutic work", whose purpose is to renovate and to furnish associative apartments, which needed furnishing or improvements to the living spaces. It is based on the principle of voluntary service and self-help by and for users, and it is led by a workshop supervisor, and an occupational therapist, assisted by an artist. It is a first step towards the return to employment, through the help of active groups.
Art, culture and leisure
The Frontiere$ centre
The Frontiere$ centre initiates artistic activities, in the framework of a hospital/culture partnership, which was created 18 years ago. It started with the rehabilitation of the J. Bosch Clinic, a former unit for compulsory treatment, by the patients who had stayed there, with the help of an architect. A scale model of the Centre was presented during a cultural week Pavillon 11 - Procès de la folie in 1984. At that time, the mental health department sector Lille-Métropole wanted the Centre to be located in the city. This was impossible because of local political and medical pressures, which wanted employment linked to "madness" to remain at the site in Armentières. The sector was a part of the "Health, Culture and Musical practice in institutions" mission, organised in 1983-84 by the French Ministry of Culture and the French Ministry of Health. Since then, 49 h of cultural work per week have been implemented by the EPSM Lille-Métropole for artistic activities. Full-time artistic participation was created 2 years ago. For over a year, an arts professor has been hired by the E.P.S.M. Lille-Métropole. All cultural structures of the sector, or the city of Lille, are entrusted with these activities; groups are led by artists and supervised by nurses. For activities carried out by the school of body practice in Villeneuve d'Ascq and the Dance association in Lille, groups are organized by these institutions and users and resident users are gathered in these artistic schools.
Art has the particular faculty of establishing equality between patients and non-patients for artistic production. It allows evaluation and social acceptance. Contemporary art at least, the spearhead of our work in the sector, like mental disorders, requires interpretation, it cannot be understood immediately. The integration of artists into the psychiatric sector contributes to the production of imaginative works: Its creativity reaches beyond the stigmatization that people with mental disorders suffer from. As is suggested in this brief description, it is not Art Therapy: The purpose is not to "cure through art", but rather to enable non-stigmatisation thanks to art and contact with artists.
| Network: No Longer have Partners, but be a Partner|| |
In addition to the multiplicity of care facilities and their integration into the urban framework, the originality of the East Lille sector is its diversity of links established with the different partners, within a real network.
The elected officials
The elected officials lead this partnership and are committed to social inclusion by making available-housing facilities, consultation places, municipal rooms for catering and therapeutic activities. By making use of their networks of relationships, they open doors and smoothened difficulties in order to provide their fellow citizens, suffering from mental illness, with a real place in the community.
Social institutions are other essential partners: Social workers, a communal center of social action and the general Council are often included in the support, and guarantee people's rights. Using these services, in collaboration with educational associations ensures housing provision and solutions to problems of financial resources and rehabilitation.
The cornerstone of this collaboration can be illustrated by the sharing of the General Council's premises in the Centres for Prevention and Social Action of Mons en Baroeul and Hellemmes, for psychiatric consultation. In addition, special links have been established via formal agreement with the associations in Lille devoted to the homeless, in collaboration with 6 other general psychiatry sectors. This service has been the promoter and partner of a mobile team concerned with Mental Health and homelessness, called DIOGENE, which meets homeless people in the area of Lille, and can refer them to a public psychiatric facility if need be.
The National Lille Orchestra, the theatrical association QUANTA, the Nieke Swennen company, independent artists, plastics technicians, photographers and musicians have made it possible to offer therapeutic activities that are fully integrated into the local cultural landscape. Going to a concert, creating a ballet and taking part in an exhibition preview are new experiences for some patients, and a factor facilitating better contact with others and with the real world. The Frontiere$ gallery was managed for years by the artist Gérard Duchêne, and is now being run by David Ritzinger. Its window onto the street displays this alliance between care and art.
Users and family groups
Users and ex-user groups are favored partners, which are considered as "experience experts" in the field of Mental Health. These associations, members of the FNAPSY (Fédération Nationale des associations d'ex-patients en psychiatrie, i.e. National Federation of associations for psychiatry, ex-patients), develop a program of representation and training for users. They are actively associated to the research programs. Representatives from UNAFAM (Union Nationale des Amis et Familles des Malades psychiques (National Union of Friends and Families of people with psychiatric disorders i.e. national union of families and friends of mentally ill people) sit on the Commission for allocating accommodation, and are called upon more and more to take part in events organized by the sector and in its projects.
Mutual self-help groups (GEM: Groupes d'Entraide Mutuelle), meeting and self-help centres managed by users, have become essential partners for rehabilitation and for the fight against social isolation. They were created in 2005 through government funding (French Mental Health Plan 2005-2008) and run by users themselves in autonomy most of time. In 2009, 280 groups were in activity, out of which half of these groups were piloted 100% by users NGOs. These groups certainly do fight against isolation, yet they tend, above all, to become bridges allowing users to progressively leave the psychiatric care system.
Health partners in the towns
Last but not least, another long-standing partnership has been established with the other local care providers. First of all, general practitioners in the urban districts in the sector, who are essential collaborators in all follow-up, are involved. They enable the referral of a patient to a CMP (medico-psychological centre) consultation and receive regular reports for each consultation or hospitalization. Outside hospitalization, the GPs are the only prescribers for patients, nominated by the consultant psychiatrist. The frequency of exchanges in mail, phone calls and meetings enable constant discussion on the way a patient should be catered for, given that, as family doctors, GPs are closest to the patients' daily life.
Several pharmacists are also part of this partnership, so that medication can be delivered to chemist's offices, in accordance with the need for proximity and routine observance of prescribed treatments.
Private Nurses are also often called upon to visit patients' homes, providing medications and for nursing and hygiene care, on medical prescription.
Very close links have been established with the Meeting and Crisis Centre (CAC: Centre d'Accueil et de Crise) in the regional university hospital in Lille. This unit takes in patients during an acute state of distress up to 72 h. When a patient from the sector is hospitalized, a contact is made by the sector team, which routinely goes to the CAC to decide with the patients and the referring physician as to how the patient is to be supported in the sector, with a view of continuity between this emergency unit and short to medium term care in the sector. Usually it leads to intensive follow-up in the city and/or to care in a host family.
Role of the international and national network of good practices in psychiatry in the reorganisation of the psychiatry service in East Lille (EPSM Lille Métropole)
How did the psychiatry sector of East Lille, and by extension of its referral institute EPSM Lille Métropole, benefit from International Network and continued to be included it in its future plans? We owe this mainly to experiences drawn from the international network, training visits organized by the hospital for the whole staff of the East-Lille service in different European and national sites, consequently introducing new practices to Lille which seemed interesting and positive for the support of the population in the towns of our sector:
- The studying of all good practices in Trieste ,,, in 1976 led to their implementation in east Lille suburb in 1977
- Host families as an alternative to hospitalization (one family = one bed), during a conference with all alternative global experiences in Trieste in 1986  (example taken from Madison USA 1998) led to implementation of same in Lille in 2000
- Home care 7 days a week with a mobile team: seen in
- Birmingham in 2000 and same was implemented in Lille in 2005
- Totally open psychiatric wards were seen in Merzig, 1997 and in Trieste, 1995 and same was implemented in Lille in 1999
- Nurses in the front line for welcoming patients, using appropriate tools: Seen in Mauritania in 2001 and same was implemented in Lille in 2003 in the whole sector
- Crisis centres for 72 h Centre Hospitalier Universitaire de Lille (University Health Centre), 2001
- Operational networks with the attending physicians
- Oviedo, 2002 and was implemented in Lille in 2003 with a network of GPs
- Cooperatives to access work seen in Trieste in 2003 and similarly, were set up in Lille in 2007 in an experimental program with municipalities
- Clubs and volunteers in Quebec 1987, in Luthon and Monaghan 2005 and same were implemented in Lille in 2005 thanks to the law about Self-help groups (GEM: Groupements d'Entraide Mutuelle)
- Peer support program has been witnessed in Canada 2008, USA 2009, and UK 2009 and same are being planned for Lille in 2011.
The East Lille Mental Health sector is one of the founding members of the International Mental Health Collaborating Network, created in 2001 in Birmingham. In its collaboration a pilot programs in Community Mental Health for the promotion of international cooperation has been started in Lille. The IMHCN "Mental Health and citizenship" International NGO was founded in Lille in 2006. 
| The Future of Citizen Psychiatry|| |
It is perfectly possible to implement the WHO recommendations , in France or in any other country by centralizing services for emergencies and stabilizing patients for short stay and rest of the mental services can be given through outpatient or community based health centers. Instead mental health services in Lille are truly integrated into the community with the active support of locally elected representatives. ,,, For that purpose, it is essential to go beyond hospital-centrism and to clearly shift from "psychiatry hospital services" to "individual health and social services", in the person's living environment. , Networking is essential for this paradigm shift.
For 30 years, the psychiatry service of East-Lille has evolved from the isolationism of Armentières to the Eastern suburb of Lille, fully integrated in the urban fabric, becoming more complex and more flexible. With the municipalities and the EPSM Lille-Métropole, we have set up all the structures. We only have to transfer the beds of the former psychiatric hospital, which have been almost empty since then, into a caring structure for the city; the ideal would be a general hospital. This is planned for 2012 as a 10 bed unit, close to the CHR (Regional Hospital Centre) of Lille. The integration of Mental Health into general health psychiatry in medicine is almost achieved, and it is logical to change the last psychiatric beds into a general hospital.
The integration of the mental health services into the city at proximity of citizens after a preparative work is also a powerful anti stigma strategy.  The re-localisation of in-patient beds closer to the affected population will definitely mark the end of psychiatric imprisonment and isolation in asylums. This is 21 st century psychiatry, which started 30 years ago, a psychiatry in favour of users, integrated in the community, that is to say, for the people.
| Community Mental Health Service in India and Training Need|| |
Unlike the West, in India, mental health care is delivered by outside institutions, means already de-institutionalized care. Family is a key resource in the care of patients with mental illness. Families assume the role of primary caregivers because of the Indian tradition of interdependence and concern for near and dear ones in adversities. They are meaningfully involved in all aspects of care of their sick relatives despite it being time consuming and lot of expenditure. 
Health is a state subject and government must provide basic minimum care to all mentally sick subjects. From the very beginning after independence of India, community psychiatry was practiced. Dr. Vidya Sagar had as early as 1950s involved family members of patients admitting into Amritsar Mental hospital.  As far as treatment in general hospital is concerned the first Psychiatric Unit was set up at R.G. Kar Medical College Kolkatta in 1933. Many community-based mental health delivery projects were launched during 1970s and 1980s leading the government mental health program. The famous Raipur Rani experiment in Haryana  and Sakalwara in Karnataka  established that mental health delivery is possible through primary health centers.  During this period primary care psychiatry replaced the term community psychiatry in India. After Alma Ata Declaration of World Health Assembly in 1977 that emphasized primary health care approach to achieve "Health for All" by the year 2000. Since then training of PHC doctors, nurses and community level workers started to handle mental health and replacing psychiatrists which were available in meager number. ,,, In spite of such development, community psychiatry does not take concrete shape in India. Training of general doctors and other health professionals has been envisaged in national program.
The Government of India has launched the National Mental Health Program (NMHP) in 1982, keeping in view the heavy burden of mental illnesses in the community, and the absolute inadequacy of mental health care infrastructure in the country to deal with it. The program envisages a primary health care community based approach in the rural areas supported by professional psychiatric supervision from the district level and referral services by the mental hospitals and mental health units of the general hospitals.  Mental health is still not a priority at the national and local level although mental disorders contribute significant amount of disease burden. Stigma of mental disorders is more than that found in France and there are number of false beliefs and myths existing amongst the health professionals and the community. ,, Training programs should include the socio-cultural, political and occupational aspects of mental health. This can be better imparted in trainees citing examples of community psychiatry practice in France and other areas in the world.
Number of psychiatrists in India is very less as compared to Western countries. However, India has huge health infrastructure in rural and urban areas and large number of Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (AMNs), Male Health Workers and others such as Anganwadi workers, link workers, and volunteers. Health workers are visiting the families but their focus is on family planning, maternal and child health, and communicable diseases. It is already known that providing mental health services improves the quality of overall health care delivery system.  In presence of strong family system and existing peripheral health institutions such as primary health centers, subcenters, angawadis, India can definitely provide better mental health services. Indian health workers are capable to handle mental disorders at the primary level if minimum skills are provided. House to house visits by the health workers can also include screening, referral and follow-up for mental disorder supported by medical officer of PHC.  Under the present National Mental Health Program number of PHC doctors is trained in handling psychiatric patients. Training should include other health professionals such as nurses, pharmacists, doctors of traditional system of Indian medicine, health workers male and females, ANMs, and ASHAs.  These are forefront health force dealing with various stages of mental illnesses. Empowering them with appropriate training would be a significant improvement in mental health care delivery in presence of paucity of trained psychiatrist in the country. Unlike Western world, families are already taking maximum burden of mental disorders in India. There is a need to take strong steps towards full integration of families in the care of mentally ill patients. At the same time through multi-prong approach family system should be protected from disintegration due to urbanization and industrialization. Mental health delivery system of Lille Metropole France is an excellent example of fully integrated mental health services with social system. India can learn from the Lille Metropole experiment for better generation of community participation, integration and rehabilitation.
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