[Qualitative study of a social and health network's expectations for community treatment of severe mental health problems].
Treatment of severe mental illness in the community is gaining interest under ethical, clinical and economical pressure, which has led to mental health reform and deinstitutionalisation. However, this can lead to conflicts between all the parties involved in the community. Several countries have initiated extensive efforts to coordinate health services to enhance quality of care without increasing costs. According to Gray [Hum Relat 38 (1985) 911-936.], the first conditions facilitating interorganizational collaboration are the identification of common problems, recognition of partners (legitimacy and expertise) and interest in collaborating gains to be made from such collaboration [int J Health Plann Manage 17(4) (2002) 315-32.].


OBJECTIVE
The aims of the study were to assess the representation of problems and needs from people dealing with psychiatric patients in the community with a model of action research. The action part of the study meant to influence collaboration and objective setting in the network. The research part intended to identify the main problems experienced while dealing in the community with people suffering from severe mental illness.


METHODS
In depth interviews were conducted with 25 persons involved in the community network (GPs, psychiatrists, nurses, social workers, police, judge, relatives, and users). Five open-ended questions on experienced problematic situations, network's collaboration, and expectations were asked. Content analysis of individual interviews was validated through discussion in six focus groups. Qualitative analysis used a 3 x 3 matrix model inspired from Parsons [Social systems and the evolution of action theory. Free Press; 1977, 420 p.; Health Serv Manage Res 11(1) (1998) 24-41 discussion 41-8.], and Tansella and Thornicroft [Psychol Med 28(3) (1998) 503-508.].


RESULTS
One thousand four hundred and seventy-nine propositions were grouped in 52 themes. Seventeen key problems were identified at individual, population, care-process and network levels, and were validated by the focus groups. Main problems were linked to a change in values regarding the role of psychiatric patients-from paternalistic social control to free empowered citizens-without adequate tools to deal with this in the community. Crisis management, intensive home care, and network cooperation were considered as insufficient, particularly for suicidal, dual diagnosis and difficult to engage patients.


CONCLUSIONS
Deinstitutionalisation and more respect of patients' rights were considered as positive changes for most patients, but as a risk for the most vulnerable ones. Clearer mental health policy targets were requested for suicidal, difficult to engage and dual diagnosis patients. Collaborative efforts must focus on teaching primary care professionals for suicide and dual diagnosis patients, on direct help to welfare services for difficult to engage patients and on psychiatric services for high users. Intensive home care and liaison with primary care are viewed as key components. Identifying common targets in the network may enhance collaboration. Pathways to care need to be studied, including people involved outside a "classical" health network, such as police, welfare services and patients or carers associations.
Bonsack
C
C
Département universitaire de psychiatrie adulte (DP-CHUV), site de Cery, 1008 Prilly, Lausanne, Suisse. Charles.bonsack@chuv.ch
Schaffter
M
M
Singy
P
P
Charbon
Y
Y
Eggimann
A
A
Guex
P
P
D001294:Attitude to Health; D003156:Community Mental Health Services / Q000706:statistics & numerical data*; D003688:Deinstitutionalization / Q000706:statistics & numerical data; D006801:Humans; D001523:Mental Disorders / Q000453:epidemiology / Q000523:psychology* / Q000628:therapy*; D012720:Severity of Illness Index; D012944:Social Support