[Evaluation of the use of care programs provided for under the law of 5 July 2011]

The law of 5 July 2011 introduced the possibility of outpatient care without consent in the context of care programs (CP). Despite major ethical and legal issues and frequent recourse in France, few studies are available on the use of this mechanism. An in-depth review of practices involving a large sample of CP was essential. The main objective of this study was to look at their content, the clinical profile of the patients involved, and the progress of these CP.

We carried out a retrospective, observational study, including all the CP set up between January 1st, 2016 and December 31st, 2018 in the Sarthe department. Data strictly related to the CP (content, justification, duration, patient compliance, re-hospitalizations, etc.), and patient-related variables (socio-demographic characteristics, diagnosis, antecedents, etc.) were studied.

We studied 559 CP, 70 % of which (n=391) in the context of "care by decision of the hospital director", with a wide disparity of recourse by psychiatric sector. One third of the hospitalizations without consent ended with a CP. They involved men (68.5 %, n=383), with a psychotic disorder (77.8 %, n=435), with a history of hospitalization (90 %, n=503), and with poor adherence to care (83.2 %, n=465). Cannabis use accounted for 41.3 % (n=231) of cases. Certificates initiating CP did not have a clear justification (34.6 %, n=251) or state a goal of adherence to treatment (16.5 %, n=120). The content of the different CP was homogeneous: 65.6% of medical consultations and 47.6 % with a nurse, 100 % mentioned treatment used. Their average duration was 3.4 months. Even though the CP were followed (69.9 %, n=391), 52.8% (n=295) ended with reintegration, mainly justified by symptomatic relapse (34.8 %, n=147), and new CP were put in place almost systematically (90.6 %, n=260). However, reintegrations were shorter than first-time admissions (26 vs. 95 days). When a decision was lifted (n=174), it was based on the criteria of clinical stability (35.7 %, n=120) and compliance with the CP (27.6 %, n=93). Half of hospitalizations in "care at the decision of the State representative" ended with a CP. These CP were longer (4.5 months) and with a higher rate of reintegration (62.2 %) than for those in "care at the decision of the hospital director". There was no significant difference of CP compliance according to the mode of psychiatric care.

Our study allows a precise vision of patients concerned by CP: men with risk factors for psychiatric dangerousness, with a severe clinical profile. It also found a high rate of re-hospitalization despite good adherence with the CP which is in line with a device allowing the work of an alliance to care and interventions at the beginning of relapse. CP have poorly personalized content and are poorly justified by psychiatrists although it is a freedom-restricting measure, highlighting the need for increased awareness amongst psychiatrists of the legal framework of their practice regarding care without consent.