AT My students are struck by how much variation there is in the practice and

At my students are struck by how much variation there

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AT: My students are struck by how much variation there is in the practice and diagnosis in psychiatry in different countries. They want to believe psychiatry is a universal science that transcends national boundaries. So could you map out some of the key differences between France and other countries and tell us how you would address this issue of national differences? YL: There are two very different problems. One is the difference between health care systems in the different countries. That does have a strong impact on psychiatry as with other specialties. The health care system in France is handled by the state. Reimbursement, until recently is almost 100% for severe illnesses, but only 70% for illnesses which are not as severe. So, if you have a very severe illness and need long-term treatment, you would be reimbursed 100%. So you can go to any GP or clinic as many times as you want. It’s up to you, not to the system. The state is very reluctant to implement anything new because it increases the cost of health care. The public is never fully aware of the cost; it is not well understood. There are other countries, like the UK where there is much more awareness by the public on what the difficulties are. For example, of the cost of a drug treatment or reasons for the long waiting time for an appointment with a specialist. There are major differences in how people see psychiatry, but there is stigma in all countries at different levels. There has always been stigma toward conditions where you have no treatment. When tuberculosis had no treatment, it was shameful to have tuberculosis, and you wouldn’t marry your daughter to the son of a person who had it. As soon as an effective treatment was available, the stigma disappeared. We see that today for depression; with rather good results for antidepressants, the stigma is decreasing. Many people will go to friends or employers and admit, “I’m depressed.” That means depression is relatively accepted but to a degree that varies from country to country 7
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AT: I was interviewing someone two days ago who is an expert on geriatric depression in the United States, and learned if you are depressed over the age of 65 Medicaid won’t reimburse psychiatrists well enough for them to take on an elderly patient. Drug costs are spiraling out of control so a lot of elderly people who are not affluent cannot afford the best or the newer treatments. It made me wonder whether it might not be better to be a person with a mental illness in a country with universal health care. Having grown up in Canada, I’m a big proponent of universal health care, but in terms of the patient, how would treatment vary for someone living in the U.S. versus France? YL: Strangely, the major difficulty is not that different. A patient, regardless of whether they live in France or in the US, has only a 50% chance to be properly treated with an antidepressant. And that’s very optimistic because the 50% are treated after an unacceptable delay, which can be years and not just weeks. In addition not 100% of the
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  • Summer '07
  • HARRIS-WARRICK,R.M.
  • Psychiatry, yl

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