Suicide et délinquance juvénile : phénomènes distincts ou manifestations d’une même problématique ?

Cet article examine la relation entre suicide et délinquance chez les jeunes. Une revue des recherches suggère que les comportements suicidaires sont exceptionnellement fréquents chez les jeunes Québécois qui présentent des comportements délinquants ou perturbateurs. Ainsi, au moins 32 % des jeunes de 18 ans et moins décédés par suicide au Québec au cours des années 1995-96 avaient reçu des services des Centresjeunesse, organismes responsables de l'intervention auprès des jeunes contrevenants et des jeunes en besoin de protection. Parmi ces victimes, les jeunes contrevenants et les jeunes qui ont des troubles sévères du comportement, qui constituent environ 33 % de la clientèle des Centresjeunesse, avaient commis 69 % des suicides. L'examen des recherches récentes propose trois ensembles d'hypothèses pour tenter d'expliquer les taux élevés de comportements suicidaires chez ces jeunes, hypothèses portant respectivement sur 1) la psychopathologie et les trajectoires de vie, 2) l'impulsivité, l'agressivité et la réaction au stress et 3) l'impact à plus ou moins long terme des événements de vie négatifs. Certains facteurs organisationnels liés aux milieux d'intervention destinés aux jeunes délinquants sont aussi discutés. En conclusion, nous faisons des recommandations pour améliorer la prévention du suicide dans ces milieux.This article examines the relation between juvenile delinquency and suicide in adolescents. A review of the research suggests that suicidal behavior is extremely frequent among Quebec delinquent or severely disruptive adolescents. At least 32 % of Quebec adolescents who committed suicide in 1995 and 1996 had been involved with the "Centres jeunesse" (CJ), a governmental organization in charge of juvenile delinquents and youths in need of protection. Among those suicide victims, juvenile delinquents and severely disruptive adolescents, who represent 33 % of CJ customers, committed 69 % of all suicides. A review of recent research suggests three sets of hypotheses for explaining the high level of suicidal behaviors among délinquant and disruptive adolescents, in terms of 1) psychopathology and Life history, 2) impulsivity, aggressivity, and stress adjustment, and 3) the short and long term impacts of negative life events. Certain organizational factors of the intervention environments for delinquent and disruptive adolescents are also discussed. In conclusion, we recommend strategies for improving suicide prevention in those environments

General practitioners' management of mental disorders: A rewarding practice with considerable obstacles

<p>Abstract</p> <p>Background</p> <p>Primary care improvement is the cornerstone of current reforms. Mental disorders (MDs) are a leading cause of morbidity worldwide and widespread in industrialised countries. MDs are treated mainly in primary care by general practitioners (GPs), even though the latter ability to detect, diagnose, and treat patients with MDs is often considered unsatisfactory. This article examines GPs' management of MDs in an effort to acquire more information regarding means by which GPs deal with MD cases, impact of such cases on their practices, factors that enable or hinder MD management, and patient-management strategies.</p> <p>Methods</p> <p>This study employs a mixed-method approach with emphasis on qualitative investigation. Based on a previous survey of 398 GPs in Quebec, Canada, 60 GPs representing a variety of practice settings were selected for further study. A 10-minute-long questionnaire comprising 27 items was administered, and 70-minute-long interviews were conducted. Quantitative (SPSS) and qualitative (NVivo) analyses were performed.</p> <p>Results</p> <p>At least 20% of GP visits were MD-related. GPs were comfortable managing common MDs, but not serious MDs. GPs' based their treatment of MDs on pharmacotherapy, support therapy, and psycho-education. They used clinical intuition with few clinical tools, and closely followed their patients with MDs. Practice features (salary or hourly fees payment; psycho-social teams on-site; strong informal networks), and GPs' individual characteristics (continuing medical education; exposure and interest in MDs; traits like empathy) favoured MD management. Collaboration with psychologists and psychiatrists was considered key to good MD management. Limited access to specialists, system fragmentation, and underdeveloped group practice and shared-care models were impediments. MD management was seen as burdensome because it required more time, flexibility, and emotional investment. Strategies exist to reduce the burden (one-problem-per-visit rule; longer time slots). GPs found MD practice rewarding as patients were seen as grateful and more complying with medical recommendations compared to other patients, generally leading to positive outcomes.</p> <p>Conclusions</p> <p>To improve MD management, this study highlights the importance of extending multidisciplinary GP practice settings with salary or hourly fee payment; access to psychotherapeutic and psychiatric expertise; and case-discussion training involving local networks of GPs and MD specialists that encourage both knowledge transfer and shared care.</p

Évaluation de la réforme des services psychiatriques destinés aux adultes au pavillon Albert-Prévost 1

Cette étude de cas analyse l'implantation de la réforme du dispositif de soins destinés aux clientèles adultes du Pavillon Albert-Prévost. Le niveau de mise en oeuvre et les effets du nouveau dispositif ont été mesurés, et l'influence du contexte politique et structurel a été analysé. À la fin de la période d'observation, la mise en oeuvre de l'intervention n'était pas encore complétée mais elle avait déjà entraîné des effets intéressants, surtout en ce qui concerne l'accessibilité et l'efficience. Ces effets furent atteints par des mécanismes dont certains n'avaient pas été prévus au projet de réforme. Les auteurs ont également identifié un ensemble de facteurs contextuels qui ont facilité ou ralenti la mise en oeuvre de la réforme et la réalisation des effets attendus.This case study analyzes the implementaion of the reform of care destined to clienteles at the Pavillon Albert-Prévost. The level of implementation and the effects of the new systme have been measured and the influence of the political and structural contexts have been analyzed. At the end of the observation period, the implementation of the intervention was not yet completed but had already entailed interesting effects especially concerning access and efficiency. These effects were achieved through some mechanisms not previously planned for in the reform project. The authors have also identified several environmental facors facilitating the implementation of the reform and the realization of expected effects.Este estudio de casos analiza la implantación de la reforma del dispositivo de cuidados destinado a la clientela adulta del Pabellón Albert-Prévost. Se han medido, el nivel de puesta en marcha, los efectos del nuevo dispositivo y la influencia del contexto político y estructural se analizaron. Al final de periodo de observación, la puesta en marcha de la intervención no se había completado pero ya había traído efectos interesantes, sobre todo en cuanto a la accesibilidad y la eficacia. Estos efectos fueron alcanzados por mecanismos, de donde algunos no habían sido previstos en el proyecto de reforma. Igualmente, los autores ha identificado un conjunto de factores contextuales que han facilitado o retrasado la puesta en marcha de la reforma y la realización de los efectos esperados

7. L’analyse de la production

L’analyse de la production étudie les relations entre le volume et la qualité des services produits et les ressources utilisées pour leur production. Elle comporte deux volets : l’analyse de la productivité et l’analyse de la qualité. L’analyse de la productivité porte sur la relation entre le volume des services produits et les ressources utilisées. L’analyse de la qualité porte sur plusieurs caractéristiques des services produits, dont la qualité technique, la qualité interpersonnelle, l’ac..

Cognitive multi-tasking in situated medical reasoning

This study evaluates the hypothesis that medical reasoning in real clinical situations involves multiple cognitive tasks whose complex interactions are coordinated in an opportunistic manner. A problem-solving architecture originating from research in artificial intelligence, the blackboard model, is proposed as an integrative framework for representing these characteristics of situated medical reasoning and for reconciling different theoretical perspectives about medical reasoning. A naturalistic clinical situation, involving the manipulation of the patient record by an internist while managing a case, provides the empirical data for this in depth qualitative case study. The video recording of the subject's record manipulation behavior allows the cueing of retrospective think-aloud verbalizations and the preservation of the real-time aspects of problem solving. The association of theory-driven task analysis using the blackboard model with data-driven propositional analysis confirm that medical reasoning in this situation indeed comprises a variety of cognitive tasks, which are described. Also, the opportunistic character of control knowledge and the complex interactions between control strategies and cognitive tasks are confirmed and described. The blackboard model allows the principled representation of these characteristics of situated medical reasoning, thus supporting its integrative character. However, certain aspects of the data, mostly related to the ambivalence of several concepts that are used by the subject during the course of problem-solving, are not explained in the most parsimonious manner by the blackboard model, nor by symbolic cognitive architectures in general. A connectionist alternative is proposed which seems to better account for these phenomena. Finally, a tentative neurophysiological interpretation of the blackboard framework is offered for integrating the symbolic and connectionist perspectives. This study has additional implications co

Politiques et plans d’action en santé mentale dans l’OCDE : leçons pour le Québec ?

Cette étude examine les politiques de santé mentale énoncées au cours des quinze dernières années par les pays de l’OCDE et les provinces canadiennes afin d’en décrire les variations, d’identifier certaines configurations et d’en tirer des leçons pour le Québec. Vingt et une politiques sont analysées en faisant appel à un modèle conceptuel dérivé de la théorie de l’action sociale de Parsons. Les politiques varient en termes de différenciation (besoins et groupes priorisés, niveaux d’intervention, finalités, bases factuelles, niveaux de spécification), en termes d’intégration (mécanismes d’efficacité variable allant du fonctionnement en créneaux à l’intégration complète de certaines composantes) et en termes de gouvernance (théories de programme plus ou moins explicites ou fondées, importance variable donnée aux structures, aux processus et aux résultats, mécanismes d’imputabilité et de financement, systèmes d’information et gouvernance clinique variables). Cinq configurations sont identifiées : santé publique, professionnelle, technocratique structurelle, technocratique fonctionnelle et politique. La politique québécoise actuelle, correspondant à une configuration technocratique structurelle, pourrait être bonifiée par le renforcement de ses aspects de santé publique, professionnels et fonctionnels si les obstacles politiques pouvaient être surmontés.Objectives. The objectives of this research are: 1) to provide a conceptual framework for analyzing mental health policies; 2) to compare mental health policies across a sample of OECD jurisdictions; 3) to describe configurations of mental health policies; 4) to identify practical implications for the Province of Quebec.Methods. Design: This research is a comparative synthetic study of mental health policies. Sampling: The web sites of the Ministries of health of the thirty-four OECD countries and ten Canadian Provinces were searched for mental health policies proposed within the last fifteen years. Twenty one such policies (with an English or French version) were retrieved, covering thirteen OECD countries, six Canadian Provinces and the WHO. Analysis: Content analysis was performed based on the categories (differentiation, integration, governance) and sub-categories of the aforementioned conceptual framework. Eight policies that together cover the variations encountered between all policies were used to identify typical configurations.Results. A conceptual framework derived from Parsons’ Theory of Social Action posits that social action systems must exhibit a level of internal differentiation that corresponds to the heterogeneity of their external environment and also a level of integration that allows them to remain coherent despite the complexity of their environment. Governance mechanisms help them maintain an equilibrium between differentiation and integration.In terms of differentiation, mental health policies exhibit much variation between the needs and the groups that are prioritized (age, gender, ethnicity, culture, etc.), the types of interventions that are proposed (promotion, prevention, treatment, rehabilitation, etc.), the systemic levels at which interventions take place (society, government as a whole, health care system, organizations, programs, individuals), and the level of specification and scientific basis of proposed interventions.In terms of integration, policies promote various mechanisms belonging to four general categories of increasing effectiveness from hierarchical separation of mandates, to exchange of information, to collaborative planning, and to complete structural integration and co-localisation of certain components (ex. dependence and mental health services).In terms of governance, policies present program theories of varying explicitness and scientific bases, and with different emphases on structures, processes or outcomes. Management models also vary in terms of precision, accountability, financing mechanisms, information systems, and the importance of clinical governance and quality improvement.Five configurations of mental health policies are identified (the public health, the professional, the structural technocratic, the functional technocratic, and the political), each comprising typical combinations of the preceding ingredients.Conclusion. The current Quebec mental health policy belongs to the structural technocratic configuration. It specifies fragmented mental health structures with mild integration mechanisms. In the future, it should consider improving its public health aspects (inter-sector work on the determinants of mental health), professional aspects (emphasis on scientific evidence, clinical governance and quality), and functional aspects (integrated specialized community mental health and addiction services). But political factors may prevent it from doing so

Politiques et plans d’action en santé mentale dans l’OCDE : leçons pour le Québec ?

Cette étude examine les politiques de santé mentale énoncées au cours des quinze dernières années par les pays de l’OCDE et les provinces canadiennes afin d’en décrire les variations, d’identifier certaines configurations et d’en tirer des leçons pour le Québec. Vingt et une politiques sont analysées en faisant appel à un modèle conceptuel dérivé de la théorie de l’action sociale de Parsons. Les politiques varient en termes de différenciation (besoins et groupes priorisés, niveaux d’intervention, finalités, bases factuelles, niveaux de spécification), en termes d’intégration (mécanismes d’efficacité variable allant du fonctionnement en créneaux à l’intégration complète de certaines composantes) et en termes de gouvernance (théories de programme plus ou moins explicites ou fondées, importance variable donnée aux structures, aux processus et aux résultats, mécanismes d’imputabilité et de financement, systèmes d’information et gouvernance clinique variables). Cinq configurations sont identifiées : santé publique, professionnelle, technocratique structurelle, technocratique fonctionnelle et politique. La politique québécoise actuelle, correspondant à une configuration technocratique structurelle, pourrait être bonifiée par le renforcement de ses aspects de santé publique, professionnels et fonctionnels si les obstacles politiques pouvaient être surmontés.Objectives. The objectives of this research are: 1) to provide a conceptual framework for analyzing mental health policies; 2) to compare mental health policies across a sample of OECD jurisdictions; 3) to describe configurations of mental health policies; 4) to identify practical implications for the Province of Quebec.Methods. Design: This research is a comparative synthetic study of mental health policies. Sampling: The web sites of the Ministries of health of the thirty-four OECD countries and ten Canadian Provinces were searched for mental health policies proposed within the last fifteen years. Twenty one such policies (with an English or French version) were retrieved, covering thirteen OECD countries, six Canadian Provinces and the WHO. Analysis: Content analysis was performed based on the categories (differentiation, integration, governance) and sub-categories of the aforementioned conceptual framework. Eight policies that together cover the variations encountered between all policies were used to identify typical configurations.Results. A conceptual framework derived from Parsons’ Theory of Social Action posits that social action systems must exhibit a level of internal differentiation that corresponds to the heterogeneity of their external environment and also a level of integration that allows them to remain coherent despite the complexity of their environment. Governance mechanisms help them maintain an equilibrium between differentiation and integration.In terms of differentiation, mental health policies exhibit much variation between the needs and the groups that are prioritized (age, gender, ethnicity, culture, etc.), the types of interventions that are proposed (promotion, prevention, treatment, rehabilitation, etc.), the systemic levels at which interventions take place (society, government as a whole, health care system, organizations, programs, individuals), and the level of specification and scientific basis of proposed interventions.In terms of integration, policies promote various mechanisms belonging to four general categories of increasing effectiveness from hierarchical separation of mandates, to exchange of information, to collaborative planning, and to complete structural integration and co-localisation of certain components (ex. dependence and mental health services).In terms of governance, policies present program theories of varying explicitness and scientific bases, and with different emphases on structures, processes or outcomes. Management models also vary in terms of precision, accountability, financing mechanisms, information systems, and the importance of clinical governance and quality improvement.Five configurations of mental health policies are identified (the public health, the professional, the structural technocratic, the functional technocratic, and the political), each comprising typical combinations of the preceding ingredients.Conclusion. The current Quebec mental health policy belongs to the structural technocratic configuration. It specifies fragmented mental health structures with mild integration mechanisms. In the future, it should consider improving its public health aspects (inter-sector work on the determinants of mental health), professional aspects (emphasis on scientific evidence, clinical governance and quality), and functional aspects (integrated specialized community mental health and addiction services). But political factors may prevent it from doing so

Facteurs encourageant ou limitant l’utilisation des services d’urgence pour des raisons de santé mentale par les patients grands utilisateurs de ces services

Objectifs Les services hospitaliers d’urgence sont souvent engorgés, et leur utilisation pour des raisons de santé mentale (SM) y contribue particulièrement. Au Québec, en 2014-15, 17 % des utilisateurs des services d’urgence ayant des troubles mentaux avaient visité l’urgence au moins 4 fois, pour quelque raison que ce soit. Le fait que ces patients recourent fréquemment aux urgences témoigne souvent d’une inadéquation des services qui leur sont offerts. Mieux comprendre les motifs de cette utilisation fréquente des urgences permettrait de mieux répondre aux besoins de ces patients. Cette étude avait pour but d’identifier les facteurs encourageant ou limitant l’utilisation des urgences par les grands utilisateurs de ces services, qui sont définis ainsi s’ils utilisent les urgences au moins 3 fois sur une période d’un an.Méthodologie Entre avril et septembre 2021, 20 professionnels en SM ont été interrogés au sujet des facteurs qu’ils percevaient comme encourageant ou limitant les grands utilisateurs des services d’urgence à utiliser ces derniers. Ces participants oeuvraient à l’urgence psychiatrique d’un institut universitaire en SM situé dans un grand centre urbain, ou dans d’autres services de ce même hôpital (p. ex. module d’évaluation-liaison), ou ils étaient des partenaires de l’urgence du territoire (p. ex. centres de crise). Les données ont été traitées par le biais d’une méthode d’analyse de contenu réalisée en différentes étapes (transcription des données, codification des contenus, etc.), et guidées par un cadre conceptuel comprenant 4 catégories de facteurs encourageant ou limitant l’utilisation fréquente de l’urgence pour raisons de SM. Ces facteurs étaient reliés au système de santé, aux profils des patients, aux professionnels de la santé ou aux caractéristiques organisationnelles du réseau de la SM.Résultats Plus de facteurs encourageant l’utilisation de l’urgence que de facteurs limitant son usage ont été relevés. Ces facteurs étaient principalement liés au système de santé (notamment dans le cas de l’indisponibilité des services en SM) et aux profils des patients, particulièrement de ceux ayant des troubles mentaux complexes associés à des problèmes psychosociaux. Les caractéristiques organisationnelles, notamment le déploiement d’innovations à l’urgence ou en partenariat avec celle-ci, bien que globalement peu fréquent, semblent plutôt limiter l’usage de l’urgence.Conclusion Cette étude soutient l’importance de développer davantage d’innovations à l’urgence et en lien avec les autres services de l’hôpital et de la communauté, ceci afin de mieux répondre aux besoins des grands utilisateurs des services d’urgence et d’en réduire ainsi l’usage. L’urgence devrait optimiser son rôle de dépistage, de traitement bref, d’orientation et de monitorage de la qualité des services aux patients, particulièrement pour ceux que les services ambulatoires en SM ne desservent pas adéquatement.Objectives Hospital emergency departments (ED) are often overcrowded, and patients using ED for mental health (MH) reasons contribute in great part to this situation. In Quebec, in 2014-15, 17% of ED users with mental disorders had visited ED at least 4 times for various reasons. These patients’ frequent ED use usually reflects the inadequacy of the services provided to them. A better understanding of the underlying reasons behind this frequent ED use would enable stakeholders to formulate recommendations that would help improve services, making them more suited to the needs of these patients. The aim of this study was to identify the factors that encourage or limit the use of ED by frequent ED users, the term “frequent ED users” being defined as patients who use ED at least 3 times over a one-year period.Methodology Between April and September 2021, 20 ED professionals were interviewed concerning factors they perceived as encouraging or limiting ED use among frequent ED users. Participants worked in a psychiatric ED or in other hospital services (e.g., assessment-liaison module), or were partners of the ED within the territory (e.g., crisis centers). Study data were analyzed using a content analysis method carried out in various stages (e.g., data transcription, content coding), and guided by a conceptual framework comprised of 4 categories of factors that encourage or limit frequent use for MH reasons. These factors were related to the healthcare system, patient profiles, health professionals, and the MH network’s organizational characteristics.Results More encouraging factors than limiting ones were identified as pertains to ED use. Most factors were associated with the healthcare system (and particularly with the unavailability of MH services), and with patient profiles, more specifically those with complex mental disorders compounded by psychosocial problems. Organizational characteristics, in particular the deployment of innovations in the ED or in partnership with it, although not widely deployed overall, tended to limit ED use.Conclusion This study highlights the importance of developing more innovations in the ED and in conjunction with other hospital and community services to better meet the needs of frequent ED users, and thus reduce their use of these services. ED should optimize their role in the screening, brief treatment, referral, and quality monitoring of services for patients, particularly those not adequately served by outpatient MH services