Les demandes de consultation en pédopsychiatrie : étude descriptive sur cinq années dans un service universitaire

[Did child-psychiatry patients really experience the dreaded clinical degradation during the COVID-19 pandemic lockdown?]

Objectifs

La période de confinement qui s’est déroulée en France de la mi-mars à la mi-mai 2020, à l’occasion de la pandémie COVID-19, soulève d’importantes questions sur ses effets psychologiques directs et indirects chez les enfants et adolescents. Considérée intuitivement comme nuisible, voire traumatisante dans le discours médiatique, nous avons tenté de mieux qualifier ses effets à partir de deux démarches complémentaires. D’une part, nous avons réalisé une revue de la littérature sur le sujet, d’autre part, nous y avons associé une objectivation de l’évolution de l’état clinique global des enfants au sein de la file active du service de psychiatrie infanto-juvénile du CHRU de Brest pendant la période de confinement. La revue de la littérature portant sur les effets psychologiques de situations de confinement ou de quarantaine à l’occasion d’épidémies passées ou actuelle de COVID-19, notamment en Chine, rapporte de nombreuses données sur leurs conséquences délétères. Les effets relatés sont de nature variable : symptômes anxieux et dépressifs principalement, mais aussi Stress Post Traumatique, dans des proportions importantes. Cependant, la définition des situations vécues et les contextes dans lesquels se sont déroulées ces études sont en fait peu comparables à la situation française. Par ailleurs, les effets de la peur de la contamination n’y sont pas différenciés de ceux liés au confinement lui-même.

Patients et méthodes

Parmi les enfants et adolescents suivis dans le service, 354 ont bénéficié d’une mesure de l’impact du confinement sur leur état clinique global évalué à la Clinical Global Impression Improvement (CGI-I) par leur praticien habituel au cours de la période du 16 mars au 11 mai 2020.

Résultats

Nos résultats mettent en évidence que 50 % des enfants ont connu un état clinique global inchangé en comparaison à leur état avant le confinement, 25 à 30 % ont connu une amélioration et 20 à 25 % ont montré une légère dégradation pendant la période de confinement. L’état décrit est globalement stable dans le temps au cours des huit semaines de la durée du confinement. L’âge ou la sévérité préalable de la pathologie n’a pas d’influence significative, même si on note une amélioration globale plus fréquente chez les adolescents.

Conclusion

Ces résultats sont assez discordants avec le discours général. Plusieurs hypothèses sont discutées pour expliquer les raisons de cette absence de dégradation qui pourrait éventuellement être étendue aux enfants et adolescents en général pendant cette période.

[The evolution of child psychiatry emergencies: Results and reflections from a Nancy University Hospital study]

INTRODUCTION

Mental illness is one of the most common causes of disability, morbidity and mortality in childhood. According to the scientific literature, the prevalence of mental health disorders is an estimated 10% to 20% in the USA and similar results are found in France. Although primordial, outpatient care often appears insufficient with inequalities in its geographical distribution and its accessibility. These past decades have been marked by an increase in consultations for mental disorders in pediatric emergency departments. Is this trend indicative of a "defect" in the healthcare organization? Identifying the root causes of this inflation in psychiatric consultations seems of paramount importance in the improvement of healthcare policies. In France and worldwide, only a few studies deal with this subject. That is why we proposed to observe the evolution of the number of consultations for mental health reasons in the pediatric emergency department of Nancy University Hospital and to detail their characteristics.

MATERIALS AND METHODS

Ancillary comparative and retrospective study (2003-2013) on minors having received a child psychiatry consultation within the pediatric emergency department of Nancy University Hospital.

RESULTS

The number of consultations for mental health reasons increased by 119% (97 in 2003; 212 in 2013), while consultations for pediatrics reasons remained stable over the period studied. Consultations mainly dealt with females representing 55.6% of consultations in 2003 and 63.7% in 2013. Mean age of consultants was stable: 13.9 years (standard deviation=3.3 years) in 2003; 14.1 (2.5) years in 2013. Family structure witnessed a three-fold increase in the single-parent model. Regarding consultation motives, behavioral disorders were significantly more represented in 2013: 27.7% (RR=1.7; 95% CI 1.0-2.8; P<0.05) versus 16.5%. As far as diagnosis is concerned (ICD-10), emotional and behavioral disorders increased to 35.9% from 12.6% (RR=2.8; IC95% 1.6-5.1; P=0.0001).

CONCLUSIONS

In France, as well as in other western countries, the number of visits in pediatric emergency departments for mental health reasons more than doubled over a 10-year span. This growth mostly concerned externalizing disorders as a motive for consultation. Causes for this increase are multifactorial and closely related to the prevalence of psychiatric disorders in children. Some studies showed that economic factors played a major role on mental illness during such a downturn as the financial crisis of 2007-2008. Unemployment caused by economic crises can weaken pediatric caregivers and therefore their patients. Evolution of family structure and value also explains this trend. These past decades, the two-parent model, relevant till the 1960s, has evolved to a point where single parents are more quickly overwhelmed. Family values are now focused on consensus rather than duty and hedonism has become a central value. Women are more involved in the working world which became for all a performance field. Several studies have shown that social settings where competitiveness is the norm breed externalized disorders in children by advocating short-term efficiency. Moreover, the widespread use of screens in households as well as early exposure impact the psychomotor development, decrease the amount of sleep and may be responsible for the occurrence of many psychiatric disorders. There are some epidemiological reasons too. In 1971, Omran introduced a concept called "epidemiological transition" explaining how mental health issues appeared in the limelight through to the decline of infectious and cardiovascular diseases. This phenomenon has already occurred in western countries which could explain the increase in the prevalence of psychiatric disorders. In Africa, there is evidence it may have already started. Beyond all these considerations, the increase in consultations for mental disorders in pediatric emergency departments can be explained by a change in care consumption habits. Going straight to the local emergency department, accessible on a 24/7 basis, is easier than waiting for an outpatient appointment and is also free for the have-nots lacking proper insurance coverage. Scarce resources in ambulatory care may also explain the increased recourse to emergency services. Several reports have shown a lack of child psychiatrists and their uneven geographical distribution. For example, in the US only a third of children with mental disorders receive proper care, a lack which doubled between 1997 and 2010. Despite the reason for this trend, it is important to propose a better fitting of the healthcare system to the population needs, and to improve prevention and early identification. All these changes require further collective reflection.