Les données de la littérature rapportent l’existence de nombreuses comorbidités somatiques chez les patients atteints de pathologie mentale. Afin d’améliorer les pratiques, des recommandations labélisées HAS ont été rédigées en 2015, indiquant que tout psychiatre est responsable de la prise en charge somatique des patients n’ayant pas de médecin généraliste. L’élaboration de recommandations est nécessaire à la sécurisation des soins, mais se heurte encore à la pratique même de la psychiatrie, à la fois ancrée dans le champ scientifique/médical et celui des sciences humaines. Le psychiatre, plus que tout autre spécialiste, s’attache à respecter la subjectivité du patient là où l’examen somatique est objectivant. Ce constat peut entraîner un conflit éthique que nous avons tenté de résoudre en interrogeant les patients à travers leurs représentations sociales. Les résultats montrent l’ambivalence des patients qui souhaitent une prise en charge globale, sans pour autant s’attendre à l’investissement des psychiatres dans leur évaluation somatique. Ces représentations sont liées à l’héritage de la psychiatrie française mais également au lien subjectif du patient à son psychiatre dans le cadre psychothérapique et, enfin, à la position de spécialiste assignée au psychiatre traitant un champ médical spécifique. Il est donc de la responsabilité éthique du psychiatre de mettre en œuvre ses compétences médicales et ses compétences psychothérapiques en les adaptant de façon singulière à chaque patient selon sa pathologie, son degré d’autonomie et ses représentations. Le psychiatre se doit d’informer le patient sur ses compétences, son cadre de soin et les spécificités somatiques liées à sa pathologie.

Literature's data report the existence of numerous somatic comorbidities in patients with mental diseases. In order to improve practices, HAS-labeled recommendations were written in 2015. These recommendations advocate the improvement of current practices, by integrating into the accreditation procedures of institutions the somatic management of patients including a complete somatic examination of any hospitalized patient. Outpatient follow-up is also mentioned, especially when the patient does not have a general practitioner: “the psychiatrist will naturally be in charge of managing the patient's somatic problems”. This text reminds us that psychiatry belongs to the medical world and that it is necessary to improve patient care. Nevertheless, these recommendations may come up against the usual practice of psychiatrists who do not generally carry out a somatic clinical examination. Indeed, the particularity of the French psychiatric practice is that it is rooted in the field of human sciences where subjectivity plays a major role. However, the somatic examination is in essence objectifying, leading to an ethical conflict for the psychiatrist between an adapted somatic management and an optimal psychiatric management. In order to help us in our reflection, we decided to question the patients, by focusing our work on their social representations concerning the psychiatrist and his function. The objective of our work will thus be to discuss the dilemmas resulting from these recommendations in the light of other ethical principles and to propose practical reflections on their implementation with an ethical concern by placing the patient at the center of the care system. In France or internationally, no study on the social representations that patients have of their somatic care has yet been conducted.

We conducted a prospective study in the form of semi-structured interviews with a sample of 21 patients treated in a general psychiatric ward. The interview guide included four themes: definition of the doctor and the psychiatrist, the course of care in psychiatry, the relationship between patients and therapists in psychiatry, and the role of the psychiatrist in somatic care in psychiatry. The results show the ambivalence of patients who wish to receive comprehensive care without expecting psychiatrists to invest in their somatic evaluation. These representations are linked to the heritage of French psychiatry, but also to the subjective link between the patient and his psychiatrist in the psychotherapeutic framework and finally, to the position of specialist assigned to the psychiatrist treating a specific medical field.

It is therefore the psychiatrist's ethical responsibility to question the practical implementation of his medical skills (in particular in the field of somatic comorbidities) and his psychotherapeutic skills by adapting them in a singular way to each patient according to his pathology, his degree of autonomy and his social representations in order not to be harmful on the psychic level while wanting to be beneficial on the somatic level. The psychiatrist must inform the patient of his or her competencies and limitations in terms of somatic care and of the specific somatic aspects of the patient's pathology. Finally, patients followed in psychiatry often have a lack of access to care as well as an unfavourable socio-economic level. In this context, they may have difficulty accessing the various medical specialists. Most inpatients benefit from appropriate somatic care thanks to the development of somatic care units in the institutions. Thus, we see that the will to improve the situation in the hospital has led to socio-economically favourable solutions and to the training of competent general practitioners in this field. It is necessary to continue efforts in this direction, but also in general medicine. Even if psychiatrists are aware of patients’ somatic pathologies, take them into account, and occasionally perform a somatic examination, they cannot replace a trained and competent general practitioner.