a) Summary
Our study reports the management of patients with work-related CMD in primary care. GPs provided psychological support to nearly 90% of patients; they prescribed psychotropic medication to more than 80% of patients. They referred 39.8% of patients to psychologist or psychiatrist. Sick leaves were prescribed to more than a half of the patients, with an average length of 5.36 weeks. 26.1% of patients were referred to OP. Low referral rates to psychologists, psychiatrists and OPs indicate that GPs are often alone in the management of those patients. This could be a choice from GPs that have enough skills in this area and can therefore manage these patients alone but, for other GPs the lack of cooperation with other specialists could generate difficult situations in which the GP can sometimes be helpless to deal with those patients.
No work-related factors were associated with psychotropic medication and referral to psychologist or psychiatrist. Work-related factors were associated with sick leave prescription and referral to an OP. Higher rates of sick leave were related with suicidal risk, bigger company, emotional demands and social relationships at work. Referral to an OP was more frequent for patients with depressive disorders and high work intensity, while it was lower for white collar workers.
b) Comparison with existing literature
GP’s management of patients with work-related CMD
Our results are consistent with previous studies on GP’s management of patients with CMD, indicating that there is little special management in case of work-related CMD, compared to CMD without the context of work.
Rate of psychotropic prescription and their pharmacological class in case of work-related CMD are indeed consistent with previous studies in CMD in primary care. In France, more than 90% of the GPs prescribed psychotropic to patients with depressive disorders (36). According to another study, 80% of patients receiving antidepressants or anxiolytics had a depressive or anxiety disorder diagnosed by the GP (16).
Rates of psychological support observed in our study in case of work-related CMD are also consistent with the scientific literature in CMD. In France, as in other countries, 2/3 of GPs propose their patients a psychotherapy, which is often associated with the prescription of psychotropic medication (20–22,37). Psychological support is particularly important for work-related issues, as it helps in the returning to work procedure (26).
Referral rates to psychiatrist or psychologist in case of work-related CMD are also consistent with previous studies in CMD (25,28). Low rates of referral could be related to difficulties to access to those specialists, to non-reimbursement of consultation with psychologist, patients’ refusal or lack of training of the GP (22,36). This could be also a choice from GPs according to their psychological task (15).
Two results should be highlighted in the specific context of work-related CMD.
Our study measures a low rate of referral to OP that could be explained by suspicion about the impartiality of the physician. OP are often employed by the company and could be perceived as subject to their employer. The role of OP seems also to be not well known by GPs (28,38).
Rate of sick leaves in case of work-related CMD is consistent with a Norwegian study where 45% of patients with CMD have a sick leave prescribed by the GP (39). The average length of sick leaves is compatible with data of the French national health insurance, that shows that there is a high rate of long term sick leaves for individuals with CMD (40).
Factors associated with GP’s management of patients with work-related CMD
Our study highlights several factors associated with management for patients with work-related CMD. In literature very few studies explored factors associated with GPs’ management of CMD and almost none for work-related issues and referral to OP by GP.
The increased prescription of psychotropic with the increase of age for patient with depression (41) and in case of psychologic complaints and more severe mental disorders (42) have already been described. We didn’t find any association with work characteristics.
Referral to mental health specialist have been associated with psychiatric history, depressive symptoms, suicidal risk (43,44) and with the opportunity to work with mental health specialists (45). We didn’t find any association with work characteristics.
For sick leaves, our results indicate that GP follow trends that have been highlighted in the worker population. Depressive disorders have been ranged as the first cause of sickness certification for CMD (46). It is interesting to note that GP takes account dimensions of work for sick leaves: they are more frequent in case of low social support at work and high psychological demands (47,48). The size of the company is also associated, indicating that it’s easier to be absent from work when there are colleagues who can replace you. This has been highlighted in a Japanese study (49).
Our study explores for the first time referral to OP by GPs. We show that they are associated with work-characteristics. Fewer referrals to OP for white collar have to be explored further. They may be related with mistrust of the relationship between OP and the company, especially for managers. GP contact more the OP in case of higher work intensity, which makes sense when trying to adapt the working conditions.
c) Strengths and limitations
As described in previous articles on the Héraclès study, some limitation have to be acknowledged (10,50,51). First, there is possible selection bias for GPs. Participating GPs could be especially interested in CMD because of personal interest or patients’ rate of CMD. Therefore, participating GPs could have a better experience of managing those patients and thus a different practice towards them. However, physicians who participated were representative of the Nord – Pas-de-Calais region GPs, thus limiting this bias. Second, our study was conducted in the Nord - Pas-de-Calais, a region with a low density of medical health specialist (52). This could influence the GPs’ practice especially for referral to other health professionals. Moreover low income in this area could led to a more frequent management of CMD by the GP. Another possible limitation is the absence of standard procedure for GPs to diagnose CMD. However, in France such procedure doesn’t exist in primary care. Finally the definition of the link between work and CMD could be a limiting factor even if we relied ourselves on the WHO definition and scientific literature (1,53–55). Indeed, there is no validated and consensual definition to measure work relatedness that could be judge too subjective because it often lay on the physician judgment.
Despite these limitations, the results of this study are valuable, because to our knowledge, this is the first study in Europe to analyse management of patients with work-related CMD by the GP. Moreover, contrary to studies in occupation setting our study was conducted among primary care patients which include a large panel of workers in the labour force including worker who have a poor relation with occupational practice (independent workers, workers in small companies or workers who don’t have an OP, etc.). An international study shows that the average occupational health services coverage of workers was 24.8% (55). Finally, study questionnaires were filled by the GP who is often the referring physician of the patient and is well informed of the patient medical history and thus will be the best to assess if the disorders are related to work.