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%. They referred approximately 40% of patients to a psychologist or psychiatrist. Sick leave was prescribed to more than half of the patients, with an average length of 5.36 weeks. 26.1% of patients were referred to an OP. Low referral rates to psychologists, psychiatrists and OPs indicate that GPs often manage these patients alone. This could be the GPs choice if he or she has sufficient skills in this area, or a sign of lack of cooperation with mental health and occupational health specialists.
No work-related factors were associated with neither psychotropic medication prescription nor referral to a 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, employment in a large company, as well as 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 CMDs outside the context of work. In France, on average, more than 90% of the GPs prescribed psychotropic medication to patients with depressive disorders (36). Another study found that 80% of patients receiving antidepressants or tranquilizers had a depressive or anxiety disorder diagnosed by their GP (19).
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 offer their patients psychological support, which is often associated with the prescription of psychotropic medication (16–18,37). Psychological support is particularly important in case of work-related issues, as it helps in the process of returning to work (26).
Referral rates to psychiatrists or psychologists in case of work-related CMD are also consistent with previous studies (25,28). Low rates of referral could be related to difficulties in accessing these specialists, lack of coverage by the national health insurance system, patients’ refusal or lack of the GPs lack of training (18,36). This could also be the GP’s choice (15).
Two results should be highlighted in the specific context of work-related CMDs.
First, our study reports a low rate of referral to OPs that could be explained by suspicion about the physician’s lack of impartiality. OPs are often employed by companies and could be perceived as subject to their employer. Additionally, GPs may not know the role of OPs in detail (28,38).
Second, rates of sick leave in case of work-related CMD are 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 leave is compatible with data from the French national health insurance, showing that there is a high rate of long term sick leave for individuals with CMD (40).
Factors associated with GP’s management of patients with work-related CMD
Our study highlights several factors associated with the management of patients with work-related CMDs. In the literature, very few studies explored factors associated with GPs’ management of CMDs and almost none for work-related issues and referral to OP by GP.
The relationship between the prescription of psychotropic drugs and the patient’s age in case of depression (41) or psychologic complaints and more severe mental disorders (42) has previously been described.
Referral to a mental health specialist has been associated with psychiatric history, depressive symptoms, suicidal risk (43,44) and the opportunity to work with mental health specialists (45).
For sick leave, our results indicate that GPs follow trends that have been highlighted among workers. Depressive disorders are the first cause of sickness certification for CMDs (46). It is interesting to note that GPs take into account dimensions of work to prescribe sick leave: 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 important, indicating that it is 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 OPs by GPs. We show that this is associated with work-characteristics. Fewer referrals to OPs for white collar have to be explored further. They may be related to mistrust of the relationship between OPs and the company, especially for managers. GP contact the OP more frequently in case of higher work intensity, which makes sense when trying to adapt working conditions.
c. Strengths and limitations
As described in previous articles based on the Héraclès study, some limitations have to be acknowledged (10,50,51). First, there is possible selection bias of GPs. Participating GPs could be especially interested in CMDs because of personal interest or patients’ rate of CMDs. 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 GPs’ practice, especially for referral to other health professionals. Moreover, low income in this area could led to a more frequent management of CMDs by the GP. Another possible limitation is the absence of standard procedures for GPs to diagnose CMD. In France such procedures do not exist in primary care. Finally the definition of the link between work and CMDs could be a limiting factor, even if we relied on the WHO definition of work-related disorders and the scientific literature (1,53–55). Indeed, there is no validated and consensual definition of work-relatedness of psychological difficulties.
Despite these limitations, the results of this study are valuable, because to our knowledge, this is the first study in Europe to study the management of patients with work-related CMDs by the GP. Moreover, contrary to studies in occupation settings, our study was conducted among primary care patients, which include a large panel of workers in the labour force including workers who have a poor relation with occupational practice (independent workers, workers in small companies or workers who do not have an OP, etc.). An international study shows that the average occupational health services coverage of workers is 24.8% (55). Finally, study questionnaires were completed by the GP who is often the referring physician and is well informed of the patient’s medical history and can assess if the disorder is related to work.