General practitioners’ management of patients consulting for “mental distress at work”

Abstract

BACKGROUND:

Mental distress at work is a complex multifactorial phenomenon liable to impact health and personal life.

OBJECTIVE:

To assess the proportion of general practice consultations for mental distress at work and determine how general practitioners (GPs) manage these patients and the factors leading to consultation.

METHODS:

The frequency of consultations for mental distress at work was assessed on a self-administered questionnaire sent to the general practitioners (GPs) of the Loire administrative Département (France). Information on factors leading to consultation on management was obtained by a self-administered questionnaire in a sample of GPs and patients.

RESULTS:

Twenty-two patients were included by 16 GPs. 27% of patients were referred to an occupational physician. The frequency of consultations for mental distress at work was about 2%. Patients may wait several weeks or months before consulting, although a majority reported an impact on family life and health. A triggering event was often present, but no work accident procedure was undertaken.

CONCLUSION:

This study highlights the importance of better identifying adverse experience of working conditions and impaired mental health and reporting this to an occupational physician who can undertake preventive measures. Communication between occupational physician, employee and GP needs to be improved.

Keywords

Medical consultations psychosocial risk factors work-related common mental disorders

1 Introduction

Among work-related diseases, mental health problems are the second most frequent group after musculoskeletal disorders and the first cause of work-related sickness [1, 2]. Previous studies have shown that common mental disorders (CMD) can be related to work characteristics such as: job insecurity, working hours, work social support, decision latitude, decision authority, effort reward imbalance of job strain [3 –6]. In France, data from the national health insurance show that 20% of sickness absences are caused by mental disorders, and this proportion is even higher for long-term sickness absences (on average 111 days) [6]. The social cost of stress, related to healthcare expenditure, absenteeism, early retirement and premature death, amounted to € 2-3 bn in 2007 [7]. In 2016, applications for psychological pathology to be recognized as an occupational disorder were accepted in 596 cases, 40% up on 2015. According to Rivière et al., in primary care, prevalence estimates of CMD range from 3% to 25% for anxiety disorders and 6% to 25% for depression [6]. General practitioners (GPs) are key players in the management of patients consulting for mental distress at work, setting up individualized medical follow-up with specialist referral if need be. On the frontline for individuals with mental health problems, they often deal with work-related common psychiatric disorders [4]. To our knowledge, a few studies have evaluated the prevalence of work-related mental disorders [4, 8].

The present study assessed the frequency of consultation for mental distress at work, GPs’ medical management and the factors underlying consultation.

2 Methods

The study was approved by the French data protection commission on November 21, 2016, and by University Hospital ethics committee on January 13, 2017 (IRBN032017/CHUSTE). A self-administered questionnaire was e-mailed to all GPs (n = 800) in the Loire administrative department of France via the local Order of Medicine (OM), to be filled out on-line using the LimeSurvey application. Data were secured and anonymized. Respondents could make free comments at the end of the questionnaire.

Survey variables comprised sociodemographic data (age, gender) and occupational data (working time per week, number of consultations for mental distress at work, type of medical treatment). The rate of consultations for mental distress at work was determined by dividing the number of patients consulting the GP per week by the number examined for mental distress at work.

A transversal descriptive study was made of patients in the Loire area consulting their GP for mental distress at work from February to end May 2017, using two self-administered paper questionnaires: one survey was completed by the patient and one survey was completed by the GP. Twenty-two GPs were contacted for this study, and were asked to include patients on the following criteria:

male or female aged > 18 years;

first consultation for mental distress at work.

Non-working patients and those unable to read French were excluded.

GPs received a document explaining the study procedure, inclusion period and inclusion and exclusion criteria, and were asked to provide patients with clear, honest and appropriate oral information; eligible patients also received a written information document. Patients were free to decline to take part in the study without impact on treatment.

The patient questionnaire covered:

socio-occupational and demographic items: age, gender, marital status, socio-occupational category;

characteristics of the mental distress: symptom onset, trigger factors, impact on personal life and health, level of stress;

expectations regarding the consultation.

The GP questionnaire covered:

socio-occupational items: gender, seniority, number of days worked per week; these data were collected using the same questions as in the OM survey of all Loire area GPs, so as to determine the rate of consultation for mental distress at work per GP;

medical treatment: referral, medical prescription if any, sick-leave if any, diagnosis, etc.

The GP questionnaire was completed at the end of the consultation. The study was approved by the French data protection commission (Commission Nationale de l’Informatique et des Libertés: CNIL) on November 21, 2016, and by University Hospital ethics committee and the regional review board (respectively, January 12, 2017, Ref.: IORG0007394, and June 29, 2017, Ref.: 2017-A01404-49).

Data were rendered anonymous. Descriptive analysis used SAS software, version 9.3 for chi² or Fisher tests to compare frequencies, with the significance threshold set at p < 0.05.

3 Results

Eight hundred GPs were asked by the local Order of Medicine to fill out an on-line questionnaire. 118 (71 female, 47 male) did so: i.e., response rate, 14.7%. Sixteen of the 22 GPs eligible to include patients for the second study did so, and included 22 patients (15 female, 7 male). Socio-occupational characteristics such as gender, seniority and working time did not differ between GPs answering the Order of Medicine survey and those including patients and responding to the study questionnaire (Table 1). The mean rate of consultation for mental distress at work was 2.9% on the OM survey and 2.1% in the study series.

Table 1
Socio-occupational comparison between general practitioners (GP) sample and Order of Medicine (OM) survey of GPs in the Loire area

Variables GPs OM P-value

n % n %

Gender Male 8 50 47 39.8 0.60

Female 8 50 71 60.2

Seniority (years) <5 2 12.5 30 25.4 0.49

[5–15] 7 43.7 36 30.5

[15–25] 4 25.0 21 17.8

≥ 25 3 18.8 31 26.3

Half-days worked per week <7 6 37.5 25 21.2 0.16

[7–8] 2 12.5 16 13.6

[8–9] 5 31.3 25 21.2

≥9 3 18.7 52 44.0

Patients per half-day <10 2 12.5 8 6.8 0.36

[10 –14] 7 43.7 58 49.1

[14–15] 2 12.5 6 5.1

≥15 5 31.3 46 39.0

Distress patients per week in last month 0 3 18.7 1 0.8 0.025

[1 –3] 10 62.5 63 53.4

[3–4] 2 12.5 17 14.4

≥4 1 6.3 37 31.4

Variables	GPs	OM	P-value
Gender	Male	8	50	47	39.8	0.60
	Female	8	50	71	60.2
Seniority (years)	<5	2	12.5	30	25.4	0.49
	[5–15]	7	43.7	36	30.5
	[15–25]	4	25.0	21	17.8
	≥ 25	3	18.8	31	26.3
Half-days worked per week	<7	6	37.5	25	21.2	0.16
	[7–8]	2	12.5	16	13.6
	[8–9]	5	31.3	25	21.2
	≥9	3	18.7	52	44.0
Patients per half-day	<10	2	12.5	8	6.8	0.36
	[10 –14]	7	43.7	58	49.1
	[14–15]	2	12.5	6	5.1
	≥15	5	31.3	46	39.0
Distress patients per week in last month	0	3	18.7	1	0.8	0.025
	[1 –3]	10	62.5	63	53.4
	[3–4]	2	12.5	17	14.4
	≥4	1	6.3	37	31.4

GPs: General practitioners sample. OM: Loire Order of Medicine survey.

Medical management of patients consulting for the first time for mental distress at work was characterized by longer than usual consultation time, systematic sick leave (of less than two weeks in half of the cases), and medical treatment in half of the cases. Reasons for sick leave were mental pathology (anxiety, depression, anxiety-depressive syndrome) in two-thirds of cases and burnout in one-fifth. No sick leave prescriptions were for work accidents or occupational disease. One quarter of patients were referred to an occupational physician (Table 2).

Table 2

Characteristics of general practitioners’ medical treatment

Variables		n	%
Longer consultation	No	4	18.2
	Yes	18	81.8
Psychology referral	No	14	63.6
	Yes	8	36.4
Psychiatry referral	No	20	90.9
	Yes	2	9.1
Occupational medicine referral	No	16	72.7
	Yes	6	27.3
Specialist referral	No	22	100
	Yes	0	0
Medical treatment	No	12	54.5
	Yes	10	45.5
Sick-leave certificate	No	0	0
	Yes	22	100
Work accident certificate	No	22	100
	Yes	0	0
Occupational disease certificate	No	22	100
	Yes	0	0
Sick-leave duration	<7 days	1	4.5
	[7–14 days]	11	50.0
	≥ 15 days	10	45.5
Sick-leave reason	Anxiety	5	22.7
	Anxiety-depressive syndrome	8	36.4
	Depression	1	4.5
	Burn-out	5	22.7
	Asthenia	2	9.1
	Bursitis	1	4.5
“Reaction” status declared on medical certificate	No	16	72.7
	Yes	6	27.3

More than two-thirds of the patients were under 45 years of age, and one third were single, widowed or divorced. Mental distress at work showed at least a few months’ progression in most cases. More than half rated their job stress > 7 on a visual analog scale (VAS). More than two-thirds identified a trigger factor. While 86% had already spoken about their mental distress at work, only 13% had mentioned it to a member of the occupational medicine team. Most reported impact on family life and health. Nearly three-quarters expected the consultation to provide an opportunity to be listened to, two-thirds expected a sick-leave prescription, but less than a quarter expected medical treatment. A minority expected referral to the occupational physician, a psychologist or a psychiatrist (Table 3).

Table 3

Socio-occupational characteristics of patients and GP consultation factors

Variables		n	%
Demographic data
Gender	Male	7	31.8
	Female	15	68.2
Age (years)	18–25	1	4.6
	26–35	6	27.3
	36–45	10	45.5
	46–55	4	18.2
	> = 56	1	4.6
Marital status	Single	5	22.7
	Partnership	7	31.8
	Married	9	40.9
	Divorced	0	0
	Widowed	1	4.6
Socio-occupational category	Farmer	0	0
	Artisan, shop-keeper, CEO	0	0
	Executive, superior intellectual professional	6	27.3
	Intermediate professional	2	9.1
	Office worker	11	50
	Manual worker	2	9.1
	Other	1	4.6
Duration of distress at work	Days	2	9.1
	Months	14	63.6
	Years	6	27.3
Talk before consulting
No		3	13.6
Yes		19	86.4
	Spouse or partner	13	59.1
	Friend or relative	9	40.9
	Hierarchical superior	7	31.8
	Personnel representative	2	9.1
	Colleague	10	45.5
	Psychologist/psychiatrist	1	4.6
	Occupational medicine staff	3	13.6
	Labor inspector	0	0
Trigger event	Yes	18	81.8
	No	1	4.6
	Don’t know	3	13.6
Impact
Family life	Yes	21	95.5
	No	1	4.6
	Don’t know	0	0
Health	Yes	19	86.4
	No	1	4.6
	Don’t know	2	9.1
Stress VAS (visual analog scale) 0: no stress; 10: maximum imaginable stress	<7	3	13.6
	[7–8]	7	31.8
	[8–9]	5	22.7
	≥9	7	31.8
Expectations from consultation
Listening	No	6	27.3
	Yes	16	72.7
Treatment	No	17	77.3
	Yes	5	22.7
Sick-leave or work accident	No	8	36.4
	Yes	14	63.6
Referral to psychologist/psychiatrist	No	22	100
	Yes	0	0
Referral to occupational medicine	No	21	95.4
	Yes	1	4.6
Referral to specialist consultation	No	21	95.4
	Yes	1	4.6

4 Discussion

The frequency of consultations for mental distress at work was about 2%. Although a majority reported impact on family life and health, patients may wait several weeks or months before consulting.

The rate of GP consultation for mental distress at work was about 2%. Héraclès [6], in a series of GPs in the Nord-Pas-de-Calais Region of France, between April and August 2014, gave one of the first estimates of work-related psychological disorder in general practice: a quarter of working patients presented work-related psychological suffering. Analysis of treatment testified to strong GP commitment, with psychological interviews and medical prescriptions in most cases and sick-leave in half, but with little referral to occupational physicians, psychologist or psychiatrists. The present results likewise found little communication between GPs/patients and occupational physicians regarding mental distress at work.

A health and job retention policy based on a worker support approach should include practices targeting primary and secondary prevention [9]. According to the French Labor Code (article L. 4622-3), occupational physicians play a purely preventive role, to avoid any impairment of workers’ health status due to working conditions, notably by monitoring health and safety conditions at work, contagion risk and health status. The occupational physician acts as a consultant for the management, employees, staff representatives and the health and safety and working conditions committee (Comité d’Hygiène de Sécurité et des Conditions de Travail), providing advice on improving living and working conditions in the firm, adapting work-posts, techniques and work rhythm to actual human physiology, protecting workers against nuisances in general and especially work accident risks or use of dangerous substances.

The French health authority (Haute Autorité de Santé), in a 2017 report entitled “Clinical identification and management of burnout syndrome” [10], recommends that, with the patient’s agreement, the GP liaise with the occupational physician or an occupational pathology specialist, to raise an alert and have some information about the workplace. Analysis of the work-post and working conditions by a multidisciplinary team coordinated by the occupational physician is indispensable. Factors hindering cooperation between GPs and occupational physicians include medical confidentiality and concerns about the patient’s job security [11].The individual medical records are not presently available to the occupational physician, and exchanges with the GP require the employee’s agreement. Few GPs refer their patients to occupational physicians during sick-leave for the purposes of the end-of-leave consultation [12].

To promote return to work after sick-leave exceeding 3 months, a pre-return consultation with the occupational physician is set up by the GP, the national insurance consultant physician or the patient (Labor Code, Art. R.4624-29), in which the occupational physician may recommend work-post adaptation or change or occupational training to facilitate change of work-post or job. Unless the employee objects, the occupational physician informs the employer and the consultant physician of these recommendations so that all necessary measures should be taken to ensure return to work (Labor Code, Art. R. 4624-31).

According to the present findings, few patients spoke about their mental distress at work to any member of the occupational health department before consulting their GP. There are numerous factors hindering communication between employees and occupational physicians: misapprehension of the role of the occupational physician and of the possibility of meeting, difficulty of making contact, lack of a relation of confidence, and concerns about independence with respect to the employer [12]. Employees often mistrust occupational physicians due to the influence they have over hiring decisions through aptitude assessment and their role as advisors to the employer [12]. Occupational physicians, however, actually play a key role in keeping the employee in work.

According to the Labor Code (Art. R. 4624-31 and R. 4624-32), return-to-work consultations with an occupational physician are set up after maternity leave, sick-leave for occupational disease, or more than 30 day’s leave for a work accident or non-occupational illness or accident.

The return-to-work examination aims:

to check that the original or revised work-post is compatible with health status;

to examine work-post alterations or adaptations or job change proposed by the employer in the light of any occupational medicine recommendations made following the pre-return consultation;

to recommend work-post alterations or adaptations or job change;

or, as appropriate, to recommend the employee as inapt to return to work.

The issue of mental distress at work highlights the role of psychosocial risks in the deterioration of employees’ mental health [13]. More than three-quarters of GP respondents to a web questionnaire thought GP training ion mental distress at work to be inadequate: “Medical school culture does not deal with issues of health at work” [14]. Notably, no work accidents were reported in the present sample, despite patients often reporting trigger factors leading to GP consultation. Certain recent misadventures with the Order of Medicine, which transmitted employers’ complaints against practitioners who made the connection between work and ill health, may cause physicians to hesitate to make such work-accident reports. In this context, support from the occupational physician or national health insurance consultant is precious [14]. In work accidents, the relation with working conditions is implicit, and the health insurance authorities do not expect the GP to demonstrate it. The Regional Union of Community Health Professionals (Union Régionale des Professionnels de Santé Médecins Libéraux) of the Provence-Alpes-Côte-d’Azur Region of France drew up a guide to distress at work: “Le médecin libéral face à la souffrance au travail de ses patients” (“The community physician and patients’ distress at work”), listing mistakes to be avoided concerning the terms employed in sick-leave or work-accident certificates: the medical certificate must be strictly descriptive and clinical, dealing with the pathology rather than its cause; thus, the physician should not write anything like “depressive reaction to working conditions”. Equally, “harassment” is a legal term, not a medical diagnosis.

No declarations of occupational disease were made in the present series. In a 2007 study, “Les médecins face à la santé au travail: une étude qualitative dans le Sud-Est de la France” (“Physicians and health at work: a qualitative study in South-East France”), under-declaration of occupational disease concerned occupational cancer, asthma and musculoskeletal disorder [15]. Respondent physicians stressed the difficulty of drawing up the initial medical certificate. In regard to mental distress at work, burnout is not a disease recognized in the international classifications (ICD-10 and DSM-5) or in the official French list of occupational diseases. Regional Occupational Disease Recognition Committees (Comités Régionaux de Reconnaissance des Maladies Professionnelles: CRRMP) may make decisions on a case-by-case basis, but patients have to show at least 25% permanent incapacity in order to be examined. There are no occupational disease tables in France relating psychosocial risk and mental pathologies; however, a major depressive episode or anxiety disorder may be recognized as an occupational disease by the CRRMP in an “exceptional” procedure provided for in §4, Article L 461-1 of the Health Insurance Code.

Patients’ expectations consist above all in wanting their doctor to hear them out. Listening is a fundamental pillar of treatment. According to a 2017 article in the Revue Médicale de Liège, “Professional fatigue syndrome (Burnout)”, only attentive listening allows the different clinical presentations, somatic and psychological, of distress at work to be interpreted [16]; the authors recommend scheduling a second consultation, to leave the patient more time. More than 80% of physicians in the present study reported that consultations involving distress at work are longer than usual. A large-scale quantitative and qualitative study conducted by the Technologia consultancy under the auspices of the UMC health insurance company in 2012, entitled “Les effets du travail sur la vie privée” (Impact of work on private life) sought to understand and, if possible, measure the impact of working life on private life, in all dimensions: social life, family life, love life, and sex life. Work monopolized daily life for 50% of employees (and 61% of executives), ahead of family life (30%), the life of the couple (17%) and social life (3%). According to Technologia, most employees are torn between the importance they give to their work and the importance they struggle to give to their private life, and family life in particular: working time tends to creep up on the rest. In the present study, most patients reported history of distress going back several months or even years. By initiating more systematic dialogue about their patients’ work, GPs could help improve prevention of occupational risk, in teamwork with the occupational physician.

Most patients in the study were expecting sick-leave, which all were accorded, for less than two weeks in most cases. It seems to be essential to get away from work and its anxiety-inducing environment so as to be able to take some distance. Sick-leave duration varies with the severity of distress. A burnout prevention guide was drawn up by researchers and field experts in collaboration with the INRS (Institut National de Recherche et de Sécurité: national research and safety institute) and ANACT (Agence Nationale pour l’Amélioration des Conditions de Travail: national agency for improvement in working conditions), advising 2–3 months’ sick-leave associated to psychotherapy. In reality, sick-leave averages between 6 and 18 months, according to Marie Peze, a Doctor of Psychology, psychoanalyst and expert witness who set up the first “distress at work” consultation in the Nanterre hospital reception and care center in 1997.

Several limitations of our study should be acknowledged. First, GPs participation was selective. GPs who volunteered to participate in the study could have been especially interested in mental health, however socio-occupational characteristics such as gender, seniority and working time did not differ between GPs answering the Order of Medicine survey and those including patients and responding to the study questionnaire. The GP response rate could have been increased by repeated reminders. The requirement to include only patients consulting for mental distress at work for the first time limited the number of inclusions, but reduced selection bias. The use of the same questions in the Order of Medicine survey and in the study questionnaire allowed sample representativeness and the rate of GP consultation for mental distress at work to be assessed. A patient selection should also be considered, however the physicians participating in the study were instructed to ask all eligible patients to participate in the study. A third limitation was to do with the definitions of work-related psychiatric disorders: the attribution of work-relatedness makes by the GPs or the patient is subjective. For the measurement of GP-diagnosed psychiatric disorders, there were no standardized procedures for the diagnosis. This could have introduced bias in the measurement however in France GPs do not use standardized procedures to establish diagnoses of psychiatric disorders among their patient. Besides we have to cautious about the results because of the small sample size which does not allow the results to be generalized to the French population.

5 Conclusion

In the present study, most GPs in the Loire area reported difficulties in dealing with distress at work. Screening for the impaired physical and/or psychological health status in case of distress at work reported by the patient should guide the GP’s clinical approach. It is not the GP’s role to establish a link between symptoms and work. The slowness of reaching a diagnosis of mental distress at work is a real problem: it is alarming to find that patients wait several weeks or even years before consulting their GP, despite experiencing impact on family life and health. For preventive purposes, the factors underlying such complaints need to be clarified. Referral to occupational medicine could be improved by improving communication between patient and GP. It should be borne in mind that all employees have the right to ask for a consultation with their occupational physician [17]. The present study highlights the importance of reporting negative experience of working conditions and impaired mental health to the occupational physician, so that he or she can undertake preventive measures.

Conflict of interest

The authors declare that they have no competing interests.

Funding

This research was supported in part by the University Hospital from Saint-Etienne.

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