Background and aim
Mental health disorders (MHDs) affect more than 10% of the world’s population, representing 792 million people [
1]. In Germany, their 12 month prevalence is 27.7% [
2]. MHDs are the second most common reason for an incapacity to work [
3] and cause more days of sick leave than all other diseases [
4]. The prevalence of MHDs also appears to have exhibited an upward trend over the last 15 years [
4] placing a growing financial burden on public healthcare systems while also leading to huge losses in earnings. People with MHDs are also two to four times more likely to be unemployed after recovery [
5].
General practitioners (GPs) are often the first health professionals to be consulted by patients with MHDs in Germany [
6]. Hence, GPs are responsible for providing patients with sick leave certificates (i.e., taking them out of work) [
7] and later often navigate them through the return -to -work (RTW) process [
8].
Scientific literature indicates that other health professionals of the German health care system also consider GPs playing a crucial role in preventing and treating MHDs in employees [
9]. Thereby it seems particularly important how the individual GP defines his or her role and how the perception of one’s role can influence the treatment and RTW process of their patients as those GPs who tend to play more roles are assumed to be more informed about their patients’ needs [
10]. For example, an Australian study resulted in a broad variety of roles a GP may play when treating patients with schizophrenia, such as “ongoing management”, “family liaison and support”, and “initial crisis management” [
11] where other professional groups could participate, too. There is a need for further research on the specific roles of GPs in Germany and their individual limitations, as well as an understanding of whether assigning specific roles to other health professionals might improve the treatment and RTW process of patients with MHD.
The existing international data indicate that we need to do further research on GPs themselves in order to understand their needs of improvement regarding their case management, communication skills, the impact of personal beliefs and prejudices [
12]. For example, it has been shown that despite the special relationship between German GPs and their patients, the topic of future work ability is often barely touched in their conversations [
13]. Little is known about the fostering and hindering factors for GPs when treating patients with MHDs in Germany, but a recently published qualitative study from Sweden could demonstrate that GPs often feel boundaries in treating patients with MHDs through the current health care system which does not provide enough time and structure to address the multifactorial needs of a patient with an MHD, whereas more communication and teamwork with other health care professionals and expanding their knowledge about individual needs of their patients with MHDs was described as a factor for care improvement [
14]. Another study from France could show that most of the GPs found patients with MHDs more time- and care-consuming, more difficult to treat and needing consultations more frequently than patients with other health issues [
15].
Another relevant topic is the GPs’ need of further education on work-related stress factors and MHDs, which could, according to recent studies from Germany and the Netherlands, be reached through better interdisciplinary cooperation with other stakeholders, for example occupational physicians or psychotherapists [
16‐
18]. So far there is little information about the collaboration of GPs and other health care professionals in Germany, but data from France and Norway indicate that there is a lack of accessibility, professional exchange and collaboration between GPs and other health care professionals [
19,
20]. The RTW process in Germany after long-term absence from work is commonly conducted through a gradual return between six weeks and six months, mostly initiated and accompanied by GPs [
21] but in German research, little attention was paid to the strategies the GPs use to determine right time for the RTW of their patients. Data from other European countries, as well as Australia and Canada, show that the GPs experience the subject of RTW as a complex problem requiring their medical and non-medical skills and expressed their difficulties in assessing the work capacity of their patients as well as the lack of objective measures [
22,
23].
Against this background, this study was undertaken to obtain a better understanding of German GPs’ practices when dealing with patients with MHDs, with a special focus on RTW issues. We wanted to learn about the factors that increase the likelihood of success in the RTW process from a GP’s perspective, as well as the obstacles that still need to be overcome to improve the rate of successful RTW. We also wanted to develop ideas about how to prevent long-term, mental health- related absences from work.
We designed six research questions (RQs) that we aimed to answer:
-
1) How do GPs describe their role in treating patients with an MHD?
-
2) What kind of strategies do they use in their everyday life with their patients with MHDs, especially when having to handle long-term sick leave?
-
3) How can their knowledge contribute to their success regarding RTW?
-
4) Where do GPs experience boundaries and difficulties with regard to treatment of MHDs and supporting RTW?
-
5) How do they perceive the cooperation with other health professionals?
-
6) What are their opinions on the established RTW methods in Germany and how should a successful RTW process look like?
Methods
Our qualitative study followed the technique of
reflexive thematic analysis [
24,
25], meaning that this study is about the individual meanings and experiences of the GPs we interviewed [
26]. Data analysis started in parallel to the data collection to determine when the information gathered by the interviews could not be broadened any further and no more new themes could be generated. We took that as a sign of data saturation and ended the recruitment.
Recruitment and participants
Potential participants were contacted via email, phone or mail. They were chosen following the researchers’ network of contacts and using the network of K.L., who collaborated with a network of GPs as a member of the General Institute of Medicine at TUM. Participants received a short description of the study design and contact information in advance of the interviews. They were also informed that the study was performed as part of a doctoral thesis. The participants had to be trained as GPs and work at a doctor’s practice in Munich or its metropolitan area.
To broaden the focus of responses we used purposive sampling, that is, sampling of GPs from urban/rural areas and GPs of male/female gender.
Overall, 12 participants (GPs) were recruited for this study, half of whom were female. Their mean age was 57 years, the youngest being 51 years old and the oldest 70 years old. Almost all of them (11/12) worked full-time. Overall, 5 of the 12 worked at a doctors’ practice in an urban area, whereas the other seven worked in at a rural area. Most of the GPs were long-serving, having between 11 and 40 years of work experience (Table
1).
Table 1
Characteristics of participants
I1 | f | n/a | PT | rural | n/a | 18 | 36:52 | P |
I2 | m | 51 | FT | rural | 1300 | 19 | 37:57 | P |
I3 | m | 70 | FT | urban | 2000 | 30 | 29:38 | P |
I4 | f | 60 | FT | urban | 600 | 17 | 42:49 | P |
I5 | f | 52 | FT | urban | 530 | 24 | 25:40 | P |
I6 | f | 58 | FT | urban | 100 | 40 | 23:47 | P |
I7 | m | 60 | FT | rural | 1000 | 32 | 34:01 | Z |
I8 | f | 55 | FT | rural | 900 | 17 | 35:36 | Z |
I9 | m | 57 | FT | rural | 2500 | 27 | 34:39 | T |
I10 | m | 51 | FT | urban | 1600 | 18 | 45:15 | Z |
I11 | f | 53 | FT | rural | 900 | 11 | 40:35 | P |
I12 | m | 57 | FT | rural | 1200 | 20 | 26:15 | T |
Interviews/data collection
Before holding the interviews, a semi-structured interview guide was created using the “SPSS” method by Helfferich [
27]. The interviews took place between October 2019 and February 2021.
The first interview was performed by J.H., a male professor of psychiatry and psychotherapy, experienced in qualitative research and M.G., a female student of medicine at the time, inexperienced in qualitative research. The next eleven interviews were performed by M.G alone.
Interviews were generally held in the participants’ consultation room or office. However, some were held via Zoom or over the phone due to COVID-19 restrictions. The participants were informed that the interview was to be audio-recorded and transcribed. A time limit of 60 min, which had been discussed beforehand with the participants, was set. Each interview was held in a semi-structured form using an interview guide and ended with the completion of a short questionnaire to collect auxiliary information, such as age, years of work experience, and the workload at the doctor’s office. Each interview started with four open-ended key questions that were followed by more specific questions. This helped to avoid closed questions, or at least helped to set them aside until the end of the interview.
The four key questions covered 1) the GP’s experience regarding employed patients with MHDs in general, 2) their strategies when encountering a patient with an MHD asking for a sick leave certificate, 3) how they handled patients with long-term sick leave or patients who were in need of or returned from psychiatric inpatient treatment, and 4) their opinions on the established RTW methods in Germany and how a successful RTW process should look.
When ending the interview, the participants were given the possibility to emphasize on or add certain topics that seemed important to them. Throughout the interview, the researcher attempted to develop and sustain a lively conversation.
There were no repeat interviews carried out.
Data analysis
Transcription was carried out following the rules of Dresing and Pehl as described in their handbook [
28]. All interviews were strictly anonymized by the researchers. No transcripts were returned to the participants for comment or correction. The
Reflexive thematic analysis [
24,
25] was applied to the data, following the authors’ guide of analytic stages. It was delivered with an underlying constructionist epistemology, following an experimental orientation, meaning that this study is about the individual meanings and experiences of the GPs who were interviewed [
26]. D.B., an experienced qualitative researcher, answered the questions of M.G. regarding the execution of the analysis method.
M.G. revisited all transcripts mindfully and critically while taking notes of certain items of potential importance.
Coding was done inductively, using MaxQDA software. Therefore, the whole dataset was re-read thoroughly to create codes. Some codes consisted of a few words, while others consisted of many lines of text. Each code had to be easily understandable, even without the attached data. After having completed the coding, the collected codes were revisited, sometimes consolidating similar codes or adjusting codes to be more specific. In the end, there were 955 codes in total.
As a next step, the main themes were identified. Subsequently, a search for similarities between certain data was conducted, looking for recurring ideas throughout.
This process resulted in
overarching themes,
themes, and
subthemes [
24]. Overarching themes and subthemes were visualized on a thematic map.
Finally, before writing the report, each theme was given a precise definition to avoid overlapping themes.
Meetings to introduce and discuss the findings with another inexperienced female researcher and at the time student of medicine, A.P., and an experienced qualitative researcher, D.B., as well as J.H., took place after the coding process and after having established the first overarching themes. K.L., a male professor at the General Institute of Medicine at TUM, offered his feedback regarding paper-writing. A.P. also helped with proof-reading, revised the written report and gave her constructive feedback.
After writing the report, we checked whether any important information was missing using the Consolidated Criteria for Reporting Qualitative Research checklist (COREQ) [
29].
Discussion
Main findings
This study showed that GPs see themselves as very relevant in the rehabilitation of patients with MHDs because they can help with medical, administrative, and social issues, playing different roles for their patients, for example companion, therapist, social worker, et cetera. This may also indicate a lack of involvement of other non-professional groups, as it is necessary for GPs to regularly take on roles that society and the health care system do not seem to provide for patients with MHD. On the contrary, it underlines the importance of GPs for this cohort of patients and their rehabilitation process (RQ1).
GPs need a large body of knowledge and many different competencies, ranging from medical to administrative ones. A lot of their expertise is drawn from work experience, experienced anamneses and the special relationship to their patients as a GP (RQ3). Because of that, they develop individual strategies to support their patients with MHDs (RQ2).
However, GPs often have difficulties fulfilling their roles satisfactorily because of the lack of time, the frustration with having no simple solution, or bureaucratic obstacles (RQ4). Improving the interfaces for collaboration with other health professions might help, as the GPs reported poor connection and rare interactions with other stakeholders (RQ5).
We also discovered many additional individual factors associated with long-term absence from work, such as personality traits, fear of stigmatization and the interpretation of the workplace as negative or positive to the patients is also crucial to successful RTW (RQ4, RQ6).
Contributions to existing literature
To our knowledge, this study is the first to have investigated factors of RTW among people with MHDs using
reflexive thematic analysis and interviewing GPs in Germany. Once more it was confirmed that GPs play an important part in the treatment of MHDs, as already shown in various studies [
30].
One main finding of our study is the large variety of roles a GP can play when treating a patient with a MHD with providing a list of every mentioned role by the interviewed GPs.
Other studies have indeed investigated on the roles of GPs before, but mostly regarding special diseases or peer groups without mentioning MHDs, for example in cancer prevention [
31]. Also, our study could show the sources of knowledge and strategies GPs use when treating patients with MHDs.
We could confirm that GPs often have insecurities regarding the treatment of people with MHDs and often feel pressured when repeatedly asked to certify sick leave or prescribe medication [
32]. Other studies even suggested that they feel unsure about their diagnoses in general [
33].
GPs indicated that the likelihood of success when treating MHDs is often linked to their patients’ personality traits, which is supported by scientific reports [
34,
35]. Other studies hinted that the severity of reported symptoms seems to be a prognostic factor concerning sick leave [
36]. De Vries et al. could also show how the attitude of people with MHDs toward their disease can somehow predict their RTW success [
36].
Some GPs told us about the fear of their patients of being stigmatized by society or at the workplace. Existing literature suggests that when feeling stigmatized as a result of their MHD, patients can hesitate for longer before even consulting a physician [
37]. The effect of work on patients with MHDs was previously investigated in another qualitative interview study among 30 GPs, which also showed ambivalent opinions about work [
38].
A key result of our study picking up this topic is, that a positive meaning of work to patients can have a strong influence on a successful RTW. A qualitative Danish study, even identified two groups of GPs, showing the influence of GPs opinions on work: One mainly thought that patients should only receive sick leave for a shorter period and act to encourage their patients to RTW as soon as possible. The other group tended to think that work exacerbates their patients’ condition; therefore, they thought they were taking this pressure off them when certifying sick leave, while taking no special action to promote the RTW process [
39]. This study concluded that the overall understanding of work among GPs is rather positive, but it became clear during our interviews that GPs are often hesitant about determining right time for their patients to RTW. This is also a common problem among employees themselves [
34]. High workload, lack of validation, or the feeling of having to do useless work or being overqualified can damage the mental health of employees [
40]. In comparison, being unemployed can have similar effects on health and even lead to a shorter life expectancy, whereas a fulfilling job can lead to an overall higher quality of life [
41].
Limitations
This study has the following limitations. The sample size was rather small due to recruitment problems during the beginning of the COVID-19 pandemic. Accordingly, the presence of selection bias cannot be ruled out. However, data saturation was reached. Also there was a time limit set beforehand, although the authors do not believe it to be a disruptive factor, because most of the interviews found its natural end before the 60 min were elapsed. Moreover, the results of this study are grounded on the experiences and opinions of selected German GPs. They are of course heavily influenced by the way the German healthcare system works. Therefore, the findings of this study cannot to be considered as transferable to other healthcare systems.
It was not investigated if there is a difference when RTW or concerning stigmatization regarding the type of diagnosis in the spectrum of MHDs. Also, the important issue of gender differences in help seeking, getting diagnosed with an MHD, regarding stigmatization and RTW, was not brought up during the interviews.
Implications for research and practice
The recently growing proportion of sick leaves associated with MHDs shows the importance of the issue of MHDs and RTW. This explains why further research on the topic is desperately needed. Our study could show that existing interfaces have to be improved. The different stakeholders in the field of psychiatric care should focus on better cooperation with GPs. First of all, GPs themselves are in need of better support. More training concerning patients with MHDs could be helpful. Cooperation between experienced psychiatrists and GPs could potentially lead to more scientifically well-founded decisions [
42]. We would also like to highlight the problem that there is still some work to be done on the education of GPs concerning the issue of work issues and RTW.
A recent study developing a training for GPs regarding work-related stress factors unfortunately had no significant effect on improving the patients’ work-related self-efficacy or better recognition of work-related stress factors by the GPs [
43]. Maybe it would be interesting to investigate the success of interventions and trainings taking place earlier in medical education.
Moreover, other stakeholders could take over some of the GPs’ many roles in the future. For example, social workers could help guiding the patients through the RTW process. Another idea is to foster the use of “practice nurses” who, for example can, offer regular appointments. They could, according to their education, offer patients and their families support in the assessment and treatment of MHDs [
44]. There is a need to further explore the roles of a family physician from the perspective of their patients, society, and other health professionals. This may help to sharpen the role definition of a GP, with the potential to find members of non-professional and professional groups able to take on some of the roles, possibly leading to a reduction in role pressure for GPs. This could ultimately lead to more time and space for fulfilling the "original" role of the GP, and even allow for more effort in interdisciplinary collaboration.
Additionally, better cooperation between GPs and employers may lead to a higher success rate of RTW. The promotion of pre-vocational training or supported employment appears to have a lot of potential in this context [
45]. A recent study implied that greater RTW success was achieved when using targeted RTW interventions and already starting them while the patients are still on sick leave or at a psychiatric clinic [
46]. A study has just started at Hannover Medical School using an RTW program designed for patients on sick-leave due to MHDs. This program connects medical and psychotherapeutic support with interventions at the workplace and offering web-based post-rehabilitation support [
47].
Employers could enhance their RTW rates by paying more attention to trained external consultants such as disability managers [
48]. Then, strengthening of institutions such as integration services is needed to support both employers and employees.
Finally, programs providing education about MHDs at the workplace could reduce the stigma for the patients, resulting in greater success when RTW [
49].
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