New thesis highlights challenges for doctors while certifying sickness for patients with mental disorders

Nearly nine out of ten doctors in primary care think a decision on sickness absence is improved if they are in touch with the patient's employer -; but only four out of ten are. A University of Gothenburg thesis highlights several challenges for doctors when certifying sickness for patients with common mental disorders.

Doctors think it's difficult, and with good reason. It's a complex task in which they don't get the full support they need."

Paula Nordling, MD, PhD, Sahlgrenska Academy's Department of Community Medicine and Public Health, University of Gothenburg

Her thesis includes a review of international qualitative studies in which doctors describe how they assess patients' work capacity. The basis is the clinical investigation, but other, job-related and private factors in the patients' lives also affect their fitness for work. These factors may be hard for the doctor to assess. Especially problematic is assessing common mental disorders, such as depression, anxiety and stress-related disorders, in which symptoms and their impact on functional capacity may be difficult to verify.

One piece of the puzzle that is often missing is information about the patient's work situation. Based on a major questionnaire survey from Karolinska Institutet, Nordling examined how often 4,228 general practitioners (GPs) in Swedish primary care were in contact with sick-listed patients' employers, and whether they were satisfied with these contacts.

As many as 86 percent of the GPs considered that getting in touch with patients' employers was important for the quality of their own work with sickness certification. On the other hand, only 39 percent reported that they had been in touch, either personally or through other health and medical staff, with these employers.

Communication and trust

GPs who collaborated with other health professionals at their clinics, or with the person who coordinated rehabilitation measures, were in contact with patients' employers to a greater extent. The GPs' satisfaction with the employer contacts was, in turn, connected to whether they experienced support from their managers and sufficient resources in their work with sickness certification.

In an attempt to facilitate contacts among GPs, patients and employers, Nordling developed a simple communication support, "the Capacity Note" (Resurslappen), which was used in a randomized study in primary care.

Some of the approximately 20 questions were answered jointly by the patient and the GP, and some by the patient together with his/her manager or supervisor. According to the users, the approach could contribute to improved communication about the patient's health and work situation, and to an enhanced understanding of how common mental disorders can affect work capacity.

Participating patients emphasized the value of their situation being given legitimacy, and some were helped in their decisions about their sick leave and work situation. Overall, the users stressed the importance of honest communication, trust and time properly set aside for the discussion about mental ill-health and work situation.

Individual and organizational support

According to Nordling, the results reported in her thesis indicate that initiatives are necessary at both individual and organizational level to strengthen GPs' work with sickness certification.

"Doctors need more training in insurance medicine -; not only how to write certificates, but also knowledge of the complex interplay between individual and context in the sick-leave situation. Unfortunately, to date, the scientific knowledge about this is very limited when it comes to common mental disorders," she says.

"Doctors also need the right organizational prerequisites to enable them to do a good job with sick leave cases. Specific resources such as time, guidelines, support from management, and scope for cooperation both within and outside the clinic can facilitate GPs' assessments of patients' work capacity and need of sick leave."