Opinions of general practitioners about psychotherapy and their relationships with mental health professionals in the management of major depression: A qualitative survey
Opinions of general practitioners about psychotherapy and their relationships with mental health professionals in the management of major depression: A qualitative survey
HeÂ lène Dumesnil 0 1
TheÂ mis Apostolidis 1
Pierre Verger 1
0 Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Sant eÂ & Traitement de l'Information MeÂdicale , Marseille, France, 2 ORS PACA , Observatoire ReÂ gional de la Sant eÂ Provence- Alpes-C oÃte d'Azur , Marseille, France, 3 Aix Marseille Univ, LPS, Aix en Provence, France, 4 Aix Marseille Univ, IRD, AP-HM, SSA, VITROME, IHU-MeÂ diterran eÂe Infection, Marseille , France
1 Editor: JoÈrg Frommer, Otto von Guericke University Magdeburg , GERMANY
Funding: The authors received funding for this
work from Direction GeÂneÂrale de la SanteÂ,
French general practitioners (GPs) refer their patients with major depression to psychiatrists
or for psychotherapy at particularly low rates.
This qualitative study aims to explore general practitioners' (GP) opinions about
psychotherapy, their relationships with mental health professionals, their perceptions of their role and
that of psychiatrists in treating depression, and the relations between these factors and the
GPs' strategies for managing depression.
lyzing their thematic content.
In 2011, in-depth interviews based on a semi-structured interview guide were conducted
with 32 GPs practicing in southeastern France. Verbatim transcripts were examined by
anaWe identified three profiles of physicians according to their opinions and practices about
treatment strategies for depression: pro-pharmacological treatment, pro-psychotherapy and
those with mixed practices. Most participants considered their relationships with
psychiatrists unsatisfactory, would like more and better collaboration with them and shared the
same concept of management in general practice. This concept was based both on the
values and principles of practice shared by GPs and on their strong differentiation of their
management practices from those of psychiatrists,
Ministère chargeÂ de la santeÂ (Directorate General of
Health, Ministry of Health).
Competing interests: The authors have declared
that no competing interests exist.
Several attitudes and values common to GPs might contribute to their low rate of referrals
for psychotherapy in France: strong occupational identity, substantial variations in GPs'
attitudes and practices regarding depression treatment strategies, representations sometimes
unfavorable toward psychiatrists. Actions to develop a common culture and improve
cooperation between GPs and psychiatrists are essential. They include systems of collaborative
care and the development of interdisciplinary training common to GPs and psychiatrists
practicing in the same area.
Although the density of psychiatrists in France is among the highest in Europe, French general
practitioners (GPs) refer their patients with major depression to psychiatrists or for
psychotherapy at particularly low rates [
]. This is especially striking in that psychotherapy is
recommended as the first-line treatment for major depression of mild to moderate intensity and
as a complement to pharmacological treatment for severe depression in France  and
A quantitative survey that we conducted in 2011 among a national panel of GPs identified a
dual paradox in GPs' opinions and practices related to psychotherapy in the management of
major depression [
]. First, GPs on the whole had favorable opinions about psychotherapy
and recognized its effectiveness for treating depression, but they rarely suggested it to their
patients with mild to moderate depression; instead they prescribed antidepressants . This
discrepancy between their opinions and their practices may be explained by obstacles related
to access to psychotherapy (unequal distribution of mental health professionals, long wait
times for psychiatrist appointments for new patients, and French policy, which does not
reimburse psychotherapy by psychologists) or patient reluctance. Our analyses, however, did not
find that any of these obstacles were associated with the GPs' treatment choices [
In their theoretical model of access to mental health care at different points along patients'
health care trajectory [
], Goldberg and Huxley argue that GPs play an important role as
gatekeepers to access to psychiatric care. In particular, they point out that a principal obstacle to
this access lies on the interface between primary care providers and the organizations and
professionals specialized in mental health care.
Both GPs' relationships with mental health professionals and their representations of these
specialists' practices might influence the access of their patients with psychiatric disorders to
adequate care. Although the literature reports numerous difficulties in relationships between
GPs and psychiatrists [9±12], we found only a single qualitative study dealing with the issue of
referrals for psychotherapy by GPs of their patients with depression [
]. This study of Swedish
GPs found that the GPs questioned did not consider psychotherapy as a treatment in its own
right for major depression and favored the use of antidepressants, regardless of the severity of
In 2011, together with the quantitative survey, we conducted an exploratory qualitative
survey of GPs in private practice to analyze their opinions and practices in the management of
depression. This article, based on that qualitative study, seeks to understand the paradoxes
described above by analyzing: 1) the opinions of these physicians about psychotherapy
(objective 1); 2) their relationships with mental health professionals (objective 2), and 3) the more
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general way that GPs perceive their profession and their role, as well as that of psychiatrists, in
the treatment of major depression (objective 3).
Materials and methods
Recruitment of participants
We randomly selected 50 physicians in the database of the French National Health Insurance
Fund for southeastern France among GPs practicing in the city of Marseille on January 1,
2011. The random drawing was stratified by physicians' age (younger than 50 years; 50 years
or older) and sex.
We sent a letter to these physicians, announcing and briefly describing this study, its
objectives, and its procedures, and then contacted them by telephone, to obtain their agreement to
participate and to make an appointment for the interview. Their written consent was collected
at the interview. To comply with the confidentiality and anonymity of the interviews promised
to the GPs, the information collected during the interviews cannot be shared in its complete
Two psychologists used a semi-structured interview guide to conduct in-depth face-to-face
interviews. The instrument, drafted with a group of experts (a GP, a mental health specialist,
an epidemiologist, and 2 social psychologists), and pilot-tested among 6 GPs, was intended to
explore a wide range of potentially relevant issues about the management of major depression.
It covered, in particular, an analysis of GPs' choices and strategies when starting to treat
patients for major depression, their relations with mental health specialists, their opinions of
psychotherapy and pharmacotherapy, and their perceived role, self-efficacy, and difficulties in
managing patients with major depression (S1 Appendix). Although the instrument was
prepared to ensure that the same themes were studied in each interview, there were no
predetermined responses, and participants were encouraged to talk freely. Data were collected from
March to May 2011. Each psychologist interviewed half the GPs. The interviews lasted 36
minutes on average (15±116 minutes) and were all audiotaped with the GP's consent, then
completely transcribed manually (as Word files), and anonymized by both researchers. All the
interviews were conducted, transcribed, and analyzed in French.
At the conclusion of the interviews, the participants also completed a short questionnaire
about their individual (age, sex) and professional (years of practice, group or solo practice, and
training in mental health) characteristics.
The two social psychologists who conducted the interviews separately performed thematic
analyses of all the interviews and then crossed their results (triangulation of researchers). We
performed an analysis of thematic content to analyze the data related to GPs' opinions about
psychotherapy and their collaboration with psychiatrists.
The two psychologists analyzed each subject's words according to their thematic content
], applying a common multiple-step method for each transcript: First, they familiarized
themselves with the data by repeatedly reading the transcripts and listening to the interview
audiotapes. Next, an initial framework for interpretation was developed based on the study
objectives and the interview guide, in the form of a grid or table for each interview (Table 1).
The themes that emerged spontaneously from a participant's discourse were distinguished
from those in response to questions from the interview guide, because spontaneously
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1 Spontaneous (S): spontaneous mention of a theme / In response to (R): evocation of a theme in response to a question from the interviewer guide
mentioning a theme rather than discussing it only once it is raised by the interviewer can be
revealing of the importance the interviewee attributes to it. Spontaneous mention may
indicate, for example, that the theme is frequently encountered, presents the most difficulties, or is
a major concern or worry.
Next, a cross-sectional analysis was performed for each theme, and a table produced for it
The analysis consisted in describing the different subthemes mentioned, their importance
for the physicians (themes mentioned most frequently or at least repeatedly during an
interview, those appearing spontaneously, and so on), their consensual nature (or not), and the
relations between them.
We did not submit our study to an ethics committee because this approval is not required for
qualitative research studies in France. But we rigorously applied the standard ethical
requirements for such studies: we requested the written consent of participants (all of them general
practitioners) after explaining the study's purpose and procedures, including the
anonymization of every aspect of the transcripts that could enable identification of the participants and
their right to withdraw from the study at any point.
In reporting the results, we state that a theme was mentioned spontaneously or in response to
a question only when the type of mention was similar for most of the doctors we interviewed.
Description of the sample
Of the 50 physicians we reached, 32 agreed to participate and were finally interviewed (64%).
Nineteen (59%) were men and 21 (66%) were aged 50 years or older. The proportions in group
and solo practices were identical. They had been practicing medicine for a mean of 24 years
(range: 2±35 years). Nearly half (47%) reported participating in a continuing medical
education program on mental health during the previous 3 years. Of the 15 GPs who declined to
participate, 47% were men and 40% 50 years or older.
Theme: . . .
Spontaneous (S)/ In response to (R)1
Excerpt from interview
. . .. . .
Opinions about psychotherapy
GPs rarely mentioned psychotherapy spontaneously. Participants defined psychotherapy as
supportive interviews conducted by a professional with specific training, in contrast to the
informal support that they provide. They think that psychotherapy enables patients to confide
in someone, to unload or unburden themselves emotionally: a psychotherapist helps patients
to work on themselves, to identify the cause of their ill-being, and to mobilize their personal
The GPs defined the informal support that they provide to patients in the same terms, but
recognized that they have neither the theoretical framework nor the academic training to
Their discourse on the subject of psychotherapy was unspecific and mentioned only a few
themes: its utility and relevance for patients with depression, its dependence on patient
adherence, and the obstacles to access to it. The different types of psychotherapy, their indications,
effectiveness, and benefits were little discussed. Some GPs indicated their preference for
cognitive-behavioral therapy; others spoke, more frequently, about psychoanalysis:
ªLying on a couch and describing your troubles (GP29)."
ªOften you can only make progress toward understanding the cause of problems by searching,
by exploring the repression of memories in the unconscious. Pathogenic experiences are often
We identified three profiles of physicians according to their opinions about treatments for
depression and their therapeutic strategies (Table 3). The first profile comprised GPs with very
decided opinions, unfavorable to psychotherapy, and with a preference for pharmacological
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· Prescription of antidepressants as a last
· Psychotherapy proposed almost routinely
· To use only in the most severe cases, but
· Uncomfortable prescribing
· Desirable for most patients with
· Younger physicians
· A treatment in its own right of depression · Treatment with advantages and disadvantages
Profile 3 (N = 20)
Physicians with mixed practices
· Variable practices: Possible prescription of
antidepressants and/or psychotherapy,
depending on the situation
· Consideration of patient's preferences
· Sometimes indispensable
· Medication makes it possible to manage acute
situations, but does not cure
· Must not be prescribed whenever or however
· Variable effectiveness, substantial obstacles to
· Make it possible to act on the cause of the
· Cannot be offered systematically to all patients
· No associated characteristics
"It can work, but not all the time".
"[The patients] must be capable of reflection, of
analysis (. . .), have some minimum level of
education (. . .). It's not accessible to everyone."
treatment (6/32). The second profile corresponded to GPs with very positive opinions about
psychotherapy and notably prudent about antidepressants. These physicians reported that
they very frequently suggest psychotherapy to their patients (6/32). The third profile covered
GPs with globally positive opinions about psychotherapy but who nonetheless reported
reservations about it. The latter applied mixed practices and adapted their prescriptions to each
GPs' collaboration with mental health professionals
Most of the GPs spontaneously mentioned their relationships with mental health professionals,
mainly psychiatrists. Participants mentioned the following themes (Table 4): the frequency of,
reasons for, and obstacles to referring patients, GPs' relationships with these mental health
specialists, and the differences in practices between GPs and psychiatrists.
Of the 12 participants who mentioned the frequency with which they referred their patients
to mental health specialists, 10 said they did so only in complex or severe situations.
Besides the difficulties in access to psychiatrists (long wait time for appointments, cost of
consultations with specialists in private practice) mentioned by most (23/32), more than half
the GPs also reported that they were dissatisfied with their current collaborations (19/32).
They complained especially about a lack of communication (10/32): the rarity of conversations
about the patients, the specialists' failure to respond to GPs about the referral, and mutual
difficulties in understanding one another. Some GPs reported experiencing more problems
working with psychiatrists than with other specialists.
"The dark spot is the (. . .) lack of communication with psychiatrists (. . .) we all communicate
with the other [specialists] except them, it's strange (GP26)."
Nonetheless, the majority of GPs wanted to communicate more with psychiatrists and
coordinate better with them, to improve the quality of care, to facilitate the patients' care plan,
and to break their own isolation.
"There is perhaps not enough dialogue between general practitioners and private-practice
psychiatrists. Nonetheless, I would really like for us to succeed in talking more often and better. I
think it would be good, it could only be useful for everyone (GP3)."
GPs' perception of their own and psychiatrists' roles and practices
Management of depression. Nineteen participants mentioned the respective roles of GPs
and psychiatrists in managing patients with depression. Twelve thought that they should
manage depression while psychiatrists should care for psychotic disorders and patients at risk of
suicide. Some GPs considered that they had acquired the knowledge and skills necessary for
managing depression through experience, despite their lack of initial training in mental health.
Psychiatrists nonetheless remain a potential resource should they encounter difficulties in
caring for a patient (11/19).
"Depressed patients, we see them every day or almost, we're used to them, we recognize them,
we know how to handle them, to treat them. (. . .) and then if really we are having difficulty, if
we see that truly the patient is not doing well, that things are dragging, we can always contact
a psychiatrist at that point (GP4)."
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PLOS ONE | https://doi.org/10.1371/journal.pone.0190565
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"Finally, we can manage all mental health disorders on an outpatient basis, except for crises
Other GPs (5/19) had a different vision and reckoned that everything linked to mental
health should be handled by psychiatrists, whom they perceived as experts with more relevant
skills than GPs. Among these 5 GPs, none belonged to the first profile very favorable to
"We are clearly not in the same league. . .it's their specialty. . .everything that is a hard case, in
quotes, mental illness, that's their domain (. . .) there is a reason that it's a specialty in its own
right, and there's a reason we call them when we can't manage with some patients (GP6)."
Some GPs considered that their role is principally to identify patients with depression and
refer them to specialists.
"We are better equipped to identify diseases than psychiatrists. That's the heart of our work:
screening, recognizing, and directing to specialists. Well, it's the same for mental health
GPs' common vision of depression management. Despite these divergent views of their
role, a common vision of appropriate management emerged from the GPs' discourse: the
patient is at the center of the care, which must be comprehensive and adapted on a
case-bycase basis, according to his or her characteristics, personal life story, and environment.
"It's the core of our work (. . .): we are constantly obliged to adapt to each of our patients, to
deal with their history, their family, their situation. Each patient is unique, each decision we
make must also be unique (GP23)."
Most of participants stressed their relational skills: listening, supporting, and advising are
the heart of their work, an integral part of the management of depression, and what patients
expect of their GPs.
"Listening is the basis of my work, especially in diseases like that. It's true that I take an
enormous amount of time with patients, that I sometimes find myself with patients who spend
nearly 45 minutes in the office. So yes when I'm running late, they complain a little, but
otherwise, they appreciate being listened to and that’s what they come to see me for (GP28)."
A language close to that of their patients. Vocabulary used by GPs to designate
depression was mostly non-technical, very close to ordinary daily vocabulary. Only one GP
mentioned DSM IV, and two used the term "depressive episodes.º Instead they mainly used terms
such as "true depression," "small/big depression," "deep or serious depression,"
neurotic/nervous disease," and "very depressed.º Similarly, some physicians seemed to distance themselves
from the medical terms usually used in psychiatry, even as they used them.
"It’s up to us to distinguish between a true depression, a major depressive episode (. . .) as we
are supposed to call it (GP2).º
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· Distant and cold with
· Know little about their
patients and their histories
· One-off consultations
Verbatim excerpts from interviews
“We know the families (. . .) I know their environment, I know their
husband, I know their children (. . .) obviously, the first time the psychiatrist
sees you, he doesn't know your children or your husband“.
· Technique, position as expert "I'm a clinician (. . .) I don't like this kind of tool [diagnostic scales] and
· Use of screening tools then I base my judgments on the symptoms I observe; I'm a clinician. I leave
· Reference to the literature that to the psychiatrists".
and to diagnostic
· Scientific vocabulary
· Education and training
"We talk about depression as it's written in books, with abulia, apathy, disinterest, the person
doesn’t even comb their hair anymore, doesn't eat, and blows up over nothing, starts to
blubber, and that, those are depressive symptoms (GP21).º
A comparison of their practices with those of psychiatrists. Participants frequently
compared their practices to those of psychiatrists (Table 5). They described themselves as
closer to their patients, listening to them better than the psychiatrists did. Some reported
negative feedback from patients describing psychiatric consultations that were too short (11/32)
and psychiatrists who did not listen (8/32). They described their practices as less technical than
those of psychiatrists, based on pragmatic field experience, contrary to psychiatrists, with their
Our qualitative study is the first in France to analyze in detail the opinions of GPs about
psychotherapy, their relationships with mental health professionals, and their perceptions of their
profession, their role, and those of psychiatrists, and to describe the relations of these factors
with GPs' strategies for managing major depression.
One of its principal results is that GPs had distinct attitudes toward psychotherapy, falling
into three different categories according to their opinions of this type of treatment (Table 3).
The majority of GPs were reasonably favorable to psychotherapy. They perceived its usefulness
but also underlined its disadvantages. Some GPs were very favorable to psychotherapy,
proposing it almost routinely to patients with depression. On the contrary, some GPs opposed to
this type of treatment. These opinions were consistent with their treatment choices for patients
Their collaboration with psychiatrists was a major concern of the GPs: they considered
their relationships with these specialists unsatisfactory and asked for more and better
collaboration with them.
Finally, the participants shared the same concept of management in general
practiceÐcomprehensive and individualized patient management, relational skills, pragmatic knowledge
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based on experience; and they distinguished these practices and methods from those they
attribute to psychiatrists.
Strengths and limitations of the study
Several strengths associated with the methods used in the study should be underlined. The
GPs were selected by a random drawing that was stratified for age and sex to ensure the
participation of GPs of different ages and sexes, because these variables are often associated with
differences in physicians' care practices [
]. Our study was thus able to examine the
diversity of GP's opinions and points of view in terms of their demographic characteristics.
Next, two researchers collected and analyzed the data. The resulting triangulation
strengthened the validity and reliability of the data produced [
]. This survey also has some
limitations. First, it is possible that physicians who agreed to participate in this survey are more
interested in or more frequently faced in their practice by depressive disorders than the
nonparticipants; as compensation, however, it increased the wealth of points of view about the
different ways of managing them. In view of the size of the sample, prudence is necessary in
generalizing these results. Nonetheless, interviewing 32 GPs allowed us to meet a wide variety of
GPs and to attain theme saturation. Moreover, the similarity of some of our results to those in
a quantitative study of a representative national study of French GPs  suggests that they are
not specific to the GP population we interviewed. The second limitation stems from its entirely
urban setting. Because the supply of specialists in mental health in rural areas is considerably
smaller than in cities, the inclusion of rural GPs might have modified our findings about GPs'
use of psychiatric referrals and their modes of collaboration with psychiatrists.
Interpretation of results
Differing opinions of psychotherapy. The first objective of this survey was to improve
our understanding of the paradox that general practitioners, despite their favorable opinions
of psychotherapy, rarely suggest it to patients with depression [
]. Our results, which show
that GPs differ in their opinions of psychotherapy, qualify the preceding observation. Ardent
defenders of psychotherapy accounted for only a minority of the GPs in our sample. The
others, less favorable to psychotherapy, tended to offer this treatment less often to their patients,
which may help to explain the low rate at which GPs in France refer their patients with
depression for psychotherapy [
GPs' discourse about psychotherapy was sparsely furnished and referred principally to
psychoanalysis: long and expensive treatment, Freudian theories of the unconscious, etc. Other
types of psychotherapy were mentioned very little. This is in line with other study results
showing that GPs express themselves about psychotherapy and especially psychoanalytic
approaches in ways that match the perceptions of laypeople [
]. This suggests that GPs may
share with laypeople representations about psychotherapy and psychoanalysis.
Those results might reflect GPs' lack of training in and knowledge of psychotherapy:
previous results show that most GPs (82%) would like to be better trained about psychotherapy [
The GPs' relatively infrequent mention of psychotherapy and the few themes related to
them may also be related to some of their attitudes toward therapy: some GPs do not consider
it to be a treatment for depression to the same degree as drugs are, but rather an adjunct
treatment. In a qualitative survey in Sweden, every GP questioned responded that psychotherapy
could not replace pharmacotherapy in patients with major depression [
More generally, the pharmacological model for the management of depression is dominant
among GPs [13,20±23], and antidepressants remain the strategy most frequently used by GPs
in the treatment of depression, even mild to moderate, in France [
], as abroad [
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physicians in France have a positivist view of drugs, are persuaded that continuous progress
occurs in their development, and moreover tend to underestimate the risks and side effects of
the treatments they prescribe . They are also notable for their particularly high level of
medication prescription: 90% of GP visits in France conclude with a prescription, compared
with 72% in Germany and 43% in the Netherlands [
Difficulties of collaboration between GPs and psychiatrists. As in our quantitative
national survey of GPs [
], the participants in this study explained their low recourse to
psychotherapy by the existence of obstacles to access to this type of treatment, linked to what they
consider to be both its insufficient supply and its high cost. But the results of this qualitative
study also suggest that the difficult collaboration between GPs and psychiatrists is another
major obstacle to the referral of patients with depression.
Numerous publications in various countries have pointed out the difficulties of
collaboration between GPs and mental health professionals, as well as GPs' dissatisfaction with it [9±
11,13,26±31]. Like ours, these studies show relational difficulties between GPs and
psychiatrists, including lack of communication and difficulties in understanding each other.
Nonetheless, the reasons for these relational difficulties merit examination. Most GPs expect positive
effects from this collaboration, in terms of continuity and quality of care and access to it, and
would like to strengthen it [
Previous publications have already reported that GPs, like some of those participating in
this study, report that they find it harder to work with psychiatrists than with other specialists
]. One hypothesis that might explain this is the lack of a clear definition of the
respective roles of GPs and psychiatrists in the organization of care and follow-up for depression, at
least in France [
]. In a study of Belgian GPs and psychiatrists in 2009 [
], more than half
the psychiatrists thought that it was preferable for patients who need antidepressant treatment
to be managed by a psychiatrist, while only 3% of GPs agreed. Similarly, 74% of the
psychiatrists, but only 47% of GPs thought it was better for specialists to conduct the psychotherapy of
patients with depression. These results show that GPs and psychiatrists have different visions
of the management of depression and of their respective roles in it. This context may enhance
the perception of competition between them in this particular context of patients with
], at least for GPs and psychiatrists in private practices.
GPs' strong professional identity. Several elements testify to the existence of a strong
common professional identity among GPs, based both on the values and principles of practice
shared by GPs and on their strong differentiation of their management practices from those of
GPs stressed their relational skills and their experience in the field more than their technical
and medical skills. This suggests their willingness to be close to their patients and to satisfy
their needs, especially one of their principal needsÐto be heard and listened to [
]. It also
points out GP's insistence on affirming the specificity and added value of general medicine
compared with other specialties.
The distancing from psychiatrists goes hand in hand with the affirmation of GPs' skills and
a devaluing of the same skills in psychiatrists, but without devaluing the latter's technical
competence. According to the theory of social identity developed by Tajfel and Turner [
proposed a framework for studying intergroup conflicts, individuals belonging to the same
professional group can tend to accentuate the resemblance between the members of their own
group and their differences compared to members of other groups, which thus leads to
discrimination against the others. This process would allow GPs to maintain their profession's
positive social identity, although they may also have a devalued perception of their function
relative to specialists [
]. It also makes it possible to reaffirm their legitimacy and competence
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in the management of depression, in a context in which their drug prescription practices are
the object of substantial social criticism [40±42].
This professional identity may present an obstacle to the collaboration of GPs and
psychiatrists. Shared values, the existence of a common language, and the mutual impression that
collaboration will improve the quality of care are essential prerequisites for the development of an
interprofessional collaboration [
]. Improving the collaboration between GPs and
psychiatrists thus appears to require the development of a common culture between them with a
shared vision for the management of depression and of the role each plays for the patient.
Conclusions. The results of this study provide new avenues for explaining the low rate of
referrals by GPs for psychotherapy in France. They show the interest of taking into account
GP's opinions about psychotherapy and about mental health professionals, as well as their
perceptions about their profession and their role in the management of depression. Several types
of activities aimed at improving the cooperation between general practitioners and mental
health professionals could be tested and assessed in France [
]. They include systems of
collaborative care, the effectiveness of which have been demonstrated on several occasions
, and the development of interdisciplinary training [
], common to GPs and psychiatrists
practicing in the same area. These types of activities should promote the development of a
common culture between these professionals and help to create local informal care networks
across the country.
S1 Appendix. Interview guide.
S2 Appendix. Information sheet to participants.
We thank Jo Ann Cahn for her translation of the manuscript.
Conceptualization: HeÂlène Dumesnil, TheÂmis Apostolidis, Pierre Verger.
Formal analysis: HeÂlène Dumesnil.
Funding acquisition: Pierre Verger.
Investigation: HeÂlène Dumesnil.
Project administration: Pierre Verger.
Resources: Pierre Verger.
Supervision: Pierre Verger.
Validation: HeÂlène Dumesnil.
Visualization: HeÂlène Dumesnil. Methodology: HeÂlène Dumesnil, TheÂmis Apostolidis, Pierre Verger.
Writing ± original draft: HeÂlène Dumesnil.
Writing ± review & editing: HeÂlène Dumesnil, Pierre Verger.
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