Barcons et al. BMC Family Practice (2019) 20:155 https://doi.org/10.1186/s12875-019-1036-2 RESEARCH ARTICLE Open Access Effectiveness of a multimodal training programme to improve general practitioners’ burnout, job satisfaction and psychological well-being C. Barcons1,2* , B. García3, C. Sarri4, E. Rodríguez4, O. Cunillera5, N. Parellada6, B. Fernández7, C. E. Alvarado8, C. Barrio9, J. C. Fleta10, D. Ruiz11 and R. Torrubia12 Abstract Background: The changes in the models of care for mental disorders towards a community focus and deinstitutionalisation might have risen General practitioners’ (GPs) workload, increasing their mental health concerns and the need for solutions. Pragmatic research into improving GPs’ work-related health and psychological well-being is limited by focusing mainly on stressors and through not providing systematic attention to the development of positive mental health via interventions that develop psychological resources and capacities. The aim of this study was twofold: a) to determine the effectiveness of an intensive multimodal training programme for GPs designed to improve their management of mental-health patients; and b) to ascertain if the program could be also useful to improve the GPs management of their own burnout, job satisfaction and psychological well-being. Method: Eighteen GPs constituted a control group that underwent the routine clinical Mental health support programme for primary care. An experimental group (N = 20) additionally received a Multimodal training programme (MTP) with an Integrated Brief Systemic Therapy (IBST) approach. Through questionnaires and a clinical interview, level of burnout, professional satisfaction, psychopathological state and various indicators of the quality of administrative and healthcare management were analysed at baseline and 10 months after the programme. Results: In relation to government of mental-health patients indicators, on the one hand MTP group showed statistically significant improvements in certain administrative health parameters, but on the other it did not improve opinions and attitudes towards mental illness. Regarding GPs management of their own burnout, job satisfaction and psychological well-being assessments, the MTP presented better scores on global psychopathological state and better evolution of satisfaction at work; psychopharmacology use dropped in both groups; in contrast, the MTP did not improve burnout levels. Conclusions: Findings of this preliminary study are promising for the MTP (with an IBST approach) practice in primary care. More research evidence is required from larger samples and randomized controlled trials to support both the hypothetical adoption of MTP (with an IBST approach) as a part of a continuing professional-training programme for GPs’ management of mental-health patients and its positive effects on work-related health factors. Keywords: Brief systemic therapy, Burnout, General practitioners, Job satisfaction, Primary care, Psychological well-being * Correspondence: barcons@hotmail.com 1 Hospital Sagrat Cor, Serveis de Salut Mental Martorell, Centre de Salut Mental d’Adults del Berguedà, Plaça dels Països Catalans, núm. 4, 2a planta Berga, 08600 Barcelona, Spain 2 Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona (UAB), Bellaterra, 08193 Barcelona, Spain Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Barcons et al. BMC Family Practice (2019) 20:155 Page 2 of 12 Background benefits in burnout, stress and anxiety levels [17, 18]. Like- Burnout, job satisfaction and a psychological well-being wise, cognitive-behavioral-based interventions have also dis- construct are key work-related health factors that need to played short-term improvements in stress outcomes [19, 20]. be assessed and controlled in any work environment, and Recently, a modified mindfulness-based cognitive therapy hence also in primary-care services. Their correct manage- course also demonstrated the potential to reduce stress and ment could improve the quality of healthcare offered, pro- burnout [21]. Furthermore, in a controlled trial evaluating a moting greater patient satisfaction and better treatment simple letter, giving feedback and interpreting psychological compliance, improving morbidity and mortality, as well as scores together with a self-help sheet, contributed to a reduc- reducing the likelihood of hospitalization [1, 2]. tion in psychological distress after 3 months [22]. Related sys- Despite variabilities in defining these constructs, links be- tematic reviews and meta-analyses have recommended tween burnout, job satisfaction and psychological well- implementation of the aforementioned approaches, among being have been established [3–5]. Recent research shows others [23, 24], but such reviews also questioned the alleged that GPs have a higher prevalence of mental health prob- good outcomes due to a detection of various shortcomings. lems, such as symptoms of burnout, and are less satisfied For example, Murray and colleagues conducted a systematic with their work-life balance than is the case with the gen- review of 5392 studies related to interventions aimed at im- eral population [6]. Taking into account the discrepancies proving GPs’ psychological well-being, and detected distinct in results between the longitudinal and cross-sectional sur- shortcomings and risks of bias such as insufficient informa- veys, we observe, first, that given the high levels of burnout tion on the temporal stability of the improvements sought; and frequency and patient safety incidents within primary use of self-administered questionnaires as primary outcome care, research on this issue is essential. Nonetheless, burn- measures; and long-term follow-up of mental illness not be- out prevalence fluctuates over time and countries, observ- ing reported, among others [25]. Given these circumstances, ing some studies reporting high rates in their samples [7], it is difficult to ascertain which elements of these therapies whereas others describing lower rates [8]; one survey con- are really of use for improving doctors’ work-related health ducted in 13 European countries found a 12% of GPs scor- and psychological well-being. Beyond the debate asking ing high for all burnout dimensions [9]. Regrettably, which of the array of therapeutic targets are eligible and what according to longitudinal studies, GPs’ burnout prevalence their real impacts are, it would seem to be more effective tends to remain relatively stable [10]. Second, despite the and appropriate to shift from the deficient approach under- contextual differences between longitudinal surveys of GPs’ pinning stress-response improvement towards a more pro- job satisfaction, available evidence does not confirm a de- active approach for fostering mental health that empowers clining degree over recent years despite the aforementioned and enhances work and personal resources [26]. high rates of burnout and poor mental wellbeing [11–13]. Considering its multiple and complex nature, it is Third, so far less attention has been given to GPs’ psycho- unlikely that a single approach from a given discipline logical well-being, although certain risk factors in GPs’ (such as psychology) could be sufficient to effectively mental health are indicated by the bibliography, such as address these work-related factors and the psycho- lack of reward by patients [14]. logical well-being of GPs. In this context, Collabora- Even given the associations found between these three tive Care Models (CCMs) offers a framework in which factors, to date there is no sound theory that connects related disciplines can be combined, consequently them. Perhaps the strongest proposal would be the Job allowing for an evaluation of their respective interven- demands control model, since, according to the greater tions. CCMs are team-based, multicomponent inter- part of occupational stress and health research, most ventions that have been shown to be cost-efficient in studies of psychosocial factors as antecedents of im- improving mental and physical outcomes for a range paired well-being and work-life imbalance have been of mental-health conditions across diverse populations based on this model [15]. and primary-care settings [27, 28]. To our knowledge, Attending to the rise in the number of visits, the increasing CCM methodology has never been tested on the burn- complexity of clinical work and the scarcity of resources [16], out, job satisfaction and psychological well-being of previous levels of burnout, job satisfaction and psychological GPs rather than that of patients. One possibility to put well-being might change, with a concomitant need for GPs this bio-psychosocial programme into practice would to be better skilled at coping with this increased burden at be to promote GPs’ patient-management strategies less personal cost. In this context, a number of limited con- and competences for distinct pathologies, most espe- trolled psychological interventions have already shown cer- cially for mental disorders. In fact, GP-patient encoun- tain benefits associated with the improvement of GP ters focussing on mental-health concerns represent a burnout, job satisfaction and—especially—psychological well- large proportion of GPs’ patient lists and workload. In being. Mindfulness-based programmes may perhaps obtain a our context, even though this remain under-detected, prominent status in such contexts, showing short-term 1.4 million primary-care patients sought assistance for Barcons et al. BMC Family Practice (2019) 20:155 Page 3 of 12 some type of mental-health problem in Catalonia in Inclusion criteria 2016, which represented 24% of total primary-care Subjects had to be GPs working in public primary-care visits [29]. As a comparison, this exceeds the esti- units. These units also had to belong to the assistance mated 12.7% of such visits for Australia in 2014–15 sector of our ambulatory mental-health service. GPs [30], for example. To understand this figure, we need needed to be willing to attend at least 80% of the train- to take into account the fact that primary health care ing programme and to fulfil the psychometric measures. is the access to the mental health system for the vast majority of the population in Europe [31]. These num- Participants and recruitment strategy bers may well increase in the near future given the Our public ambulatory mental-health service provided as- widespread benefits and acceptance of the importance sistance to all four primary-care units in Sant Boi (Barce- of primary-care-oriented health systems in terms of lona) throughout the routine clinical Mental-health greater effectiveness, efficiency and equity [32]. It is support programme for primary care. All GPs involved therefore not surprising that, in light of the high were invited to participate. In this programme, in order to prevalence and disability of mental disorders, recent strengthen cooperation, a mental-health team regularly calls to action for global mental health have been visited each primary-care unit to conduct assistance, co- made [33]. GPs will have a key role in this mental- ordination and training tasks. These primary-care units health assistance. covered a population of 95,313 inhabitants in 2016; such a Taking into account the research considerations indicated territorial representation provides patients from urban above, by means of empowering activities and instructions, and semi-urban areas. GPs could enhance their individual and group-management After a presentation on the management of psychiatric strategies and the competences applicable to mental-health patients, GPs from all primary care centres were invited patients in primary care. We should also note that GPs to participate in the study. Those who agreed to partici- mainly tend to work alone, and also that passive dissemin- pate were given the baseline assessment questionnaires. ation of guidelines to improve the recognition and manage- In addition, an interview with an independent rater ment of mental disorders have generally and to date been (Psychiatry Medical Residency Training programme) was found to have minimal positive outcomes [34]. In our rou- scheduled for each participant. During this interview, be- tine clinical Mental-health support programme for primary sides delivering questionnaires, the Brief Psychiatric Rat- care, these abilities were taught in an intermittent and un- ing Scale (BPRS) was applied to assess participants’ structured manner, in accordance with both down-top (pri- psychiatric symptoms. BPRS was not used to allocate mary-care-centre coordinators) and top-down demands participants to intervention groups. The rater was (GPs’ comments in internal qualitative surveys). Our team trained by a senior specialist in administering BPRS. All was therefore requested to devise strategies for delivering interviews were carried out within a maximum period of better integrated mental health with less personal cost. As a 15 days from sign-on. The rater was blind to the study’s result, the aim of this study was binary: a) to determine, for objectives. the first time, the effectiveness of an intensive multimodal Subsequently, GPs were allocated to the experimental training programme (MTP) with an Integrated Brief Sys- group (EG) or control group (CG). Allocation was not temic Therapy (IBST) approach for GPs designed to im- random; instead, it corresponded to the primary-care prove their management of mental-health patients; and b) unit for which the participant was working for. Each to ascertain if the program could be also useful to improve group was composed of GPs from 2 primary care ser- the GPs management of their own burnout, job satisfaction vices, respectively. and psychological well-being. In order to assess the first ob- jective, quality-of-healthcare-management indicators were Intervention design analysed along with GPs’ opinions about mental illness; to The CG underwent our clinical routine programme for evaluate the second one, in addition to questionnaires, the primary care, titled Mental-health support programme use of a clinical interview and psychopharmaceutical indica- for primary care. It was aimed at treating mild mental tors were also deemed necessary. disorders in primary-care units from a normalizing and preventive perspective. To accomplish these goals, a team of mental-health specialists visited each primary- Method care setting to provide frequent and direct assistance. We conducted a quasi-experimental study with two These included a psychiatrist regularly performing non-randomised groups. Pre and post-intervention weekly clinical and advisory functions; a clinical psych- measurements were registered among GPs working in ologist also performing clinical and advisory tasks (fort- the public-health system between January 2016 and nightly); and a nurse providing monthly advisory and February 2017. training tasks. Barcons et al. BMC Family Practice (2019) 20:155 Page 4 of 12 In the EG, within the aforementioned programme 3. Social work: a senior social worker carried out one framework, we added and carried out a multimodal session reporting on social and community services training programme (MTP). The intervention was struc- that might be suitable for distinct patients, but most tured as a continuing-education course with group psy- especially for those suffering mental disorders. choeducational activities. It was coordinated by the These services included non-governmental clinical psychologist guided by the psychotherapy model organization, family-patient associations, social and the CCMs. Course duration was 9 hours in total clubs, etc. and consisted of nine weekly sessions. MTP comprised different clinical group sessions (1 h/session), each con- Finally, regarding non-psychiatric medical conditions, ducted by the same professional, in this order: GPs were encouraged to reach a consensus on what not to do as a team (as opposed what to do, which is already 1. Clinical Psychology: a senior clinical psychologist well-established in clinical guidelines), given its low effi- carried out six sessions of integrated brief cacy or efficiency. systemic therapy (IBST), which essentially All participants in the study were offered the course integrates solution-focused and problem-focused free of charge. models. Training was conducted according to At the end of the study, the EG went back to monitor guidelines [35–37]. In the initial session, partici- only the Mental health support programme for primary pants’ attitudes in the management of dysfunc- care. Nonetheless, within the ordinary coordinating tional cases were discussed (for example, meetings with GPs, mental-health specialists continued paternalistic behavior; difficulties establishing lim- referring to the programme’s concepts and procedures, itations for patients’ requests, etc.). Here, as at and team agreements were made (for example, if the the end of each session, the aim was to reach case was already being treated by our mental-health ser- group consensus regarding the given topic, which vice, assistance was not duplicated in primary care when could then be useful for participants’ work envir- the reason for consultation was the same). At all events, onment. In the remaining sessions, distinct tech- no formal mandatory supplementary work was issued niques were taught such as defining complaints during or after the training. in specific behavioural terms; investigating unsuc- The MTP was therefore an ad-hoc clinically rooted cessful attempted solutions to a problem; using training programme for GPs’ management of mental- the patients’ position to negate problem- health patients, although to some extent its psychological maintaining solutions; negotiating specific and dimension could be applicable to all types of cases. It seeks positive goals; discussing patients’ ambivalence to improve all weaknesses and defects detected by the and resistance management; identifying excep- Mental-health support programme for primary care that tions to problem sequences; discussing possible we were already carrying out. For example, detection of pre-treatment improvement; using scaling ques- mental disorders, which are often unobserved and/or un- tions to encourage series of small steps; giving recognised by GPs; shortage of communication and man- patients credit for their improvements; verbal and agement skills; scarcity of teams’ collaborative strategies, non-verbal language techniques. etc. These shortcomings were factors affecting GP burn- out, job satisfaction and well-being, which were the ultim- Real-patient videos were presented, and practical exer- ate targets that we intended to address. cises were carried out during the sessions. GPs were also encouraged to bring their own cases of patients who Outcome measures might be experiencing difficulties. Outcome measures are shown in Table 1. We administered validated versions of these instru- 2. Psychiatry: a senior psychiatrist carried out two ments for both EG and CG to each participant, selecting sessions designed to provide instruction on how to those that were most used in the related Spanish bibliog- correctly conduct a psychopathological raphy in order to facilitate any comparison: examination, while also detailing the areas that need to be examined and the correct terminology to use. 1. Self-reported psychometric measures: The intention was not for GPs to establish a (a). Socio-demographic questionnaire designed ad thorough diagnosis but rather for their hoc for this study. This included 8 items related examinations to be more productive and more to personal, social and work information accurate. This makes coordination meetings with (b). Psychopharmacology use: Within the clinical mental-health services more constructive and is of interview, GPs were asked about the current use use for therapeutic planning. of psychiatric medication. Barcons et al. BMC Family Practice (2019) 20:155 Page 5 of 12 Table 1 List of Outcome measures Outcomes Instruments Management of mental-health patients indicators Administrative and healthcare indicators (a) Total annual visits for all pathologies; (b) Rate (percentage) of annual visits linked to Mental Health; (c) Rate of Accessibility Opinions about Mental Illness Struening and Cohen’s Opinion about Mental Illness questionnaire (OMI) (38) Burnout, job satisfaction and psychological well-being indicators Job Satisfaction Font-Roja Job Satisfaction Questionnaire (FR) (39) Burnout Maslach Burnout Inventory (MBI) (40) Psychological well-being Brief Psychiatric Rating Scale (BPRS) (41) Psychopharmacology use Current use of psychiatric medication; asked within the clinical interview (c). Struening and Cohen’s Opinion about Mental and most widely used scales by clinicians and Illness questionnaire (OMI) [38]. The Spanish researchers to measure psychiatric symptoms. It adaptation has shown satisfactory global presents adequate psychometric properties reliability (Cronbach’s alpha = .81). It has 63 (Cronbach’s alpha for Positive scale α = .73; items, yielding five standardized opinion- Negative scale α = .83; Global psychopathology attitude factor scores: Negativism (α = .81); So- α = .87). We used the 18-item version. Single cial/interpersonal (α = .70); etiology (α = .71); items are rated on a Likert-type scale (1, not Authoritarianism (α = .79); Restrictiveness present; 2, very mild; 3, mild; 4, moderate; 5, (α = .68); Prejudice (α = .69). moderately severe; 6, severe; 7, extremely severe). (d). Font-Roja Job Satisfaction Questionnaire (FR) The range of possible BPRS total scores is [18– [39]. The extended version presents adequate 126], where a higher score indicates more psy- psychometric properties (Cronbach’s chiatric symptoms. alpha = .79). It has 26 [1–5] Likert-type items. It contains 9 job satisfaction dimensions: Satisfac- As regards administrative and healthcare indicators, tion at work; Work tension; Professional compe- these were provided by the regional health authority. For tence; Work pressure; Professional promotion; the baseline data, these indicators were registered in 2015 Interpersonal relationship with superiors; Inter- and 2016 (and extracted in 2016 and 2017, respectively, personal relationships with peers; Extrinsic char- for the current study). For the post-intervention data, we acteristics of status; Labor monotony. used the following as indicators of the objective work bur- (e). Maslach Burnout Inventory (MBI) [40]. The den for each GP: (a) total annual visits for all pathologies; Spanish version corresponds to the later (b) rate (percentage) of annual visits linked to mental renamed MBI-Human Service Survey (MBI- health; (c) rate of accessibility: annual percentage of pa- HSS). It has shown adequate psychometric tients’ attempted requests for visits for the following 48 h properties within its three dimensions of and that were successfully scheduled for each professional. burnout: Emotional exhaustion (EE) (Cronbach’s In all three cases, data on patients enrolled for home-care alpha = .89), Depersonalization (DP) (α = .57); programmes, chronically complex patients and patients and Personal accomplishment (PA) (α = .72). with chronic advanced diseases were rejected. Total MBI score is obtained as: EE + DP + LPA. Follow-up assessments of GP status took place 10 months LPA (lack of personal accomplishment) is after finishing the programme. This post-programme assess- calculated as: [LPA = 48 - PA]. The cut-off points ment timing was average or higher than that observed in for MBI that we used were those proposed by other related research [17, 18]. Doulougeri and colleges in 2016: EE scores ≥27 are considered as high, 19–26 as average, ≤ 18 as Sample size low; DP scores ≥10 as high, 6–9 as average, ≤ 5 as No sample-size calculation was formally determined. low; PA scores ≥40 as high, 34–39 as average, ≤ Given our GP population (N = 45), we attempted to re- 33 as low; Total MBI scores percentile > 76 as cruit as many participants as possible. From initial estima- high, 25–75 as average, < 25 as low. tions with 45 GPs, we were aware that we would be able 2. Hetero-applied psychometric measures: to detect a 0.856 effect size in a t-test; we therefore only (a). Brief Psychiatric Rating Scale (BPRS) [41]. This had the power to detect large effect sizes and through a semi-structured interview is one of the oldest single bivariate contrast. Our team nevertheless deemed Barcons et al. BMC Family Practice (2019) 20:155 Page 6 of 12 this worthwhile in order not to achieve robust data which Baseline patient-demographic values reinforce strong claims, but rather to serve as a pilot study Groups were homogeneous in terms of age (p = 0.177), for evaluating MTP potential. years of professional experience (17[12.25, 28]; p = 0.349) Considering the observed data as the real latent distri- and sex (p = 0.045), where men were slightly more nu- bution and rectifying threshold levels of significance merous in EG. Likewise, no statistically significant differ- from 0.05 to 0.0026 through Bonferroni’s adjustment for ences were detected between proportions of indefinite multiple comparisons, in Results we indicate the power contracts (p > 0.999), mixed shifts (p = 0.291) and hours to detect as significant for the intervention effect in the of mental-health training during the last year (p = 0.129), observed pre-post change for the primary outcome mea- variables that were respectively predominant in both sures in linear mixed-effects models (LMMs). groups. No statistically significant differences between groups were observed for length of time on current con- Data analysis tract (p = 0.037), this being higher in CG. Sample characteristics were described by calculating me- dians and inter-quartile ranges (IQR) for numerical vari- Changes in outcome measures within and between ables, and absolute and relative frequencies (%) for binary groups and categorical variables. Baseline group differences were The average attendance at the nine sessions was 75% evaluated using the Wilcoxon Test for numerical variables (70%, clinical psychology; 90%, psychiatry; 65% for the and Fisher’s exact test for binary and categorical variables. social work). Attendance rates at coordinating meetings Paired Wilcoxon Signed Rank Tests were performed to or other activities that constitute the Mental-health sup- compare repeated intra-group measurements. To check port program for primary care were not registered for ei- for differences between groups in progression, we fitted ther group. unadjusted linear mixed-effects models (LMMs)—as a In relation to government of mental-health patients longitudinal proxy to bivariate analysis—to account for indicators, as regards administrative data (Fig. 1), first, the longitudinal data assessments and the complexity of no statistically significant differences between groups inter-group interactions, regressing the different outcomes were detected for the percentage of annual visits by for treatment group, follow-up, and their interaction. The each GP linked to mental health, either in overall pre- results are shown in terms of p-values of the marginal ef- post change (p = 0.360) or in inter-group evolution dif- fects, representing the significance of baseline differences ferences (p = 0.544). Second, we did observe a lower between treatment groups, overall change over time in the rate of total annual visits by each GP for all patholo- overall sample, and differences in evolution over time be- gies in the CG when examining the overall pre-post tween treatment groups, respectively. In the tables, in change (p < 0.003), although this result was not addition to the p-value and where this is significant (P- regarded as significant after Bonferroni’s adjustment; value of ≤0.05 was used as the cut-off point), association besides, it was identified a greater inter-group evolu- direction is also shown. For Inter-group differences, a + sign tion differences in the EG (p < 0.001). Finally, rate of indicates a higher score or a higher evolution in the EG; in accessibility decreased in the CG when observing over- the global change analysis, this sign indicates a higher all pre-post change (p < 0.001), which was exactly the score in the follow-up assessments. opposite to the evolution of the EG, thus contributing The main outcome measures included in the analysis to the significance of the inter-group evolution differ- were all the administrative and healthcare indicators, as ences in accessibility (p < 0.001). No significant base- well as the overall job satisfaction, burnout and well-being. line inter-group differences were detected in any of They are key work-related health factors that need to be the previously commented variables, except for total assessed and controlled, according to related surveys. annual visits by each GP linked to Mental Health, this All statistical analyses were conducted using the R soft- being higher in the EG (p = 0.040). ware package (v. 3.2.2; R Development Core Team, 2015). As regards opinions and attitudes towards mental ill- ness reported in the Struening and Cohen’s Opinion Results about Mental Illness questionnaire (OMI), a worsening Participants of all five dimensions was observed in overall pre-post Thirty-eight out of forty five GPs agreed to participate in change for both groups (Table 2), the EG presenting the study (four GPs were dismissed because they were only a different evolution in prejudice, namely a higher the authors of this study and the rest declined to collab- increase (p = 0.004+). orate). Finally, 18 GPS were allocated to CG, and 20 to Regarding GPs management of their own burnout, job EG. All 38 GPs completed follow-up measures after two satisfaction and psychological well-being indicators, with GPs were rejected (one from each group) due to retiring respect to the responses from the Font-Roja Job- from their jobs during this period. Satisfaction Questionnaire (FR), no significant differences Barcons et al. BMC Family Practice (2019) 20:155 Page 7 of 12 Fig. 1 Distribution (box-plots) of administrative parameters’ reported by 38 general practitioners, by intervention group (CG, control group; EG, experimental group), and before and after intervention (Pre, pretreatment; Post, Post-treatment) were detected between groups in terms of overall job sat- As for well-being, we observed statistically significant isfaction (Table 3). However, we did observe a decrease in reductions in Total Brief Psychiatric Rating Scale (BPRS) satisfaction at work in the CG, reflected both in overall in the EG (baseline: 23.50 [22, 24.25]; post-treatment: pre-post change (p = 0.009), although again this result was 20.50 [19, 22]; p = 0.001), while this was not observed in not regarded as significant after Bonferroni’s adjustment; CG (baseline: 24.50 [23.25, 27.75]; post-treatment: 23.50 besides, it was identified a greater inter-group evolution [21, 26]; p = 0.122) (Fig. 2). Nonetheless, in LMMs, no differences in the EG (p = 0.002). Likewise, a decrease in overall pre-post change (p = 0.100) or inter-group evolu- interpersonal relationship with peers’ scores was observed tion differences (p = 0.147) were detected. in CG (p = 0.011), but it did not reach statistical Focusing only on both single BPRS item scores or on significance. differences in intervention within the subgroup of worry- No significant statistical differences were observed in ing cases (defined as GPs suffering ≥1 from moderate to either the Total burnout or in any of the three Maslach extremely severe symptoms), no statistical differences Burnout Inventory (MBI) parameters (Table 4). were observed between groups. Table 2 Non-adjusted evolution analysis of Struening and Cohen’s Opinion about Mental Illness questionnaire’s punctuations of 38 GPs depending on intervention group (2016–2017) Control Group Evolution N = 18 Experimental Group Evolution N = 20 LMMs p-valuesa Pre Post W Pre Post W Baselineb Changec Evol.d F1 59 [57.25, 60.75] 73 [71.25, 78] 0e 58 [53.75, 61.25] 72 [68, 77.50] 0e 0.633 <0.001 + e 0.889 e e F2 44 [40, 49] 53.50 [50.25, 57] 0 42.50 [33.75, 48] 58 [50, 62] 0 0.311 <0.001+ e 0.163 e e e F3 9 [8, 11] 18.50 [17.25, 21.50] 0 10 [7.75, 12.25] 18 [17, 21] 0 0.983 <0.001+ 0.867 F4 8.50 [6.25, 10] 11.50 [11, 14] 0e 7 [6, 9] 11 [10, 13] 0e 0.555 <0.001+ e 0.303 e e e F5 7.50 [6, 9] 10.50 [9, 12] 0 6.50 [5, 8] 12 [9.50, 13] 0 0.337 <0.001+ 0.004 Abbreviations: Pre Pretreatment, Post Post-treatment, W Wilcoxon Signed Rank Tests Struening and Cohen’s Opinion about Mental Illness questionnaire’s factors: F1: Negativism; F2: Social/interpersonal etiology; F3: Authoritarianism; F4: Restrictiveness; F5: Prejudice a linear mixed-effects models; bInter-group baseline differences; cPre-post Overall Change; dInter-group Evolution differences e p < 0.0026 (intervention group versus control group) Barcons et al. BMC Family Practice (2019) 20:155 Page 8 of 12 Table 3 Non-adjusted evolution analysis of Font-Roja Questionnaire’s punctuations of 38 GPs depending on intervention group (2016–2017) Control Group Evolution N = 18 Experimental Group Evolution N = 20 LMMs p-valuesa Pre Post W Pre Post W Baselineb Changec Evol.d e F1 14 [10.50,16] 12 [9, 6] 0.031 15 [13, 16.25] 16 [15, 17] 0.065 0.304 0.009 0.002+ e F2 13.50 [12.25, 16.75] 15 [1, 16] 0.773 12 [11, 14] 13 [11, 16] 0.418 0.188 0.876 0.587 F3 4.50 [3, 6] 5 [4, 6] 0.404 5 [4, 6] 5 [4.50, 6] 0.689 0.386 0.130 0.512 F4 12 [12, 13] 11 [11, 12] 0.499 12 [10, 12.25] 12 [10,12.50] 0.904 0.543 0.618 0.728 F5 11 [10, 13.75] 12 [11, 15] 0.303 12 [9, 13] 12 [10, 13] 0.631 0.736 0.099 0.336 F6 6 [4, 6.75] 6 [4, 8] 0.510 4 [4, 6.50] 4 [4, 6.50] 0.753 0.156 0.567 0.934 F7 5 [5, 6] 6 [5, 7.] 0.095 6 [5.75, 7] 5 [5, 6] 0.057 0.032 0.122 0.011 F8 5 [5, 6] 6 [4, 6] 0.525 5.50 [4, 6] 5 [5, 6.50] 0.104 0.864 0.502 0.577 F9 5 [4, 5.75] 4 [3, 5] 0.050 4.50 [4, 6] 5 [4, 5] 0.968 0.665 0.069 0.186 Total 76 [73, 80.50] 77 [75, 78] 0.726 75 [72, 77.50] 76 [73, 83] 0.485 0.818 0.796 0.515 Abbreviations: Pre Pre-treatment, Post Post-treatment, W Wilcoxon Signed Rank Tests Font-Roja Questionnaire’s dimensions: F1: satisfaction at work; F2: work tension; F3: Professional competence; F4: work pressure; F5: professional promotion; F6: interpersonal relationship with superiors; F7: interpersonal relationships with peers; F8: extrinsic characteristics of status; F9: labor monotony a linear mixed-effects models; bInter-group baseline differences; cPre-post Overall Change; dInter-group Evolution differences e p < 0.0026 (intervention group versus control group) Psychopharmacology use dropped in both groups programme for GPs’ individual and group-management when observing overall pre-post change (p = 0.014), competences for mental-health patients, which may ul- falling from 6 to 2 GPs using psychopharmaceuticals timately enhance GPs’ work-related health and psycho- in the CG, and from 3 to 2 in the EG. Regarding type logical well-being to a certain extent. On the one hand, of psychopharmaceuticals, this decrease was especially we observed improvements in the EG for the global psy- noticeable in the case of benzodiazepine consumption chopathology state, certain administrative parameters (p = 0.037). and psychopharmacology use, along with better evolu- Finally, the statistical power analysis to detect the tion of satisfaction at work; on the other hand, MTP did intervention effect as significant in the observed pre-post not alleviate burnout level or enhance opinions and atti- change for the primary outcome measures in LMMs was tudes towards mental illness (prejudice), which deterio- as follows: power = 0.006 for overall job satisfaction; rated in both groups. power = 0.006 for Total burnout; power = 0.013 for Total Brief Psychiatric Rating Scale. Comparison with existing literature As with other programmes aimed at engaging GPs in Discussion the management of psychiatric patients based on a long- Our findings, although insufficient, highlight the poten- term and sustainable partnership, MTP advances have tial of MTP (from an IBST approach) to be hypothetic- not so far led to the programme being adopted by the ally integrated as part of a continuing training regional Institute of Mental Health [42]. Table 4 Non-adjusted evolution analysis of Maslach Burnout Inventory’s punctuations of 38 GPs depending on intervention group (2016–2017) Control Group Evolution N = 18 Experimental Group Evolution N = 20 LMMs p-valuesa Pre Post W Pre Post W Baselineb Changec Evol.d EE 24.50 [14, 41.25] 25.50 [18, 34.25] 0.756 19.50 [13.75, 23.25] 21.50 [15.50, 28.25] 0.089 0.038 0.881 0.263 DP 7 [5.25, 13.75] 9 [7.25, 11] 0.835 6 [4, 8.50] 7 [3.75, 12.25] 0.317 0.425 0.535 0.807 PA 38 [33.25, 45.25] 38 [32.25, 43.75] 0.297 38 [34, 42.50] 37.50 [29.75, 43] 0.420 0.559 0.410 0.550 Burn 46.50 [24.50, 62.25] 46 [30, 57.25] 0.727 37 [29, 49.25] 40 [33, 52] 0.331 0.243 0.600 0.637 Abbreviations: Pre Pretreatment, Post Post-treatment, W Wilcoxon Signed Rank Tests Maslach Burnout Inventory’s subscales: EE: Emotional exhaustion; DP: Depersonalization; PA: Reduced personal accomplishment Global Scales: Burn: Burnout a linear mixed-effects models; bInter-group baseline differences; cPre-post Overall Change; dInter-group Evolution differences e p < 0.0026 (intervention group versus control group) Barcons et al. BMC Family Practice (2019) 20:155 Page 9 of 12 registered in both groups and the positive outcomes of EG on other work-related health parameters, this leads us to question whether opinions and attitudes towards mental illness are a somewhat independent factor. In other words, feeling more capable to cope with mental- health patients may be distinct from our personal thoughts about and in- terests in this subject. Given our results, more in-depth, longer-lasting and distinct goal-oriented interventions might be needed to reverse these negative attitudes. Fol- lowing this line of argument, key elements here are the ad- dressing of both level of work pressure and of the low level of training and awareness in relation to mental disor- ders [46]. Regarding GPs management of their own burnout, job satisfaction and psychological well-being indica- tors, first, in contrast to other surveys, the MTP did not show better results in overall job satisfaction, nor did it achieve a reduction in GPs’ intention to change their location [20]. We were unable to carry Fig. 2 Distribution (box-plots) of Brief Psychiatric Rating Scale’s out further analyses with closely related research punctuations reported by 38 general practitioners, by intervention aimed at enhancing GPs’ mental-health case manage- group (CG, control group; EG, experimental group), and before and after intervention (Pre, pretreatment; Post, Post-treatment) ment within a CCMs because such research failed to assess this issue [42]. Although not globally, EG did present improvements in some of the Font-Roja di- In relation to government of mental-health patients in- mensions, reaching statistical significance in satisfac- dicators, first, analysing the indicated improvements on tion at work (inter-group evolution differences). our administrative health data offered by the MTP, it is Clearly, effective inter-professional management of difficult to draw clear conclusions when comparing our individual patients depends on confidence in one’s results with related surveys, given the disparity of sam- colleagues’ skills and good communication, which ples, health-system structures, etc. [27]. The achieve- are issues that are also treated by the MTP. Broader ments shown by the EG in accessibility and in total and far more complex interventions are needed in annual visits by each GP for all pathologies (inter-group order to address job satisfaction, which in turn is evolution differences) might be interpreted as case- regarded as a key element for resolving the GP re- management improvements, although our study design cruitment crisis [47]. did not allow us to draw strong conclusions or to eluci- Contrary to other interventions [17], MTP did not im- date alternative explanations. Additionally, the results re- prove burnout levels in our study. Nonetheless, at base- lated to the rate of annual visits by each GP linked to line the median level of burnout (total MBI scores) was Mental Health were inconclusive, which was probably 38 (IQR = 29, 54), being this moderate level observed ac- because GPs did not always codify mental-health visits cording with previous research [48, 49]; only 2 (5.26%) as such. GPs reported a total MBI scores percentile > 75 (as Two components that could compromise both the high), figure less prevalent than in other studies [9]. In work-related health factors and the GPs’ role in diagnos- any case, we consider tackling GPs’ burnout an import- ing mental disorders and arranging treatment are (first) ant issue that should be addressed in future interven- the stigmatising attitudes held by GPs towards mental ill- tions because GPs have high rates of burnout and poor ness, and (second) their reluctance to become involved in mental wellbeing compared with the general population shared-care practice [43]. Contrary to other similar stud- and other healthcare professionals [49, 50]. Besides, ies, MTP did not improve opinions and attitudes towards amongst other negative effects, GPs perceive that burn- mental illness [44], although our baseline OMI scores out and poor wellbeing negatively impacts their ability didn’t reflect a high prejudice towards mental disorders to deliver safe care [51]. We posit that additional re- but they did show a lack of sufficient dealings in psycho- sources should be assigned to this subject in order to pathology which is congruent with previous studies [45]. mitigate our result. Although it was not a direct target of our programme, we In line with related studies, our results reflected a high did expect positive changes as a desirable side effect. proportion of GPs presenting psychiatric symptoms [52]; Given both the negative evolution of all OMI scores taking into account only the cases where mental health Barcons et al. BMC Family Practice (2019) 20:155 Page 10 of 12 support could be somewhat recommended, at baseline 21 work commitments were set within the inclusion cri- (55.26%) GPs suffered from moderate to extremely severe teria, unlike other studies [17]. symptoms. Regarding the type of psychiatric symptoms ob- served, as signaled by the literature, anxiety, depression and Implication for practice somatic concerns were predominant [53]. The MTP im- Finally, it is clear that GP burnout, job satisfaction and proved GPs’ global psychological well-being, but contrary psychological well-being require broader and more in- to other studies [17], no inter-group change or evolution dif- depth approaches than that offered by single disciplines ferences were detected. Possible interference may have been (such as psychology) if we are to improve their institu- given rise to by psychological state being evaluated by a tional and work conditions. psychiatric interview rather than being self-administered. Although further research with methodological im- Furthermore, although score differences for single BPRS provements and prolonged instruction periods is re- items were not statistically significant, a tendency towards quired, our preliminary findings suggest that this new greater reductions was detected in the EG. clinical-rooted MTP (from a BST approach) could have Finally, so far, we have not found related psychological the potential to be adopted as part of a continuing interventions with which to compare our results in psy- professional-training programme for GPs’ management chopharmacology use. This dropped in both groups, but of mental-health patients. To some extent, it could ul- our study’s limitations again impeded us from making timately enhance GPs’ work-related health factors such any strong claims with regard to this positive outcome. as burnout, job satisfaction and psychological well-being. Nonetheless, so far, any strong claim can be stated. Study strengths and limitations As limitations of our study, first there is the modest Conclusions sample size that influences statistical significance and This study provides inside into GPs’ work-related health power, since statistically significant differences are more and psychological well-being in a period where these as- difficult to identify in smaller samples. Nonetheless, the pects might have been worsening. It highlights the need study does comprise an important proportion of the to adopt multimodal training interventions aimed at de- total amount of GPs in our health sector. Second, al- veloping GP’s psychological resources and capacities. though the administration of our clinical interview This research may help the instructors to recognize the (BPRS) could be somewhat controversial in non-clinical utility of a new intensive training programme for GPs. samples, it is not limited to indicating only the partici- This personalised approach may assist GPs especially pants’ own perceptions, as is the case with question- when treating mental-health patients in areas such as on naires. Response bias (for instance the social-desirability how to correctly conduct a psychopathological examin- bias) is a widely discussed phenomenon in behavioural ation; on learning verbal and non-verbal language tech- and healthcare research where self-reported data are niques aimed at producing behavioural changes; or on used [54]. Regarding administrative data, although rela- searching for social and community services that might tively good results were reported for the EG, it is diffi- be suitable for distinct patients. cult to compare our data externally with other health Abbreviations centres, due to disparity in terms of organization and BPRS: Brief Psychiatric Rating Scale; BST: Brief Systemic Therapy; characteristics. Additionally, indicators themselves are CCMs: Collaborative Care Models; CG: Control Group; EG: Experimental not exempt from criticism. Finally, treatment integrity Group; FR: Font-Roja Job Satisfaction Questionnaire; GP: General Practitioner; MBI: Maslach Burnout Inventory; MTP: Multimodal Training Programme; and fidelity were not assessed or supervised. OMI: Struening and Cohen’s Opinion about Mental Illness Questionnaire As strengths of our study, we would like to emphasise, first, that it was conducted in real clinical practice with Acknowledgements all its accompanying constraints: high service demand, The authors wish to sincerely thank Dr. Mª Teresa Peñarrubia, Jesús Almeda and Agustí Camino who participated in this study, and who provided work overload, restrictions on the frequency of follow- valuable feedback to help us with the development and testing process. up meetings, etc. Thus, the duration of our MTP was far from the 50 h or more invested in some other pro- Authors’ contributions grammes [55]. Second, we evaluated the sustainability of The authors have participated in this research as follows: Designing the work: CB; CS, ER, OC, NP, BF, CA, Dr. CB and JF. Acquiring the data: CB, BG, improvements (over nearly 10 months) rather than im- CS, ER, OC, NP, BF, CA, Dr. CB, JF and DR. Interpreting the data: CB, OC and mediate post-intervention effects, which differs from RT. Drafting the work/ revising the work critically for intellectual content: CB, other studies [17, 22]. Third, GPs were encouraged to BG, CS, ER, OC, NP, BF, CA, Dr. CB, JF, DR and RT. All authors read an approved the manuscript. introduce suggested MTP procedures into ordinary clin- ical practice, but in order to avoid selection bias toward Funding only highly motivated professionals no complementary This research has received no public or private funding. Barcons et al. BMC Family Practice (2019) 20:155 Page 11 of 12 Availability of data and materials environment and depressive symptoms. BMC Public Health. 2015;15:738. The datasets generated and/or analysed during the current study are not https://doi.org/10.1186/s12889-015-1954-4. publicly available due to the Data Protection and Confidentiality Policy; 6. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout however, they are available from the corresponding author on reasonable and satisfaction with work-life balance among US physicians relative to the request. general US population. Arch Intern Med. 2012;172:1377. https://doi.org/10. 1001/archinternmed.2012.3199. Ethics approval and consent to participate 7. Thommasen HV, Lavanchy M, Connelly I, Berkowitz J, Grzybowski S. Mental The protocol was approved by the Clinical Research Ethics Committee (CEIC) health, job satisfaction, and intention to relocate. Opinions of physicians in of the regional public primary-care research authority, in accordance with rural British Columbia. Can Fam Physician. 2001;47:737–44 http://www.ncbi. the Helsinki Declaration and our own national law on the protection of per- nlm.nih.gov/pubmed/11340754. Accessed 17 Sep 2019. sonal data. Written consent was obtained from all participants prior to taking 8. Dreher A, Theune M, Kersting C, Geiser F, Weltermann B. 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