# Improving frequency and content of referral correspondence between general practitioners and psychiatrists: a cross-sectional descriptive study

Céline Bouton, Anne-Victoire Fayolle, Eric Cailliez, Aline Ramond, Clément Guineberteau

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Céline Bouton, Anne-Victoire Fayolle, Eric Cailliez, Aline Ramond, Clément Guineberteau. Improving frequency and content of referral correspondence between general practitioners and psychiatrists: a cross-sectional descriptive study. Primary Health Care Research and Development, 2025, 26, pp.e88. 10.1017/S1463423625100492. hal-05461089

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Research

**Cite this article:** Bouton C, Fayolle A-V, Cailliez E, Ramond A, Guineberteau C. (2025) Improving frequency and content of referral correspondence between general practitioners and psychiatrists: a cross-sectional descriptive study. *Primary Health Care Research & Development* **26**(e88): 1–8. doi: 10.1017/S1463423625100492

Received: 22 November 2023

Revised: 25 March 2025

Accepted: 8 May 2025

**Keywords:**

Correspondence as topic; General Practitioners; mental health; Primary health care; Psychiatrists

**Corresponding author:**

Céline Bouton;

Email: celine.bouton@univ-nantes.fr

# Improving frequency and content of referral correspondence between general practitioners and psychiatrists: a cross-sectional descriptive study

Céline Bouton<fnref n="1" />,² ID, Anne-Victoire Fayolle³, Eric Cailliez³, Aline Ramond<fnref n="1" />,³ ID and Clément Guineberteau³

## Abstract

**Background:** Written referrals and follow-up correspondence between referring general practitioners (GPs) and psychiatrists is a medico-legal responsibility and integral part of caring for patients with mental illness. Objective: To describe expectations and practices that GPs and psychiatrists have when exchanging correspondence concerning patients with mental health problems. **Methods:** In this observational, declarative, and cross-sectional study, two surveys were used to evaluate the expectations, frequency, and content of correspondence exchanged between GPs and psychiatrists. The questionnaire was based on the National College for the Quality of Psychiatric Care 2010 recommendations. Conducted in a regional setting in France between 2014 and 2016, the study involved 2754 GPs and 575 psychiatrists. **Results:** Overall, we achieved a positive response rate of 33% (189/575) of psychiatrists and 23% (628/2754) of GPs, which was similar in each local region. Regarding the correspondence from GPs to psychiatrists, 478 (75%) GPs declared having written a referral for an initial consultation and 84 (44%) psychiatrists declared having received a referral. Regarding the correspondence from psychiatrists to GPs, 144 (76%) psychiatrists declared having written at least one letter after the initial consultation or during follow-up and 160 (25%) GPs declared having received return correspondence. The GPs would like to be better informed about psychotherapeutic or long-term management, leave of absence from work, surveillance measures, prognosis, and division of specialist roles. The psychiatrists would like to receive more information about previous medication trialed, the level of willingness the patient has to consult a psychiatrist and any allergies or intolerances to medication. **Conclusion:** This study highlights the need to improve the disparity between expected and received correspondence from GPs and psychiatrists concerning patients with mental health problems.

## Background

Written referrals and clear, prompt follow-up correspondence between referring general practitioners (GPs) and psychiatrists is a medico-legal responsibility and integral part of caring for patients with mental illness (French National Authority for Health 2018a; Gallais 2014; Légifrance 2023; Ministry of Health and Access to Care 2021; WoNCA Europe 2023 Edition 2023). Importantly, effective inter-disciplinary correspondence confirms medical prescriptions and limits care delays and interruptions in this vulnerable population. These delays can cause a combination of premature mortality, handicap, severe disabilities, and social exclusion (Byrne 2023; Edmunds 2018; John et al. 2018; Roberts et al. 2017).

In France, GPs are the first contact point for a large proportion of patients with mental health problems, highlighting their frontline role in managing mental healthcare in the community. Additionally, 7 out of 10 GPs report seeing more frequent requests for mental health care since the start of the COVID pandemic (Bergeat et al. 2021; Byrne et al. 2021).

Already, in 2010 good practice guidelines published by the National College for the Quality of Psychiatric Care (CNQSP) suggest GPs and psychiatrists should share useful information including physical and psychological dimensions, patient preferences and respect patient rights and autonomy. This information should be included in referral letters from the GP and follow-up correspondence from the psychiatrist (Cohen et al. 2021). To improve the diagnosis and management of patients with mental health disorders, the French National Authority for Health (Haute Autorité de Santé, HAS) published a good practice recommendation in 2011, updated in 2018, which includes a specific framework for coordination and communication between GPs and mental health professionals (French National Authority for Health 2011, 2018b). These

<figure><img src="image_2.png" /></figure>

CAMBRIDGE
UNIVERSITY PRESS

<footnote n="1">¹Univ Angers, POPS, SFR ICAT, F-49000 Angers, France; ²Department of General Medicine, Faculty of Health, Nantes University, 44000 Nantes, France and ³Department of General Medicine, Faculty of Health, University of Angers, 49000 Angers, France</footnote>

<footnote>© The Author(s), 2025. Published by Cambridge University Press. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.</footnote>
guidelines stipulate that GPs may manage psychological problems, implement further screening tests or the post-discharge period when a mental health problem is managed with a psychiatric team. There are few recent studies in the literature that have specifically examined the correspondence between GPs and psychiatrists (Cohen et al. 2021; Kinouani et al. 2024).

Effective mental healthcare management is particularly important in France, which has the highest number of mental health illness in Europe. In France, one out of five people is affected by psychological distress and 23 million euros is spent each year on psychotropic drugs to manage mental health problems, despite the controversy concerning the efficacy of these medicines without a psychiatric diagnosis (GBD 2019 Mental Disorders Collaborators 2022; Ministry of Health and Access to Care 2021; Ministry of Labour, Health, Solidarity, and Families 2023).

However, GPs have previously reported facing a lack of psychiatrist feedback as a major difficulty when fulfilling their central role in organizing mental health care (Linder et al. 2019).

# Methods

## Aim

The aim of this research was to describe the current frequency and content of GPs and psychiatrists correspondences in outpatient treatment of adult patients with mental health problems in France.

## Design

This observational, declarative, descriptive and analytical study was conducted in parallel in five areas in the Pays-de-la-Loire region, France between 2014 and 2016.

## Population studied

Full-time, primary care GPs registered with the French national medical association (Ordre des médecins), having an established general practice and managing patients with mental health problems in the community were included. GPs who were not contactable by email were excluded. Consulting psychiatrists were included but paediatric psychiatrists were excluded.

## Collecting data

One academic GP and two psychiatrists designed two distinct questionnaires, one for the GPs and one for psychiatrists (See questionnaires in supplementary material). The questions were based on the CNQSP recommendations on the methods of correspondence between GPs and psychiatrists and the researchers own experiences (French National Authority for Health 2011). The questionnaire for the GPs contained 45 questions and the psychiatrists contained 44 questions. Each questionnaire contained three sections. The first concerned the socio-demographic criteria, the second explored correspondences sent and received (frequency and content), and the third the preferred modes of correspondence. The interest of GPs in treating mental illnesses and psychological distress was evaluated using a Likert scale graduating from 1 to 10. Although the two questionnaires were independent, to remain pragmatic and clear, the main results concerning frequency and content will be presented with first the correspondence from GPs to psychiatrists followed by the correspondence from psychiatrists to GPs. The symbols * and ** will indicate the source of the responses: * for data from the GPs' questionnaire and ** for data from the psychiatrists'

<table><caption>**Table 1.** Characteristics of participating general practitioners and psychiatrists</caption><thead><tr><th></th><th>General practitioners*<br>n = 628</th><th>Psychiatrists**<br>n = 189</th></tr></thead><tbody><tr><td>Sex (Female)</td><td>281 (44.8%)</td><td>84 (44.4%)</td></tr><tr><td>Age (Years)</td><td></td><td></td></tr><tr><td>&lt;45</td><td>249 (39.7%)</td><td>57 (30.2%)</td></tr><tr><td>45-60</td><td>338 (53.8%)</td><td>88 (46.6%)</td></tr><tr><td>&gt;61 years</td><td>39 (6.2%)</td><td>43 (22.8%)</td></tr><tr><td>Place of work</td><td></td><td></td></tr><tr><td>Private outpatient practice<br>only</td><td>575 (91.6%)</td><td>74 (39.2%)</td></tr><tr><td>Hospital practice (public or<br>private)</td><td>0</td><td>94 (49.7%)</td></tr><tr><td>Hospital and outpatient<br>practice</td><td>44 (7.0%)</td><td>20 (10.6%)</td></tr></tbody></table>

questionnaire. GPs and psychiatrists received the questionnaire via email via Sphinx®Online or letter and data were collected using Epi Info (version 7). All participants gave their consent to participate in this study and responded anonymously.

## Analysis

Quantitative variables are represented as absolute number (percentage), unless otherwise stated. In the analysis, the responses 'always' and 'often' were grouped together with 'yes' and 'rarely' and 'never' were grouped with 'no'.

Variables with missing data were coded with an 'unknown' category.

## Results

*Among the 2,754 GPs solicited for the study 628 (22.8%) responded and are described in Table 1. Notably, 101 (16.1%) had had further training in treating psychological distress. Most GPs 558 (88.9%) were interested in treating mental health-related problems and psychological distress (Likert Scale rating ≥ 6) and two-thirds 389 (61.9%) were very interested, Likert Scale rating ≥ 8).

**Among the 575 psychiatrists solicited, 189 (33%) responded and are described in Table 1.

Among those who responded, 27 GPs* (4.3%) and 63 psychiatrists** (40.1%) were familiar with the CNQSP correspondence recommendations. Among these, 11 GPs* (40.7%) and 31 psychiatrists** (49.2%) considered the recommendations to be realistic.

## Correspondence from GP to psychiatrist

### Frequency

*Concerning correspondence frequency, 476 (75.8%) GPs stated that they wrote a referral letter for the first psychiatrist consultation. There were 121 (19.3%) who wrote a follow-up letter.

**One hundred five psychiatrists (55.6%) declared not receiving a letter from GPs. One hundred fifty-five (82%) psychiatrists expected to receive a GP referral.
<table><caption>**Table 2.** Domains of correspondence content from GPs to psychiatrists (*survey of GPs, **survey of psychiatrists)</caption><thead><tr><th>Domains of correspondence content</th><th>Expected by psychiatrists**<br>n = 189</th><th>Stated received<br>by psychiatrists**<br>n = 189</th><th>Stated sent by GPs*<br>n = 628</th></tr></thead><tbody><tr><td><strong>Patient history</strong></td><td></td><td></td><td></td></tr><tr><td>Medical history</td><td>169 (89.4%)</td><td>106 (56.1%)</td><td>476 (75.8%)</td></tr><tr><td>Psychiatric history</td><td>164 (86.8%)</td><td>109 (57.7%)</td><td>514 (81.8%)</td></tr><tr><td>Life history</td><td>141 (74.6%)</td><td>73 (38.6%)</td><td>412 (65.6%)</td></tr><tr><td><strong>Patient medication</strong></td><td></td><td></td><td></td></tr><tr><td>Actual psychoactive treatment</td><td>171 (90.5%)</td><td>145 (76.7%)</td><td>525 (83.6%)</td></tr><tr><td>Previous psychoactive treatment</td><td>156 (82.5%)</td><td>36 (19.0%)</td><td>459 (73.1%)</td></tr><tr><td>Drug intolerance</td><td>152 (80.4%)</td><td>37 (19.6%)</td><td>343 (54.6%)</td></tr><tr><td>Drug Allergy</td><td>129 (68.3%)</td><td>25 (13.2%)</td><td>313 (49.8%)</td></tr><tr><td><strong>Clinical examination</strong></td><td></td><td></td><td></td></tr><tr><td>Initials symptoms</td><td>163 (86.2%)</td><td>136 (72.0%)</td><td>419 (66.7%)</td></tr><tr><td>Addictions</td><td>155 (82.0%)</td><td>105 (55.6%)</td><td>468 (74.5%)</td></tr><tr><td>Symptom evolution</td><td>149 (78.8%)</td><td>93 (49.2%)</td><td>372 (59.2%)</td></tr><tr><td>Actual management</td><td>142 (75.1%)</td><td>103 (54.5%)</td><td>470 (74.8%)</td></tr><tr><td>Acceptation of psychiatric consultation</td><td>117 (61.9%)</td><td>38 (20.1%)</td><td>187 (29.8%)</td></tr></tbody></table>

## Content

Domains of correspondence content GPs communicated to psychiatrists included patient history, medical treatment, and clinical examination findings and are presented in Table 2.

*One hundred thirty-five (21.5%) of GPs reported introducing that patient introduction solely to ensure social security reimbursement.

**Whilst, 88 (46.6%) psychiatrists, letters from GPs were just a letter of introduction for reimbursement as part of the care pathway.

**Six pieces of information psychiatrists require frequently were present in over 50% of referrals. This concerned treatment with psychoactive drugs (76.7% n = 145), symptoms identified (72.0% n = 136), psychiatric and physical history (57.7% n = 109 and 56.1% n = 106), addictions (55.6 n = 105), and actual management (54.5% n = 103). However, four pieces of information that psychiatrists particularly need were missing from more than 80% of letters. *Although GPs claimed to mention them in more than 50% of cases. These were the degree to which the patient accepted psychiatric evaluation, psychotropic treatments already tried, intolerance to drugs and allergies.

## Correspondence from psychiatrist to GP

### Frequency

**One hundred forty-four (76.2%) respondent psychiatrists stated they write at least one letter during the follow-up period and 104 (55.0%) write a letter after the first consultation.

*Ninety-three-point one per cent of the GPs (585/628) stated that correspondence was irregular with psychiatrists during patient follow-up. One hundred sixteen respondent GPs (18.5%) stated receiving a correspondence after the first psychiatrist consultation, 61 (9.7%) once the diagnosis was made, and 49 (7.8%) at the end of the psychiatric treatment (Figure 1). However, 25.5% (160/628) stated that they received at least one letter from the psychiatrist during the follow-up period.

## Content

Domains of contents of correspondence from psychiatrists to GPs are presented in Table 3. *Content of the treatment prescribed by psychiatrists that GPs received and expected was found in 60.8% of correspondence (n = 382). Ten elements GPs need were present in less than 20% of psychiatrist correspondence: proposals and methods of psychotherapeutic treatment (14.8% n = 93), the necessity to classify a chronic illness (Affection de Longue Durée) (18.2% n = 114), the need for sick leave (16.4% n = 103), elements of biomedical and clinical monitoring (10.2% n = 64), risk of progression (10.5% n = 66), proposal for a care pathway (9.1% n = 57), proposal for social care (8.9% n = 56), and the sharing of roles (8% n = 50).

### Correspondence mode

GPs preferred using secure electronic messaging (50.4% n = 379) or traditional post (56.4% n = 354), than e-mail (21.7% n = 136), fax (10.8% n = 68) or by handing the letter over to the patient (18.2% n = 114).

## Discussion

### Main results

This is the first study to evaluate the difficulties and expectations from both GPs and psychiatrists concerning patient correspondence. This study supports previous research about the frequency and content of GP and psychiatrist correspondence and highlights considerable discrepancies between the professions. In general, both GPs and psychiatrists reported needing regular, detailed correspondence, in line with CNQSP recommendations, despite their lacking awareness about these recommendations. However, correspondence between GPs and psychiatrists were seen as being insufficient in both quantity and content. Furthermore, the declarations each profession made about the correspondence
<figure><img src="image_3.png" /><figcaption>**Figure. 1.** Frequencies of correspondence from psychiatrists to general practitioners. Source: GP, general practitioner.</figcaption></figure>

frequency varied remarkably from that actually received. Nevertheless, most GPs seemed interested in treating mental health, despite few having had further training in treating psychological distress.

Despite HAS recommendations encouraging frequent physician correspondence, only one quarter of GPs interviewed reported receiving a follow-up letter from a psychiatrist concerning their patient (French National Authority for Health 2018b). This corresponds with a small Californian study in which only 30 patients, (21%) had any indication from the mental health practitioner on the primary care record within three months of the initial consultation (Colaiaco et al. 2018). This lack of communication has been previously suggested to be due to fears of betraying patient confidentiality, or to respect medical and doctor-patient confidentiality (Mercier 2014). Also, whilst psychiatrists appreciate the GP's proximity to the patient's family as an information source, they fear disclosing information over which they want to retain control (Laboutière 2017).

It was reassuring to see that concerning correspondence content, GPs expected to receive a complete treatment and management report similar to reports in the UK and Australia (Selzer and Foley 2009; Serfontein et al. 2011). Unfortunately, psychiatrists often omitted to communicate critical elements such as: progression risk, psychotherapeutic treatment needs and methods, biological and clinical monitoring, chronic illness classification, sick leave prescribed, social care proposed, or role sharing. This lack of detail is concerning for GPs who expect the psychiatrist to confirm the diagnosis and so delay implementing treatment to avoid causing undue stress whilst the diagnosis remains uncertain (Gallais 2014). However, we found GPs are mostly concerned with psychiatrists putting a treatment into place (50%) than confirming a diagnosis (9.3%). Which is similar to

reports in France for diagnosis confirmation which are lower for psychiatrists (7.1%) than other specialists (28%) (Passerieux and Younes 2007). Moreover, a separate study found that 83.7% of consultations were driven by therapeutic reasons, while only 35.9% were related to diagnostic concerns, highlighting the predominance of treatment-focused requests in that context (Kinouani et al. 2024).

Concerning GP correspondence content, most psychiatrists expected to receive a referral from the referring GP containing a maximum of information. However, psychiatrists often lacked receiving information about patient acceptance for psychiatric evaluation, previous psychotropic treatments tried, intolerance to drugs and allergies. Yet, GPs claimed to have mentioned them in more than 50% of cases. This confers with NHS (UK) findings in a project to standardize correspondence, in which referral letters lacked background health information, concerns of risk, and treatment tried (Odelola and Jabbar 2017). This lower level of detail may be due to a lack of GP training in psychiatric clinical reasoning, theory and practice. This means practitioners may write brief letters that have little psychiatric terminology. Also, GPs lack time to write detailed letter and are hindered by the time it takes for a letter to be delivered. They have been reported to prefer communication by phone. This allows certain problems to be resolved with a brief consultation (Hérisson 2015). Moreover, it has been found that GPs tend to report higher rates of feedback communications when they engage in more informal interactions with any specialists, suggesting that these informal exchanges might enhance communication despite the limited detail in written referrals (Scaioli et al. 2020). Yet written correspondence is required for medico-legal reasons.

According to psychiatrists, nearly half the GP referrals only wrote a short letter introducing the patient to ensure they would be
<table><caption>**Table 3.** Domains of correspondence content from psychiatrists to GPs (*survey of GPs, **survey of psychiatrists)</caption><thead><tr><th>Domains of correspondence content</th><th>Expected by GPs*<br>n = 628</th><th>Stated received by GPs*<br>n = 628</th><th>Stated sent by psychiatrists**<br>n = 189</th></tr></thead><tbody><tr><td><strong>Diagnosis</strong></td><td></td><td></td><td></td></tr><tr><td>Diagnostic hypothesis</td><td>575 (91.6%)</td><td>315 (50.2%)</td><td>171 (90.5%)</td></tr><tr><td>Progression risk</td><td>485 (77.2%)</td><td>66 (10.5%)</td><td>89 (47.1%)</td></tr><tr><td>Environmental factors</td><td>311 (49.5%)</td><td>155 (24.7%)</td><td>151 (79.9%)</td></tr><tr><td><strong>Treatment</strong></td><td></td><td></td><td></td></tr><tr><td>Drug treatment</td><td>578 (92.0%)</td><td>382 (60.8%)</td><td>140 (74.1%)</td></tr><tr><td>Need for psychotherapeutic treatment</td><td>479 (76.3%)</td><td>120 (19.1%)</td><td>157 (83.1%)</td></tr><tr><td>Methods of psychotherapeutic treatments</td><td>455 (72.5%)</td><td>93 (14.8%)</td><td>144 (76.2%)</td></tr><tr><td>Biological and clinical monitoring</td><td>472 (75.2%)</td><td>64 (10.2%)</td><td>102 (54.0%)</td></tr><tr><td>Therapeutics propositions</td><td>551 (87.7%)</td><td>313 (49.8%)</td><td>164 (86.8%)</td></tr><tr><td><strong>Follow-up</strong></td><td></td><td></td><td></td></tr><tr><td>Follow-up organization</td><td>527 (83.9%)</td><td>188 (29.9%)</td><td>176 (93.1%)</td></tr><tr><td>Role of the GP in follow-up</td><td>485 (77.2%)</td><td>50 (8.0%)</td><td>105 (55.6%)</td></tr><tr><td><strong>Administrative</strong></td><td></td><td></td><td></td></tr><tr><td>Social care</td><td>387 (61.6%)</td><td>56 (8.9%)</td><td>312 (49.7%)</td></tr><tr><td>Need for sick leave</td><td>383 (61.0%)</td><td>103 (16.4%)</td><td>123 (65.1%)</td></tr><tr><td>Need to classify a chronic illness</td><td>437 (69.6%)</td><td>114 (18.2%)</td><td>131 (69.3%)</td></tr></tbody></table>

reimbursed for psychiatric care. However, if referrals are brief and limited to this aim, there is little interdisciplinary exchange and may suggest that referring GP lack interest or competence concerning psychiatric disorders. This observation aligns with studies suggesting a lack of mental health training among GPs, which may contribute to their limited ability to provide comprehensive psychiatric referrals or to feel less confident in managing patients (Ayalon et al. 2016; Tzartzas et al. 2022).

Concerning the mode of correspondence, we found that most GPs were concerned about protecting patient confidentiality, preferring secure messaging platforms. However, psychiatrists have been found to be poorly informed and infrequently use encrypted messaging systems, even though it is secure and hastens information transfer (Hérisson 2015). Also, some GPs preferred sending a letter via the patient. However, in the French healthcare system this requires the patient to accept to be referred by their family doctor (Legifrance 2023). Whilst medical confidentiality is preserved, it may be problematic relying on patient cooperation as many patients are unaware of inter-professional communication practices. Alternatively, short phone calls from a psychiatrist to the GP following a psychiatric admission has been shown to improve signs and symptoms of depression (Burian et al. 2016).

Moving forward, any improvements in communication will require both GPs and psychiatrists to be mutually willing to change, agree on communication objectives and tools to improve the shared patient care (Gallais 2014). This has been shown to be facilitated with inter-professional meetings that allow physicians to get to know each other better and develop a sound collaboration (Fredheim et al. 2011). Also, considering that both medical specialties lack awareness about existing guidelines and mutual understanding about correspondence needs, projects to provide structured correspondence would be helpful (Odelola and Jabbar 2017).

Furthermore, multidisciplinary conciliation meetings and professional training sessions involving GPs, psychiatrists, nurses, psychologists and social workers would promote communication in an established local network (Saint-Pierre et al. 2018). Also, gaining knowledge about psychiatry and general medicine during university internships has been proposed to improve mutual understanding (Fovet et al. 2014). This could be extended to further professional education and encouraging interdisciplinarity in clinical practice guideline updates would help to ensure mutual collaboration is applied in practice.

Furthermore, a partnership charter between GPs and psychiatrists has been proposed to involve GPs in prescribing medication. In this proposed charter, the psychiatrist proposes a treatment that the GP would prescribe and manage. This shared care may help to limit co-prescriptions and interactions, allows the GP to monitoring treatments suggested by the psychiatrist, and enables intervention without consent if a hospitalization occurs.

Lastly, in some cases, administrative issues associated with the patient pathway, such as a patient's right to free access to a psychiatrist until the age of 26 during emergency psychiatric treatment because of family or social services may hinder GP correspondence. In which case, little or no referring information from a GP (Hérisson 2015).

## Strengths and weaknesses

In this study, while the response rates of psychiatrists (33%) and GPs (23%) are relatively high compared to other research in the region (Supper et al. 2011), there remains a potential for selection bias. In particular, the two questionnaires were independent, so the respondents (GPs or psychiatrists) might not have their usual correspondent among the other respondents. This limits the conclusions of the study, but others research that have tried to
perform mirrored surveys, focused on specific patients have had
very small population. (Cohen *et al.* 2021) In addition, the study
was declarative and did not focus on patient cases. The absence of a
detailed, case-specific approach, combined with the potential for
recall bias, limits the accuracy of the data. Also, performing the
same analysis in all departments in one geographic region made it
possible to eliminate potential differences linked to local
organizations and unfavourable demographics in certain regional
departments.

Also, we proposed an online data collection system, which
suited the younger population at ease with the internet and so
provided a high level of data quality as opposed to the paper
version in Sarthe, which had a lot of missing data, limiting sub-
groups analyses for the entire region. Although the GP population
was more male-dominated and younger compared to the region
and France and the age and sex of psychiatrists differed from the
region and the rest of France, there was no difference with regard to
the activity type (Table 3). Anonymity was used to limit the impact
of desirability bias, but it remains possible that some individuals
may alter their responses based on what they believe to be more
acceptable.

In this study, we cannot determine precisely the respondent rate
among the GPs surveyed, as the rate of GPs who used email in 2014
was not known. The length and structure of the questionnaire may
have caused frustration or fatigue, reducing the rate of
respondents. The quality of the data may also be biased by the
doctors' interest in the subject: GPs who are not interested in
mental health may not have taken the time to answer the
questionnaire and may have different expectations from those of
the respondents. Lastly, two years lapsed between the first study in
2014 and the last in 2016, and several years before the results were
published. During this period, it is likely that new tools (Shared
medical records, technology-enabled care coordination, tele-
medicine, secure messaging, etc.) and organizations would have
improved communication between healthcare professionals
(Bensoussan and Prébois 2021; Iorfino et al. 2021; Odier and
Falcoff 2021; Parker et al. 2023). Unfortunately, at the same time,
the mental health of the population is deteriorating, and this
problem is exacerbated by a decline in medical demography,
particularly in France (Bergeat et al. 2021; Chevance et al. 2020;
GBD 2019 Mental Disorders Collaborators 2022). Communication
between professionals may therefore have been affected, and
further studies are needed to assess these changes.

Although this study was conducted prior to the COVID-19
pandemic, its findings remain relevant in the current context, as
many of the communication challenges identified between GPs
and psychiatrists have likely been exacerbated by the health crisis.
Indeed, the pandemic has led to an increased workload for GPs,
with a significant rise in mental health issues, making regular and
effective communication between healthcare professionals even
more crucial (Bergeat et al. 2021; Hazo et al. 2021). In addition, the
health system's response to the pandemic, including the
accelerated adoption of telemedicine and digital communication
tools, may have changed the ways in which correspondence is
exchanged. However, integrating these new tools remains a
challenge, particularly due to its complexity (Sebai and Manzani
2023). As highlighted by recent studies discussing the vulner-
abilities of patients with mental disorders during the pandemic, the
mental healthcare system itself faced significant challenges,
including a shortage of resources and difficulties in adapting to
the increased need for care, further underscoring the critical
importance of communication between GPs and psychiatrists

during this period (Chevance *et al.* 2020). It is therefore important
to conduct future research to assess whether these new modes of
communication have helped address the issues identified in our
study, or if they have introduced new barriers. While changes have
occurred since the data collection, the challenges outlined in this
study – particularly the frequency and quality of correspondence –
remain pertinent and require continued attention to improve
mental healthcare coordination.

Conclusion

Quantitative and qualitative improvement in physician corre-
spondence is invaluable for psychiatrists and GPs to collaborate
efficiently. Increasing the awareness of CNQSP recommendations
approved by the HAS and mutual awareness would improve the
quantity and quality of information exchange.

**Supplementary material.** To view supplementary material for this article, please visit https://doi.org/10.1017/S1463423625100492

**Data availability statement.** The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

**Acknowledgements.** We thank Marc-Antoine Amiel, Pauline Alleman, Karim Saidi, Amandine Pelletier, Cécile Parleani and Emilie Tine for their help during the data collection. Amy Whereat, Speak the Speech Consulting provided critical review and editing support. The authors thank Jean-Pascal Fournier for his support and valuable review of the final manuscript and Samia Mehouachi for her final help with revisions.

**Author contributions.** CB and CG were responsible for conducting the study, including the interpretation of the results and the drafting of the full report. EC conducted the search and data extraction. AVF and AR contributed to the data analysis and helped to draft the manuscript. All authors read and approved the final manuscript prior submission.

**Financial Support.** This research received no specific grant from any funding agency, commercial or not-for-profit sectors. This article is supported by the French network of University Hospitals HUGO (Hôpitaux Universitaires du Grand Ouest).

**Competing interests.** None.

**Ethical Standards.** Ethics approval and consent to participate.

Participants were informed about the study and consent to be included. The study was carried out following the CNIL methodology MR-004 for the use of personal data for research. According to the French regulations (law n° 2012-300 of 5 March 2012 relative aux recherches impliquant la personne humaine), this study did not require approval by an ethics committee. All methods were carried out in accordance with guidelines and regulations in the declaration of Helsinki.

**Consent for publication.** Not applicable.

References

**Ayalon L, Karkabi K, Bleichman I, Fleischmann S and Goldfracht M** (2016)
Barriers to the Treatment of Mental Illness in Primary Care Clinics in Israel.
*Administration and Policy in Mental Health and Mental Health Services Research* **43**, 231–240. https://doi.org/10.1007/s10488-015-0634-0

**Bensoussan M and Prébois S** (2021) Dispositif de soins partagés en psychiatrie de la Haute-Garonne [Shared psy chiatric care system in Haute-Garonne]. *L'information psychiatrique* **97**, 684–690. https://doi.org/10.1684/ipe.2021.2317

Bergeat M, Vergier N, Verger P, Lutaud R, Fery-Lemonnier E, Gaini M, Ventelou B, Buyck J-F, Metten M-A, Hérault T and Zemour F (2021) *Les demandes de soins liés à la santé mentale restent plus fréquentes au printemps 2021 [Demand for mental health care remains higher in spring 2021]* DREES.
https://drees.solidarites-sante.gouv.fr/publications/etudes-et-resultats/les-demandes-de-soins-lies-la-sante-mentale-restent-plus (accessed 14 January 2025).

**Burian R, Franke M and Diefenbacher A** (2016) Crossing the bridge – A prospective comparative study of the effect of communication between a hospital based consultation-liaison service and primary care on general practitioners' concordance with consultation-liaison psychiatrists' recommendations. *Journal of Psychosomatic Research* **86**, 53–59. https://doi.org/10.1016/j.jpsychores.2016.05.002

**Byrne A, Barber R and Lim CH** (2021) Impact of the COVID-19 pandemic – a mental health service perspective. *Progress in Neurology and Psychiatry* **25**, 27–33b. https://doi.org/10.1002/pnp.708

**Byrne P** (2023) Premature mortality of people with severe mental illness: a renewed focus for a new era. *Irish Journal of Psychological Medicine* **40**, 74–83. https://doi.org/10.1017/ipm.2022.3

**Chevance A, Gourion D, Hoertel N, Llorca P-M, Thomas P, Bocher R, Moro M-R, Lapré vote V, Benyamina A, Fossati P, Masson M, Leaune E, Leboyer M and Gaillard R** (2020) Assurer les soins aux patients souffrant de troubles psychiques en France pendant l'épidémie à SARS-CoV-2 [Ensuring mental health care during the SARS-CoV-2 epidemic in France: A narrative review]. *L'Encéphale* 46, S3–S13. https://doi.org/10.1016/j.encep.2020.03.001

**Cohen IB, Halkoum R and Fau L** (2021) Communication and coordination among attending physicians and psychiatrists—or the lack thereof. *L'Information Psychiatrique* **97**, 481–489. https://doi.org/10.1684/ipe.2021.2283

**Colaiaco B, Roth CP, Ganz DA, Hanson M, Smith P and Wenger NS** (2018) Continuity of Information Between Mental Care and Primary Care Providers After a Mental Health Consultation. *Psychiatric Services* (Washington, D.C.) **69**, 1081–1086. https://doi.org/10.1176/appi.ps.201800025

**Edmunds M** (2018) Inequitable Physical Illness and Premature Mortality for People with Severe Mental Illness in Australia. *Health and Human Rights* **20**, 273–281.

**Fovet T, Amad A, Geoffroy PA, Messaadi N and Thomas P** (2014) État actuel de la formation des médecins généralistes à la psychiatrie et à la santé mentale en France [Current state of training in psychiatry and mental health for general practitioners in France]. *L'Information Psychiatrique* **90**, 319–322. https://doi.org/10.1684/ipe.2014.1201

**Fredheim T, Danbolt LJ, Haavet OR, Kjonsberg K and Lien L** (2011) Collaboration between general practitioners and mental health care professionals: a qualitative study. *International Journal of Mental Health Systems* 5, 13. https://doi.org/10.1186/1752-4458-5-13

**French National Authority for Health** (2011) *Les couriers échangés entre médecins généralistes et psychiatres lors d'une demande de première consultation par le médecin généraliste pour un patient adulte présentant un trouble mental avéré ou une souffrance psychique* [Letters exchanged between GPs and psychiatrists when a GP requests an initial consultation for an adult patient with a known mental disorder or mental distress]. https://www.has-sante.fr/jcms/c_1050358/fr/les-courriers-echanges-entre-medecins-generalistes-et-psychiatres-lors-d-une-demande-de-premiere-consultation-par-le-medecin-generaliste-pour-un-patient-adulte-presentant-un-trouble-mental-avere-ou-une-souffrance-psychique* (accessed 5 December 2024).

**French National Authority for Health** (2018a) *Coordination entre le médecin généraliste et les différents acteurs de soins dans la prise en charge des patients adultes souffrant de troubles mentaux – états des lieux, repères et outils pour une amélioration* [The coordination between the general practitioner and the various healthcare professionals in the management of adult patients with mental health disorders – current situation, guidelines, and tools for improvement]. https://www.has-sante.fr/jcms/c_2874187/fr/coordination-entre-le-medecin-generaliste-et-les-differents-acteurs-de-soins-dans-la-pri-se-en-charge-des-patients-adultes-souffrant-de-troubles-mentaux-etats-de-s-lieux-reperes-et-outils-pour-une-amelioration* (accessed 10 February 2025).

**French National Authority for Health** (2018b, October 9) *Improving Care Coordination in Mental Health*. https://www.has-sante.fr/jcms/c_2876753/fr/ameliorer-la-coordination-des-soins-dans-le-domaine-de-la-sante-mentale* (accessed 9 January 2025).

**Gallais J-L** (2014) General medicine, psychiatriy and primary healthcare: a general practitioner point of view. *L'information psychiatrique* **90**, 323–329. https://doi.org/10.3917/inpsy.9005.0323

**GBD 2019 Mental Disorders Collaborators** (2022) Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. *The Lancet. Psychiatry* **9**, 137–150. https://doi.org/10.1016/S2215-0366(21)00395-3

**Hazo J-B, Costemalle V, Rouquette A, Bajos N and équipe EpiCov** (2021) *Une dégradation de la santé mentale chez les jeunes en 2020* [Mental health declines among young people in 2020] Dress. https://drees.solidarites-sante.gouv.fr/publications/etudes-et-resultats/une-degradation-de-la-sante-mentale-chez-les-jeunes-en-2020* (accessed 11 February 2025).

**Hérisson R** (2015) *Que pensent les psychiatres publics de l'EPSM-AL des recommandations de bonne pratique concernant la communication avec les médecins généralistes? Analyse qualitative auprès des psychiatres publics des secteurs de Lille intra-muros* [What do EPSM-AL public psychiatrists think about the good practice recommendations on communication with general practitioners? Qualitative analysis of public psychiatrists in the intra-muros sectors of Lille. Doctoral thesis in general medicine]. http://pepite.univ-lille2.fr/notice/view/UDSL2-workflow-5471

**Iorfino F, Occhipinti J-A, Skinner A, Davenport T, Rowe S, Prodan A, Sturgess J and Hickie IB** (2021) The Impact of Technology-Enabled Care Coordination in a Complex Mental Health System: A Local System Dynamics Model. *Journal of Medical Internet Research* **23**, e25331. https://doi.org/10.2196/25331

**John A, McGregor J, Jones I, Lee SC, Walters JTR, Owen MJ, O'Donovan M, DelPozo-Banos M, Berridge D and Lloyd K** (2018) Premature mortality among people with severe mental illness — New evidence from linked primary care data. *Schizophrenia Research* **199**, 154–162. https://doi.org/10.1016/j.schres.2018.04.009

**Kinouani S, Schmidt L, Giraudier S, Colomb T and Bailly T** (2024) Interprofessional collaboration between general practitioners and psychiatrists in a French rural multi-professional health center: assessment of doctors' needs and patients' expectations using a mixed methods approach. *Annales Médico-Psychologiques, Revue Psychiatrique*. https://doi.org/10.1016/j.amp.2024.09.007

**Laboutière J-J** (2017) *Psychiatrie de ville et coordination des soins* [Community Psychiatry and Care Coordination]. *L'information psychiatrique* **93**, 746–753. https://doi.org/10.1684/ipe.2017.1703

**Legifrance Social Security Code/ Amended by Law No. 2023-1268 of December 27, 2023**, Article 10, 2023-1268 (2023). https://www.legifrance.gouv.fr/jorf/id/JORFTEXT000048678304* (accessed 19 February 2025).

**Linder A, Widmer D, Fitoussi C, Fitouss Y de, Fitouss J-N and Fitouss G** (2019) The challenges of collaboration between general practitioners and psychiatrists: the case of chronic depression in French-speaking Switzerland. *Santé Publique* 31, 543–552.

**Mercier A** (2014) *Médecins généralistes, psychiatres et leurs patients : les enjeux de la communication* [GPs, psychiatrists and their patients: the challenge of communication]. *Exercer* **115**, 64.

**Ministry of Health and Access to Care** (2021, June 3) Roadmap for Mental Health and Psychiatry. https://sante.gouv.fr/prevention-en-sante/sante-me-ntale/Feuille-de-route-de-la-sante-mentale-et-de-la-psychiatrie-11179/* (accessed 10 December 2024).

**Ministry of Labour, Health, Solidarity, and Families** (2023, March 3) Synthèse du bilan de la feuille de route santé mentale et psychiatrie au 3 mars 2023 [Summary of the mental health and psychiatry roadmap assessment as of March 3, 2023]. https://sante.gouv.fr/actualites/presse/dossiers-de-presse/article/synthese-du-bilan-de-la-feuille-de-route-sante-mentale-et-psychiatrie-au-3-mars* (accessed 11 February 2025).

**Odelola C and Jabbar F** (2017) Re-Audit of the Contents of GP Referral letters to General Adult Community Psychiatrists. *Psychiatria Danubina* **29**, 607–609.

**Odier B and Falcoff H** (2021) Les communautés professionnelles territoriales de santé (CPTS), une opportunité pour la psychiatrie de secteur [Territorial professional health communities (CPTS): an opportunity for community psychiatry]. *L'information psychiatrique* **97**, 703–714. https://doi.org/10.1684/ipe.2021.2319
Parker SM, Paine K, Spooner C and Harris M (2023) Barriers and facilitators to the participation and engagement of primary care in shared-care arrangements with community mental health services for preventive care of people with serious mental illness: a scoping review. *BMC Health Services Research* 23, 977. https://doi.org/10.1186/s12913-023-09918-2

Passerieux C and Younes N (2007) Dépression : quel parcours de soin ? [Depression: what treatment pathway?]. *Santé Mentale* **116**, 25-81.

Roberts LW, Louie AK, Guerrero APS, Balon R, Beresin EV, Brenner A and Coverdale J (2017) Premature Mortality Among People with Mental Illness: Advocacy in Academic Psychiatry. *Academic Psychiatry* **41**, 441-446. https://doi.org/10.1007/s40596-017-0738-9

Saint-Pierre C, Herskovic V and Sepúlveda M (2018) Multidisciplinary collaboration in primary care: a systematic review. *Family Practice* **35**, 132-141. https://doi.org/10.1093/fampra/cmx085

Scaioli G, Schäfer WLA, Boerma WGW, Spreeuwenberg PMM, Schellevis FG and Groenewegen PP (2020) Communication between general practitioners and medical specialists in the referral process: a cross-sectional survey in 34 countries. *BMC Family Practice* **21**, 54. https://doi.org/10.1186/s12875-020-01124-x

Sebai J and Manzani YE (2023) Adoption de la télémédecine par les professionnels de santé publics français pendant la pandémie de COVID-19

[Adoption of telemedicine by French public health professionals during the COVID-19 pandemic]. Management & Prospective 40, 13-33. https://doi.org/10.3917/g2000.402.0013

Selzer R, Foley F, Steve E and McGartland M (2009) What do GPs want from a psychiatrist’s letter? *Australasian Psychiatry: Bulletin of Royal Australian and New Zealand College of Psychiatrists* **17**, 385-388. https://doi.org/10.1080/10398560902971771

Serfontein J, Dodwell D and Patel P (2011) Psychiatric discharge summaries: what do general practitioners want? *Mental Health in Family Medicine* **8**, 167-171.

Supper I, Ecochard R, Bois C, Paumier F, Bez N and Letrilliart L (2011) How do French GPs consider participating in primary care research: the DRIM study. *Family Practice* **28**, 226-232. https://doi.org/10.1093/fampra/cmq073

Tzartzas K, Oberhauser P-N, Marion-Veyron R and Saillant S (2022) Psychiatric consultation in general practitioners’ daily practice: a qualitative study on the experience of consultation-liaison psychiatry interventions in primary care settings in French-speaking Switzerland. *BMC Primary Care* **23**, 316. https://doi.org/10.1186/s12875-022-01937-y

**WoNCa Europe** 2023 Edition (2023) The European definition of General Practice/Family Medicine. https://www.woncafrica.org/file/41f61fb9-47d5-4721-884e-603f4afa6588/ WoNCa_European_definitions_2_v7.pdf.