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To obtain more knowledge on how the change in the Dutch healthcare system in 2014 and years of work experience impact the GPs’ way of working when it comes to dealing with complaints of sadness, stratified sampling was used to select three specific groups of participants. A Dutch GP has received 3 years of specialist training after the basic 6 years of medical education. The first group were the alumni general practitioners, who finished their general practice after 2014 (abbreviated in Table 1 as A), the second group were the more advanced general practitioners (abbreviated in Table 1 as GP), and the third group were the general practitioners in training (abbreviated in Table 1 as GP-T).

To recruit the more advanced GPs, an invitation was delivered at their workplace, but because of the limited response of one reply, snowball purposive sampling was used to recruit the rest of the more advanced participants (GP). The other two groups, general practitioners in training (GP-T) and the alumni general practitioners (A), were recruited via the database Department of General practice of the University Medical Centre Groningen (UMCG). An invitation to participate was e-mailed to all alumni GPs who graduated in or after 2014 and to GPs who were in their third year of training. The e-mail included information about the research, pseudonymization of data, and information about whom to contact for questions about the study. One reminder was sent to them. Finally, 13 GPs participated in this study: 3 general practitioners in training, 5 alumni general practitioners who finished their general practice after 2014, and 5 more advanced general practitioners were interviewed. Professionals were informed again before the start of the interview about the general nature of the study and gave verbal consent. For characteristics of the participants, see Table 1.

In-depth semi-structured interviews were conducted with GPs (in training) of the Northern Region of the Netherlands between March and July 2017. Interviews were held in the participant’s workplace or home. Interviews lasted approximately 45 min.

A vignette was used at the start of the interview to obtain information from the participants about knowledge, attitudes, and perceptions regarding the research topic. Subsequently, the societal, personal, and professional factors and patient characteristics were questioned, being the basis for the topics of the interview schedule. The vignette was developed by the researchers using their experiences and knowledge of psychiatry, general practice, and sociology. With utilization of the research tool of vignettes, information can be gathered on difficult or sensitive topics (Hughes and Huby, 2002). In this research, it represented a young adult with complaints of sadness (Figure 1). It is a fictitious scenario and is purely hypothetical. After the vignette was developed, several GPs revised the vignette to check the credibility.

All interviews were audio-taped and transcribed. For ethical reasons, pseudonyms were used in transcription to protect the identities of the interviewees quoted in this article. We stored the data securely so only the research team could gain access to it. A thematic analytical approach was applied, with the principles of grounded theory in mind (Strauss and Corbin, 1990) and with both inductive and deductive coding using Atlas.ti 8.4.3 by the first author. Analysis commenced with an “open” reading of the data to code the text. Axial coding through an iterative process was then conducted in accordance with the four constituent elements: societal, personal, and professional factors and patient characteristics. To enhance the validity of the analysis, a second author, AD, also coded the transcripts. The researchers compared their coding and discussed the differences until they reached consensus. The remaining interviews were coded according to the revised code list. Saturation was achieved after coding six interviews, since no new codes emerged. Furthermore, thick descriptions were made from the data by reading the data and delving deeper into each issue by exploring its context, its meaning, and the nuances that surround it. During the process, there were critical discussions in the research team to enhance the consistency and validity of the data.

Below, we will describe how GPs are influenced by societal, personal, and professional factors and patient characteristics in the way they are dealing with complaints of sadness among young adults.

Based on the results of this research—how the participants dealt with the subject—we created a typology of GPs (Figure 2). In this typology, we distinguish how the interviewed GPs were influenced by social factors, personal factors, professional factors, and patient characteristics. The first type is the fast referrer. It can be divided again into three subtypes regarding the reasons the GP has for referring the patient. The first one is the referrer because of concern. For example, there was a participant who experienced a suicide of someone she just referred to psychiatry some time before. For her, this experience is a reason to refer almost everybody with complaints of sadness to psychiatry. “Better overestimating than under estimating”, this GP argued. The second one is the fast referrer because of ease. A GP of this type, for example, was convinced that it is not the GP’s task to deal with complaints of sadness. GPs of this type were not very keen on the subject either. The third one is the fast referrer because of feelings of incompetence. These were mostly young doctors who said they lacked knowledge and training in how to deal with complaints of sadness. Therefore, it felt better for them to refer to another discipline.

The second type is the expert. This was the GP type that was interested in and felt competent with mental problems and therefore also tended to treat this kind of patient themselves. They used the DSM for this kind of problems and, if necessary, started antidepressants and sometimes even therapy by themselves.

The third type is the societal GP. This GP type considered that their responsibility may transcend pure “medical” problems and also see an important role for themselves on a more societal level: as someone with whom you can discuss life questions and existential difficulties. According to this type, in our secularized society, a GP also has the role of a “pastor” with whom people can discuss their problems. A GP of the “societal” type also argued that it is very important to abstain from sticking labels on people, especially on young adults.

The results show that participating GPs strongly differ in the way they deal with complaints of sadness among young adults although they are all inclined to act proactively. An important finding was the diagnostic struggle the participants showed. There seems to be a paradox in the way GPs think about de-medicalization on a macro level and the way they are proactively acting on a micro level. On a macro level, the interviewed participants all recognized the social factors that may lead to an increase in complaints of sadness among young adults. They mentioned the importance of refraining to stick medical labels on patients too easily and the importance of alternative perspectives instead of just the medical perspective. On a micro level, however, with a patient actually sitting in front of them, all GPs want to do something, although all the participants acted differently and they clearly “struggled” with it. Standards such as the DSM and the derived NHG standard for depression seem to contribute to this. Dutch GPs are more or less bound to the DSM and the derived NHG standards, which include medical and pharmacotherapeutic guidelines. The guidelines are held in high regard by Dutch GPs (Schäfer et al., 2010). The criteria of the DSM (and the derived NHG standards) only involve the individual (complaints). They are not being placed in a broader psycho-social context. This is part of the medical paradigm that, according to psychologist Verhaeghe et al. (2013), makes it hard to have a more societal view on the difficulties people are experiencing. The medical paradigm with corresponding language (disorders) and the subsequent goal of “treatment” (discipline) lead to a redefining and expansion of what we see as “sick” (Devisch, 2013).

For a better understanding of the difference between a complaint of sadness and a recognized depression, a clear definition of the concepts disease, illness, and sickness can be useful. This full trial was firstly applied by Twaddle (1968). The distinction between disease, illness, and sickness has become commonplace in medical sociology, medical anthropology, and philosophy of medicine (Hofmann and Hofmann, 2002). According to Twaddle, disease is defined as a “health problem that consists of a physiological malfunction that results in an actual or potential reduction in physical capacities and/or a reduced life expectancy” (Twaddle, 1968, p. 8). Illness, on the other hand, is defined as “a subjectively interpreted undesirable state of health. It consists of subjective feeling states, perceptions of the adequacy of the bodily functioning, and/or feelings of competence” (Twaddle, 1968, p. 10). Sickness is defined as “a social identity”. It is the poor health or the health problem(s) of an individual defined by others with reference to the social activity of that individual” (Twaddle, 1968, p. 11). Receiving a diagnosis from a physician can legitimize the complaints. Something that was labeled as a complaint (illness) before is from then on a disease (Jutel, 2009). This has also been emphasized by Parsons (1951), who coined the classic concept of the “sick role” to define illness from a sociological perspective. He argued that being ill was not only a biological condition, but also a social role with a set of norms and values assigned to it. According to Parsons (1951), seeking for medical care is part of the sick role. A physician has the exclusive right to legitimize a sick role: an illness (“a subjectively interpreted undesirable state of health”) becomes transformed into a disease when this is considered applicable. Doctors can in this way be seen as “moral entrepreneurs” (Becker, 1963).

Because the participants in the present study always undertook some kind of action based on the complaint of sadness, we introduce the terms “semi-legitimized sick role” and the “recognized illness.” The developed conceptual model in this research (Figure 3) displays this using the plus sign. This option applies for cases in which the GPs do act proactively and recognize the sadness complaints, but do not call it a depression yet. When they do label it as depression, a shift occurs between “illness” and “disease”, and the sick role (Parsons, 1951) is completely legitimized. The non-legitimized sick role where a complaint of sadness remains an illness after consulting the GPs is no longer relevant because the participants always acted in some way. This option (an illness that stays an illness) is therefore erased from the conceptual model, which is depicted in Figure 3 by the minus sign.

The results in this study are in line with the research of Mik-Meyer and Obling, 2012 who found that for a legitimate sick role, a traditional objective pathology in the body is not necessarily needed and subjective complaints (illness) may be enough for a GP to construct and legitimize the sick role. This happens by constructing and negotiating a sick role even when there is a lack of a clear-cut medical diagnosis and it is difficult to label a particular illness. This study also shows that “psychiatrization” is not an “exclusive problem” of only psychiatry and psychiatrists, but something that is also driven by non-psychiatric professionals, like GPs.

Based on our interviews with 13 GPs on how they handle complaints of sadness of youth, three typologies were identified: the fast referrer, the expert, and the societal GP. All participants endorsed de-medicalization on a macro level, but many had difficulties to put this into practice on a micro level.

According to the typology of GPs (Figure 2), the first subtype is the fast referrer: the referrer because of concern. This concern, coming from personal factors, could lead to refer most (young) people with complaints of sadness to psychiatry. This type therefore tends to legitimize the sick role relatively fast, with “illness” becoming “disease.” For the other two subtypes, the fast referrer because of ease and the fast referrer because of feelings of incompetence, it is not yet clear whether the sick role is going to be fully legitimized or semi-legitimized; this depends on the type and content of the follow-up contact.

In the second type, the expert tends to follow the more traditional script, working strictly according to the DSM and prescribing antidepressants themselves. This is why the sick role is legitimized relatively fast and easy whereby “illness” becomes “disease.”

The third type, the societal GP, prefers working without strictly adhering to the DSM and other standards. In this type, GPs seem to be most able to take off their medical glasses and show a more multifactorial view on complaints of sadness. Therefore, this type connects most to a course of de-medicalization that the Dutch Council for Health and Society (RvS, 2017) is pleading for. Also, this type does not tend to traditionally legitimize the sick role. Still, we did not want to do anything, that is why, in this study, we call this a semi-legitimized sick role where “illness” becomes “recognized illness.”

This research has an important restriction: the size of the included groups of GPs was too small to be able to say something about the influence of the change of the Dutch healthcare system in 2015.

Our research is useful in constructing how the sick role is (semi)legitimized for young adults with complaints of sadness by GPs and how GPs are influenced by different factors by using the typology of GPs (Figure 2). This also leads towards a better understanding in how GPs could be able and feel competent to take off their medical glasses and show a more multifactorial view on complaints of sadness. The obtained insights and knowledge from this study are a useful contribution to critical medical sociology but could also be used for (a more reflexive) practice in education and training of (future) GPs. For example, considering the finding that all GPs in our study are inclined to act and do something for youths presenting themselves with sadness complaints, future GPs could be reminded of the noble “art of doing nothing.” The principle of the (semi)legitimized sick role and the consequences of it may be helpful in learning to use time as both a diagnostic and a therapeutic tool (Heath, 2012).

Recommendations for further research would be to gain more information about the definition and prevalence of the different GP types. Another recommendation is to gain more information on the “recognized illness” with a semi-legitimized sick role that is introduced in this study, for example, by applying the constructs on recent research showing that adolescents who had received a mental health disorder diagnosis were often excluded from the labor market and education as young adults (Ringbom et al., 2021). By using the semi-legitimized sick role, contributions can be made to better understand how individuals are affected by diagnoses through the legitimizing of the sick role and how subsequently society is.