Susan Jeffrey

May 21, 2013

SAN FRANCISCO — Results of a new survey suggest that healthcare providers, even those involved in the delivery of mental health care, are not immune to bias against patients with serious mental illnesses.

Given 2 identical clinical scenarios, 1 of which involved a patient with schizophrenia, a group of healthcare providers that included psychiatrists and primary care physicians as well as primary care and mental health nurses tended to view the patients with serious mental illness more negatively than those without mental illness, and these attitudes colored their treatment decisions, including referrals.

"This finding suggests that stigma-reduction interventions that target all provider groups are needed," Dinesh Mittal, MD, a psychiatrist at the Central Arkansas Veterans Healthcare System and associate professor at the University of Arkansas, in Little Rock, and colleagues concluded.

"We had expected initially that primary care providers would have more negative bias, but we didn't find any difference between primary care and mental health providers; mental health providers were just as guilty as our colleagues in primary care," Dr. Mittal told reporters at a press conference here.

Jeffrey Borenstein, MD, chief medical officer at the Brain and Behavior Research Foundation in Great Neck, New York, and chair of the Council on Communications of the American Psychiatric Association (APA), who moderated the press conference, called this a "very important study."

Dr. Jeffrey Borenstein

"We use the word stigma, but I would use a different word — prejudice," Dr. Borenstein said. "In our society, we don't allow prejudice anymore based on a variety of factors, but we still, to whatever degree, tolerate prejudice when it comes to people with psychiatric conditions, and that has to change."

The results were presented here at the American Psychiatric Association's 2013 Annual Meeting.

A Pattern of Poor Care

Despite being at high risk for chronic medical conditions, people with serious and persistent mental health disorders such as schizophrenia receive poor care for physical health problems, the authors write. Relative to those without mental illness, these patients have been shown to receive suboptimal medical, preventive, and specialty healthcare, they note. In one study of patients presenting with chest pain, for example, Dr. Mittal noted, only 40% of patients with substance abuse or other mental illness were referred for coronary angioplasty.

Dr. Dinesh Mittal

"While the reasons for this pattern are multifactorial and complex, one potential contributor that has received very little attention is providers' stigmatizing attitudes about mental illness," Dr. Mittal and colleagues note.

In this study, the researchers aimed to assess the influence of any such bias on the care of patients with schizophrenia and compare the effect between 4 groups of healthcare providers from 5 Veterans Affairs medical centers: psychiatrists (n = 62), primary care physicians (n = 55), mental health nurses (n = 67), and primary care nurses (n = 91).

To look at this, they created a clinical vignette: a 34-year-old man with hypertension, obesity, insomnia, and chronic back pain was returning for a follow-up visit and seeking stronger medication for pain. The patient was currently being treated with naloxone and fluoxetine. He did not have any substance abuse. He was a cafeteria worker, attended church, and enjoyed fishing and reading magazines, Dr. Mittal noted. The only difference was that in 1 vignette, the providers were told the patient had a history of stable schizophrenia, and in the other, he did not.

Each provider then responded on the basis of 1 of the 2 clinical vignettes. "What we were interested in knowing was, did these providers refer this patient to an obesity clinic or weight management because he was obese, did they refer him to a sleep study because he was not sleeping well, or pain management because he had back pain?" Dr. Mittal noted. They also asked questions aimed at gauging the providers' assessment of the patient's function, competence, and ability to adhere to medications.

Results showed that overall, the providers expected lower adherence to medications, even though nonadherence rates among people with chronic mental illness are very similar to those with other chronic illnesses, he said. "We didn't find any difference between mental health and primary care providers" in this assessment, Dr. Mittal noted.

Similarly, providers were less likely to refer the patient with schizophrenia for weight management, even though recent data show that patients with serious mental illness are equally likely to benefit from weight reduction programs. The providers were again less likely to refer the patient with schizophrenia to sleep study, but there was no difference seen in the referral to pain management programs regardless of the schizophrenia diagnosis, he noted, "which is a good thing."

However, providers expected that the patient with schizophrenia would have lower social functioning, he said, "whereas we know from the data that only 25% of patients with schizophrenia have poor outcomes and lower function; 75% do as well as others."

They were also seen as having lower competence to make treatment and financial decisions, despite data showing that people with schizophrenia have adequate decision-making function unless they are psychotic, Dr. Mittal noted.

Finally, providers were also more likely to include the patient's family more in decision making, "which is a good thing, but it could represent a paternalistic attitude of some providers toward these patients, looking at the other data."

Mental Health vs Primary Care

When they set out to do this project, they did expect better performance on these behaviors between mental health professionals and primary care providers, Dr. Mittal told Medscape Medical News. "We did not find that," he said.

The only exception was for 1 variable, the providers' perception of the patients' ability to understand educational material, for which psychiatrists and primary care nurses expected patients with schizophrenia not to understand the material as well as the other groups did.

"So there were some differences, but not as much as we expected, and I think there's a reason for that," he added. "Psychiatrists, although they are better educated in terms of mental illness — the causes and the treatment — but on the other hand, if you look at our clinical lives, we see the sickest of the sick patients, and that affects our perceptions about the population. That's the bias we're dealing with."

The next phase of this study, he said, is to develop interventions to decrease this bias among providers. One of these ideas is a "contact intervention," in which they will provide more contact for providers with people with schizophrenia who are functioning well in the community.

"We know a lot of providers who are psychiatrists...providers who have schizophrenia," he said, giving the examples of Fred J. Frese, PhD, assistant professor of psychology in clinical psychiatry at Case Western Reserve University and the Northeastern Ohio Universities College of Medicine in Rootstown, who is also a mental health advocate and member of the board of directors for the National Alliance of Mental Illness, and Elyn Saks, PhD, JD, associate dean and Orrin B. Evans Professor of Law, Psychology and Psychiatry and the Behavioral Sciences at the University of Southern California Gould School of Law in Los Angeles, who spoke during the opening ceremony of this meeting. "These are very successful people."

Dr. Borenstein added that as a field, psychiatrists are looking at ways to work collaboratively with other disciplines, "so that we're doing a better job of integrating the overall care of people with psychiatric conditions. That's an important trend in psychiatry and medicine in general, because you have to treat the whole person, and you have to look at the whole person."

That trend will make a big difference over the course of time to the care of people with psychiatric conditions, he added. "On average, people with severe psychiatric illnesses such as schizophrenia end up dying at a significantly earlier age than other people due to medical problems. So it's very important — and that's why this study is an important study — that we make sure that people with psychiatric conditions like schizophrenia receive the best possible medical care along with their psychiatric treatment."

Dr. Mittal and Dr. Borenstein report no relevant financial relationships.

The American Psychiatric Association's 2013 Annual Meeting. Abstract NR12-12. Presented May 21, 2013.

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