Psych Residents Biased Against Mentally Ill Patients With SUDs

Fran Lowry

December 11, 2015

HUNTINGTON BEACH, California ― Psychiatry residents have negative attitudes toward patients with serious mental illness and concomitant substance use disorders, and these attitudes worsen over the course of their training, a new study shows.

Being cared for by clinicians who have such negative attitudes could adversely affect the care of these patients, lead author Bernadine H. Han, MD, Department of Psychiatry, Weill Cornell Medical College, New York City, told Medscape Medical News.

"Generally over the course of medical training, and particularly psychiatry training, the exposure to patients with substance use disorders for some reason, instead of making residents more excited to treat these patients, makes them have more negative attitudes towards these patients," Dr Han said.

Dr Bernadine Han

"That is a big concern in terms of quality of care and potential for recovery when patients are constantly encountering clinicians who actually don't like working with them and who are tired of seeing them over and over again," she said.

Dr Han presented the results of her study in a poster presentation here at the American Academy of Addiction Psychiatry (AAAP) 26th Annual Meeting.

Using the Medical Condition Regard Scale (MCRS), an 11-item anonymous Internet-based questionnaire, the investigators examined attitudes of 159 psychiatry residents toward four different patient types:

  • A patient with schizophrenia

  • A patient with multiple substance use disorders

  • A patient with schizophrenia and multiple substance use disorders

  • A patient with major depression

Items on the MCRS included the following:

  • "I prefer not to work with patients like this"

  • "Patients like this irritate me"

  • "I wouldn't mind getting up on call nights to care for patients like this"

  • "Treating patients like this is a waste of medical dollars"

  • "I can usually find something that helps patients like this feel better"

The investigators found that the residents' attitudes toward patients with substance use disorders alone and toward patients with schizophrenia and comorbid substance use disorders were more negative than their attitudes toward patients with schizophrenia or depression alone.

Furthermore, as the years of their residency progressed, the attitudes of the residents worsened. In all cases, older residents expressed more irritation with patients who had co-occurring schizophrenia and substance use disorders, felt greater irritation at being woken on call nights to care for them, and felt that treating such patients was a waste of medical dollars.

Disappointing, Not Surprising

"Our findings were not a surprise," Dr Han said.

"However, the degree to which the negativity exists was more disappointing than I would have hoped. I think it's inevitable to feel the frustration of seeing someone with a substance use disorder, particularly in training. We see them in acute settings where they have relapsed, and we are trying to help them get back on their feet, and then you see them again and again in the ED while you're on call, maybe in the middle of the night. That's the experience that grows the frustration and the sense that you're not helping them," she said.

Understanding that these attitudes exist is the first step to finding ways to prevent or at least mitigate them so they do not stand in the way of good patient care, Dr Han added.

"At the very least, we should make residents aware that this is happening over the course of their training, and thus hopefully improve the care of patients with substance use disorders," she said.

Double Stigma

Commenting on the findings for Medscape Medical News, Thomas R. Kosten, MD, Jay H. Waggoner Chair and professor of psychiatry and neuroscience at Baylor College of Medicine and research director of the Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, agreed that "there is bias against these patients.

Dr Thomas Kosten

"These are very frustrating patients for residents, particularly since their exposure to them is overwhelmingly in the emergency room, where people are not at their best.

"You have a double stigma with substance abuse and psychiatric disorders. You have the stigma of a psychiatric disorder, and even if you are a psychiatric resident and are quite happy to tolerate that, you've got the next stigma of substance abuse, and you know that substance abuse is leading the patients to stopping the medication that's helping them.

"No matter how open-minded and enlightened we are supposed to be, people still think that substance abuse on some level is willful misconduct or as a moral problem that is self-induced," he said.

Dr Kosten added that these negative attitudes tend to improve with the experience of clinical practice.

"Eventually, we see how these patients can improve once they stay on their antipsychotics and how worthwhile it can be to work with these difficult patients on a long-term basis," he added.

Dr Han and Dr Kosten report no relevant financial relationships.

American Academy of Addiction Psychiatry (AAAP) 26th Annual Meeting. Abstract 15. Presented December 4, 2015.

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