Bias Against Schizophrenic Patients Seeking Medical Care

Surprisingly, psychiatrists and psychiatric nurses “were just as likely” as their primary care counterparts to display negative biases toward individuals with schizophrenia seeking general medical care, according Dinesh Mittal, MD, staff psychiatrist with the Central Arkansas Veterans Healthcare System and Associate Professor in the Department of Psychiatry and Behavioral Sciences at the University of Arkansas.

In a press briefing at the recent American Psychiatric Association (APA) meeting in San Francisco, Mittal described a study in which he and his colleagues sought to determine whether mental health and primary care providers at Veterans Affairs facilities treat patients with and without schizophrenia any differently. The authors did so by analyzing the providers’ responses to clinical scenarios.

Although at high risk for chronic medical conditions, persons with serious and persistent mental disorders, such as schizophrenia, often receive poor care for their physical health problems, Mittal said.

In their research poster presented at the APA meeting, Mittal and colleagues cited the work of Kisely and associates,¹ who found that the incidence of cancer was no higher in psychiatric patients than in the general population: however, psychiatric patients were more likely to have metastases at diagnosis and were less likely to receive specialized interventions, thereby possibly explaining their higher case fatality rate.

Also cited was a study by Druss and associates,² which found that patients with any comorbid mental disorder were significantly less likely to undergo percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft (CABG) surgery after a myocardial infarction. After adjusting for demographic, clinical, hospital, and regional factors, Druss et al found that individuals with mental disorders were 41% (for schizophrenia) to 78% (for substance abuse/dependence) less likely to undergo cardiac catheterization as those without mental disorders.

To investigate possible bias among providers, Mittal and colleagues presented a hypothetical clinical vignette to 55 primary care physicians, 91 primary care nurses, 62 psychiatrists and 67 psychiatric nurses at 5 VA facilities.

The vignette described a 34-year-old man with hypertension, obesity, insomnia, and chronic back pain. The patient, currently being treated with naproxen, lisinopril, and fluoxetine, was returning for a follow-up and seeking stronger pain medications. He did not have any substance abuse. He was working in a cafeteria at a VA facility, and his job performance was above average. He attended church, enjoyed reading magazines, and occasionally went fishing.

Two versions of the vignette were created . . . one in which the patient had stable schizophrenia and was taking risperidone . . . and the other in which the patient did not have the disorder and did not take risperidone. The vignettes were distributed in 3 waves to the providers who completed their responses anonymously.

After reading their version of the vignette, the providers answered a series of questions about their clinical expectations, treatment decisions, and attitudes relative to the patient described in the vignette.

“We were interested in knowing whether the providers referred the patient to an obesity clinic for weight management because this patient was obese, for a sleep study because he was not sleeping well, and to a program because he had back pain,” said Mittal.

The researchers also wanted to know about the providers’ expectations and treatment decisions concerning the patient’s adherence, competence, and ability to take medications.

They found that all providers expected patients with schizophrenia to have lower adherence to medications- even though nonadherence rates among people with chronic mental illness are very similar to those with other chronic illnesses, Mittal said. The story was the same with regard to referrals to weight management programs.

“Obese patients with schizophrenia were less likely to be referred,” he said, “even though we know patients with schizophrenia are equally likely to benefit from such programs, as recently reported by Daumit and colleagues.”³

The providers were less likely to refer the patient with schizophrenia for a sleep study, but this difference was not statistically significant, and there was no difference in referral patterns to a pain management program.

In addition, providers expected patients with schizophrenia to have lower social functioning, Mittal said, “whereas we know that only 25% of patients with schizophrenia have poor outcomes and lower function due to chronic deterioration and the rest mostly do as well as others.”

Patients with schizophrenia were also viewed as being less competent to make treatment decisions, even though data indicate they have adequate decision-making function unless they are psychotic, Mittal added.

Misperceptions or bias related to persons with schizophrenia were not confined to any one type of provider (nurses versus doctors) or any specialty (mental health versus primary care).

In an interview with Psychiatric Times, Mittal was asked for recommendations on ways to rectify the bias problem. “Our next step is to try and find the kinds of interventions to change attitudes or increase education so biases are less,” he said. “In the medical literature, there are 2 types of interventions: contact-based and educational. The contact-based interventions are more powerful, about twice as effective as educational interventions.”

Such interventions are needed for both mental health and primary care providers, since the researchers did not find any differences in attitudes, Mittal added.

The contact, he said, needs to be different from the providers’ usual clinical interactions. At those times, they are seeing patients with schizophrenia or other psychiatric disorders when they are very sick, which just “reinforces their biases that these patients may not function as well as nonpsychiatric patients and may not have the capacity to make decisions.”

Mittal colleagues have assembled an advisory board that includes some very prominent consumers who are also providers. These include Fred Frese, PhD, currently Assistant Professor of Psychology in Clinical Psychiatry in the psychiatry departments at both Case Western Reserve University and the Northeastern Ohio Universities College of Medicine and a former member of the Board of Directors for the National Alliance on Mental Illness, and Elyn Saks, PhD, JD, Orrin B. Evans Professor of Law, Psychology, and Psychiatry and the Behavioral Sciences at the University of Southern California.

“We need to show providers that people with schizophrenia can function very well and be very productive,” said Mittal. “The problem is that most providers don’t see the people who are functioning well in community, [they see them] only when they are sick. These interactions create clinical illusions that individuals with psychiatric disorders are not able to function.”

“Since these types of interventions require a culture change, they will need to be multimodal and sustained,” he added.

Placing Mittal’s work in context, psychiatrist Jeffrey Borenstein, MD, host of the public television series, “Healthy Minds” and Editor in Chief of Psychiatric News, and Chief Medical Officer of the Brain & Behavior Research Foundation, said, “On average people with severe psychiatric illnesses such as schizophrenia end up dying at a significantly earlier age than other people because of medical problems . . . That’s why this study is so important . . . we need to make sure that people with psychiatric conditions like schizophrenia receive the best possible medical care along with their psychiatric treatment.”

References:

1. Kisely S, Crowe E, Lawrence D. Cancer-related mortality in people with mental illness. JAMA Psychiatry. 2013;70:209-217.

2. Druss BG, Bradford DW, Rosenheck RA, et al. Mental disorders and use of cardiovascular procedures after myocardial infarction. JAMA. 2000;283:506-511.

3. Daumit GL, Dickerson FB, Wang NY, et al. A behavioral weight-loss intervention in persons with serious mental illness. N Engl J Med. 2013;368:1594-1602.