Prejudices, misconceptions about serious mental illness creep into medical treatment plans

By Lauren LeBano, PsychCongress Network, May 23, 2013

Doctor shaking fingerPrejudices about individuals with mental illness play a role in many healthcare providers’ treatment decisions involving physical conditions, a randomized trial suggested.

When providers of all types — even mental health professionals — were presented with hypothetical vignettes of patients with medical conditions such as obesity, the treatment plans differed markedly when the patient also had schizophrenia, said Dinesh Mittal, MD, of the University of Arkansas for Medical Sciences in Little Rock.

Providers tended to assume that schizophrenia patients would be less adherent to instructions, more likely to miss appointments, and less competent at making their own medical decisions — none of which are justified by evidence, Mittal said at the American Psychiatric Association annual meeting here.

The biggest surprise in the study, he said, was that psychiatrists and mental health nurses had most of the same prejudices about schizophrenic patients as their counterparts in primary care.

Previous research had indicated that patients with mental illnesses often receive different treatments for medical conditions than other individuals. For example, Mittal said at a press briefing, a 2000 study indicated coronary angioplasty was performed less than half as often in Medicare patients diagnosed with mental illnesses than in otherwise similar patients without a psychiatric comorbidity.

To examine whether different types of medical providers would regard patients with mental illnesses differently from others when it comes to their medical conditions, he and his colleagues performed a prospective, randomized, survey-based trial among 275 providers at five Veterans Affairs medical centers.

The researchers presented respondents with one of two hypothetical patient scenarios, identical except that one of the patients was described as also having schizophrenia, and asking about the expectations for that patient and the types of treatment they would recommend.

The scenarios described a 34-year-old male patient with rising hypertension, moderate but increasing obesity, insomnia, and chronic back pain. This patient was coming to the clinic for a follow-up visit to seek stronger pain medication for the back pain; he was currently taking lisinopril, naproxen and fluoxetine (Prozac). He was also described as employed, with above-average work performance, and a regular churchgoer with hobbies including fishing and reading magazines.

Respondents included 91 primary care nurses, 55 primary care doctors, 67 mental health nurses, and 62 psychiatrists. Half of each group was given the scenario in which the patient also was described as having clinically stable schizophrenia managed with risperidone (Risperdal).

Overall, in response to questions about how the schizophrenic individual would behave as a patient, the participants had significantly lower expectations in most categories.

Just over 50% of respondents in all categories indicated that this patient would be competent to make his own medical decisions, compared with 84% of respondents asked about the otherwise identical non-schizophrenic patient (P<0.05).

Mean ratings of the schizophrenic patient’s expected social functioning and his ability to read and understand written materials were significantly lower, Mittal said.

Also, nearly 85% of respondents indicated that the patient might try to hurt others or himself; 59% of those asked about the non-schizophrenic patient said the same (P<0.05).

In each case, Mittal said, studies have shown that such beliefs are unfounded, at least as long as schizophrenia remains under control and no psychosis is present.

The preconceptions about the schizophrenic patient translated into differences in how the providers would care for him.

Even though at least one recent study has shown that weight loss programs are effective in obese schizophrenics, Mittal said, the healthcare professionals were significantly less likely to recommend it for the schizophrenic patient in the vignette.

They were also less likely to recommend a sleep study, although the difference in that case was smaller and nonsignificant. There was no difference at all in recommendations that the patient try a pain management program.

In one respect, however, prejudice might work in the schizophrenic patient’s favor — significantly more providers indicated that they would involve his family in his medical management. Mittal said this represents “good medical practice,” but it may also reflect a paternalistic attitude and lack of trust in the patient himself.

He said his expectation going into the study was that mental health providers would be less prone to stereotyping of the schizophrenic patient. Yet, he said, the patterns of responses they gave did not differ markedly from those of the primary care providers.

“There is a need for reducing stigma among all healthcare professionals” toward patients with mental illnesses, he said.