SAN FRANCISCO – Health care providers respond to patients’ physical problems differently, depending on whether or not the patient also has schizophrenia, a survey of 275 doctors and nurses suggested.
The investigators expected to find that the 62 psychiatrists in the study would treat patients more equitably regardless of mental illness, compared with the 55 primary care physicians, 91 primary care nurses, and 67 psychiatric nurses in the study, but that was not the case, Dr. Dinesh Mittal said at the annual meeting of the American Psychiatric Association.
Providers in each category were less likely to refer a hypothetical patient to a weight-reduction program if the patient had schizophrenia. They expected a schizophrenia patient to be less likely to adhere to treatment, less competent to make treatment decisions, and less likely to function well socially, compared with a patient without schizophrenia, Dr. Mittal and his associates found.
Those reactions are based on myths about people with schizophrenia, said Dr. Mittal, a staff psychiatrist for the Central Arkansas Veterans Healthcare System and associate professor of psychiatry at the University of Arkansas for Medical Sciences, Little Rock. The study "suggests that there’s a need for addressing bias" among health care professionals toward patients with mental illness, said Dr. Mittal, who was co-principal investigator of the study with Dr. Greer Sullivan.
The providers in the study, recruited from five Veterans Affairs (VA) medical centers, were asked to consider one of two nearly identical patient vignettes, except that one was a clinically stable person with schizophrenia and the other had no schizophrenia. The hypothetical patient was a 34-year-old male with hypertension, obesity, insomnia, and chronic back pain who was returning for a follow-up visit and seeking stronger medication for pain. He was taking naproxen and fluoxetine with no history of substance abuse. The patient worked in a VA cafeteria, attended church, and enjoyed fishing and reading magazines.
Dr. Dinesh Mittal
After reading the vignette, the participants answered questions about their clinical expectations, treatment decisions, and attitudes relative to the patient described. Because there are no scales to assess clinical expectations and treatment decisions relative to a given vignette, the investigators created scales using multiple questions about expected patient adherence to therapy, ability to understand educational materials, competence to manage health care and personal finances, social and vocational functioning, and the providers’ likelihood to involve the patient’s family in treatment.
The investigators also included single questions about whether or not the provider would refer the patient to programs for weight reduction or pain management, or for a sleep study.
The providers' self-reported likelihood of referring a patient with schizophrenia to a weight management program was 9% lower than for patients without schizophrenia, Dr. Mittal said at his poster presentation. The difference was statistically significant.
A previous study showed, however, that obese persons with serious mental illness benefit from weight reduction programs, he noted (N. Engl. J. Med. 2013;368:1594-602).
Provider scores rating the likelihood of patient adherence to treatment were significantly 6% lower for the schizophrenia patient than the patient without schizophrenia, which also reached significance. That’s despite World Health Organization data showing that the range of nonadherence rates in persons with schizophrenia is no different from those of persons with other chronic illnesses, Dr. Mittal said.
The health care providers rated the schizophrenia patient 17% less likely than the patient without schizophrenia to be functioning socially, a significant difference. A 2012 study found, however, that only about 25% of people with schizophrenia have poor long-term outcomes and lower function (Schizophr. Bull. 2012 Dec. 7 [doi:10.1093/schbull/sbs135]). "Seventy-five percent may not show functional decline similar to others without schizophrenia," Dr. Mittal said.
The patient with schizophrenia was considered 38% less competent to make treatment decisions, compared with the patient without schizophrenia, a significant difference. Previous data have shown, however, that people with schizophrenia are likely to have adequate decision-making capacity unless they are psychotic, Dr. Mittal said.
Providers were 20% more likely to say that they would include the patient’s family in treatment decisions if the patient had schizophrenia, compared with the patient without schizophrenia, again a significant difference. That might be good medical practice, or it could represent paternalistic attitudes held by providers toward people with schizophrenia, Dr. Mittal said.
The schizophrenia patient was less likely to be referred for a sleep study and slightly more likely to be referred to a pain-management program, compared with the patient without schizophrenia, but these differences in health care provider preferences did not reach statistical significance.
Only one variable differed significantly by specialty, provider type, and vignette type: Both psychiatrists and primary care nurses expected SMI patients to be less likely to read and understand educational materials than non-SMI patients. Mental health nurses, however, expected SMI patients to be more likely to read or understand educational materials than psychiatrists. Mental health nurses also expected SMI patients to be more likely to read or understand educational materials than PC nurses.