Mental health stigma and primary health care decisions
Introduction
People with serious mental illness experience health challenges yielding alarming morbidity rates (Mai et al., 2011, World Health Organization, 2005) and die, on average, 15–30 years younger than their cohort (Saha et al., 2007). In part, this occurs because of health system failures: e.g., absence of integrated care services (Lutterman, 2010) or insufficient insurance coverage (Druss and Mauer, 2010). However, research also suggests that some provider decisions may worsen health outcomes. Compared to patients not identified with mental illness, research has shown health providers are less likely to refer patients with mental illness for mammography (Koroukian et al., 2012), inpatient hospitalization after diabetic crisis (Sullivan et al., 2006), or cardiac catheterization (Druss et al., 2000). Provider endorsement of stigma might be one influence on these health care decisions for people with mental illness (Jones et al., 2008, Thornicroft et al., 2007). It is possible that perceptions about adherence to treatment mediate the connection between provider stigma and health care decisions. Namely, those with stigmatizing attitudes may believe people with mental illness are less likely to adhere to treatment recommendations. If this is the case, providers may be less likely to offer some types of health care options to people with serious mental illness. In this paper we examine two treatment options that might be offered to a patient presenting with significant pain related to arthritis: refer for specialist consult or refill the patient׳s prescription for Naproxen. The hypothetical relationship between stigma and health decisions is summarized in the right paths of Fig. 1.
Two other variables are likely influential here. First, familiarity with mental illness is inversely associated with endorsing the stigma of mental illness (Corrigan et al., 2001a, Corrigan et al., 2001b). One proxy for familiarity is the degree to which a person is comfortable seeking mental health care themselves. We expect to show that health care providers who are comfortable seeking mental health treatment are less stigmatizing. Second, we hypothesize that health care provider discipline might be expected to moderate stigma׳s effects on treatment response. It seems reasonable to think nurses and physicians with mental health training are less likely to hold stigmatizing views compared to primary care colleagues; hence, being a mental health professional might be associated with endorsing stigmatizing characteristics. However, research suggests mental health providers may endorse stigma equal to or greater than many other professions (Lauber et al., 2006, Schulze, 2007). To learn more about this relationship, we include discipline (mental health versus primary care) as an additional variable in our path model without hypothesis about expected relationship.
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Participants
Nurses, physicians, and psychologists from mental health and primary care clinics were recruited from five VA hospitals in the southeast and southwest areas of the US in 2011 and 2012. The study was approved by the VA Central Institutional Review Board. Providers who were fully informed to the study and consented to participate were given a hardcopy survey and self-addressed, postage paid envelope to return information anonymously. Research participants completed one of two vignettes of a
Results
Missing data were replaced by imputations representing means of existing data for remaining items in the measure. Mean and standard deviations of the measures included in our model are summarized in Table 1. Table 1 also includes Pearson Product Moment Correlations examining associations between constructs. Provider discipline was significantly associated with comfort with mental health care; providers from mental health clinics showed more comfort. Those who reported greater comfort were less
Discussion
This paper helps to explain the relationship between mental illness stigma and health care decisions. In particular, health care providers who endorse more stigmatizing attitudes about mental illness were likely to be more pessimistic about the patient׳s adherence to treatment. Stigma was greater among those providers who were relatively less comfortable with using mental health services themselves. This path was then associated with two separate health decisions: refer the patient to a
Conflict of interest
There are no conflicts of interest for any authors.
Acknowledgments
The authors thank Lisa Dixon, MD, MPH; Stephen Marder, MD; Richard Owen, MD; Alex Young, MD, MSPH, who were advisors to this project; site PIs Laura Marsh, MD; Drew Helmer, MD, MS; Amee J. Epler, PhD; Scott A. Cardin, PhD; and Michelle D. Sherman, PhD. We thank Penny White, BS; Lea Kiefer, MPH; Lorne Ryland, BS, BA; Rose Gonzalez, BS; and Nyree Cunningham-Pullen, MS, for assistance with data collection; and Anne Schmidt, BS, for assistance with manuscript preparation. This research was
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