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IIR 08-086 – HSR&D Study

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IIR 08-086
Understanding Provider Decision-Making
Dinesh Mittal MD
Central Arkansas Veterans Healthcare System Eugene J. Towbin Healthcare Center, Little Rock, AR
No. Little Rock, AR
Funding Period: February 2010 - September 2013

BACKGROUND/RATIONALE:
Individuals diagnosed with serious mental illness (SMI) are likely to receive sub-optimal medical, preventive, and specialty care. Mental health providers may be reluctant to refer persons with SMI for rehabilitation services. Although we do not fully understand the reasons for these health-related disparities between individuals with and without SMI, especially those diagnosed with schizophrenia, it is likely that provider attitudes play a role. While there is some indication that general health providers and mental health providers exhibit negative attitudes towards persons with any mental illness, little is known about providers' stereotypes of persons with SMI.

OBJECTIVE(S):
The aim of this study is the assessment of the stigmatizing beliefs, attitudes and behaviors of health providers towards those diagnosed with SMI. A supplement to the original HSR&D study supported our work to adapt a contact based stigma-reduction intervention tailored for VA healthcare providers.

METHODS:
We adopted a vignette survey design to assess the stigmatizing beliefs, attitudes and behaviors of primary care and psychiatric physicians and nurses and psychologists towards their patients diagnosed with SMI, specifically schizophrenia. Participants were clinicians employed by five VA hospitals in VISN 16. The vignette describing the person with schizophrenia was intended to depict a relatively high functioning person with a steady job who engaged in social and recreational activities consistently over several years.

Each survey contained one of two versions of the vignette, that were identical except that one version identified the patient as having schizophrenia. Each provider completed only one of the two vignettes. After reading the vignette, providers answered a series of questions about their attitudes, clinical expectations and treatment decisions relative to the patient described in the vignette. These questions addressed the provider attitudes regarding social distance, attribution of mental illness, and stereotyping. In addition, we also asked about providers' expectations of patient's functioning, adherence to treatment and ability to manage his care. In addition, we inquired about whether or not the provider would refer the patient to additional services or tests (sleep study, weight management and pain management programs).

FINDINGS/RESULTS:
Subjects included 351 VA providers including 205 mental health providers (psychiatrists, psychologists, and mental health nurses) and 146 primary care providers (physicians and nurses). The majority of our sample was Caucasian (63%), female (65%), and on average, providers in the sample had approximately 17 years of clinical practice. Participants completed a survey between August 2011 and April 2012. Two main findings emerged from this study. First, this study showed that compared to a person without schizophrenia, both VA mental health and primary care providers have lower expectations for persons with schizophrenia regarding their ability to adhere to treatment, make treatment decisions, and understand educational material; and that these providers refer them less often to certain services, such as weight reduction. . Second, we found that primary care providers have more negative attitudes towards persons with schizophrenia compared to mental health providers. Specifically, primary care providers had more negative attributions about a patient with schizophrenia than about a patient without schizophrenia (mean difference= 1.86, p= .02). Examples of negative attributions include blaming a person with mental illness for their illness, being angry at, or scared of them. Primary care providers also had more negative stereotypes than mental health providers towards a patient with schizophrenia than towards a patient without schizophrenia (mean difference= 5.06, p< .001). Examples of negative stereotypes include considering all patients with mental illness to be dangerous, unpredictable, weak and worthless. In addition, both primary care doctors and psychiatrists expressed a greater desire than psychologists and nurses for distancing themselves from patients with schizophrenia than those without. These findings are similar to findings from the literature that included mostly non-VA providers.

Intervention development for reducing stigmatizing attitudes of providers:
The findings of our study strongly supported the need to develop an intervention to reduce stigmatizing attitudes among VA healthcare providers. A supplement to the original HSR&D study supported our work to adapt a contact stigma-reduction intervention tailored for providers in consultation with a national expert in stigma reduction, Dr. Patrick Corrigan.

Research shows that interventions which utilize an experiential approach to challenge stereotypes by exposing people to high functioning persons with mental illness-called "contact interventions"-yield significantly greater reduction in stigmatizing attitudes than other approaches such as education alone. Thus contact-based strategies provide an evidence-based approach to reduce provider stigma, and potentially reduce disparities in receipt of medical services.

Through qualitative work, we obtained important feedback from two stakeholder groups: (1) frontline VA primary care and mental health providers (N=84 from 7 focus groups) and (2) an Advisory Board comprised of doctors, nurses and other professionals who themselves have had "lived experience" of SMI or had a close family member with SMI. We elicited information regarding the target of a stigma reduction intervention for providers, the message of the intervention, the format, setting, mode, and frequency of delivery of the intervention and how to measure change. Utilizing this feedback to adapt contact interventions described in the literature and incorporating the successful components/strategies described above, we developed the Serving All Veterans Equally (SAVE) manual to provide structure for use by providers with SMI who are in recovery to narrate their lived experience of mental illness to impact provider attitudes and clinical behaviors in a positive manner.

IMPACT:
Impact: Findings of our study call for implementation of evidence based contact interventions to reduce negative attitudes of VA providers and promote affirming clinical behaviors. These efforts have the potential to reduce disparities in care for Veterans with SMI. We are in the process of submitting a RRP to pilot implementation strategies for contact based stigma reduction intervention for providers.

PUBLICATIONS:

Journal Articles

  1. Viverito KM, Mittal D, Han X, Sullivan G. Attitudes Regarding Seeking Help for Mental Health Problems and Beliefs About Treatment Effectiveness: A Comparison Between Providers and the General Public. Stigma and health. 2017 Feb 9; doi: 10.1037/sah0000053.
  2. Smith JD, Mittal D, Chekuri L, Han X, Sullivan G. A Comparison of Provider Attitudes Toward Serious Mental Illness Across Different Health Care Disciplines. Stigma and health. 2016 Nov 14; doi: 10.1037/sah0000064.
  3. Mittal D, Ounpraseuth ST, Reaves C, Chekuri L, Han X, Corrigan P, Sullivan G. Providers' Personal and Professional Contact With Persons With Mental Illness: Relationship to Clinical Expectations. Psychiatric services (Washington, D.C.). 2016 Jan 1; 67(1):55-61.
  4. Mittal D, Corrigan P, Drummond KL, Porchia S, Sullivan G. Provider Opinions Regarding the Development of a Stigma-Reduction Intervention Tailored for Providers. Health education & behavior : the official publication of the Society for Public Health Education. 2016 Oct 1; 43(5):577-83.
  5. Sullivan G, Mittal D, Reaves CM, Haynes TF, Han X, Mukherjee S, Morris S, Marsh L, Corrigan PW. Influence of schizophrenia diagnosis on providers' practice decisions. The Journal of clinical psychiatry. 2015 Aug 1; 76(8):1068-74; quiz 1074.
  6. Mittal D, Corrigan P, Sherman MD, Chekuri L, Han X, Reaves C, Mukherjee S, Morris S, Sullivan G. Healthcare providers' attitudes toward persons with schizophrenia. Psychiatric Rehabilitation Journal. 2014 Dec 1; 37(4):297-303.
  7. Corrigan PW, Mittal D, Reaves CM, Haynes TF, Han X, Morris S, Sullivan G. Mental health stigma and primary health care decisions. Psychiatry Research. 2014 Aug 15; 218(1-2):35-8.
Conference Presentations

  1. Mittal D. Provider’s Contact with people with Mental Illness, Mental Health Stigma and Primary Health Decisions and Expectations. Paper presented at: Together Against Stigma International Conference; 2015 Feb 18; San Francisco, CA.
  2. Mittal D. VA Psychosocial Recovery and Rehabilitation Centers: How can Coming Out Proud Program be Integrated. Paper presented at: Together Against Stigma International Conference; 2015 Feb 18; San Francisco, CA.
  3. Mittal D. Tele Presentation: Understanding Provide Decision-Making. Paper presented at: National Alliance on Mental Illness National Convention; 2013 Aug 23; Washington, DC.
  4. Mittal D, Sullivan G, Reaves C, Han X, Mukherjee S, Morris S, Corrigan P. Does Serious Mental Illness Influence Treatment Decisions of Physicians and Nurses? Poster session presented at: American Psychiatric Association Annual Meeting; 2013 May 21; San Francisco, CA.
  5. Mittal D, Sullivan G, Reaves C, Han X, Mukherjee S, Morris S, Corrigan P. News Brief: Does Serious Mental Illness Influence Treatment Decisions of Physicians and Nurses? Presented at: American Psychiatric Association Annual Meeting; 2013 May 21; San Francisco, CA.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational, Prognosis
Keywords: Behavior (provider), Schizophrenia, Serious Mental Illness
MeSH Terms: none

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