داغ ننگ بهداشت روانی و تصمیم گیری مراقبت های بهداشتی اولیه

People with serious mental illness have higher rates of mortality and morbidity due to physical illness. In part, this occurs because primary care and other health providers sometimes make decisions contrary to typical care standards. This might occur because providers endorse mental illness stigma, which seems inversely related to prior personal experience with mental illness and mental health care. In this study, 166 health care providers (42.2% primary care, 57.8% mental health practice) from the Veteran׳s Affairs (VA) medical system completed measures of stigma characteristics, expected adherence, and subsequent health decisions (referral to a specialist and refill pain prescription) about a male patient with schizophrenia who was seeking help for low back pain due to arthritis. Research participants reported comfort with previous mental health interventions. Path analyses showed participants who endorsed stigmatizing characteristics of the patient were more likely to believe he would not adhere to treatment and hence, less likely to refer to a specialist or refill his prescription. Endorsement of stigmatizing characteristics was inversely related to comfort with one׳s previous mental health care. Implications of these findings will inform a program meant to enhance VA provider attitudes about people with mental illness, as well as their health decisions.

People with serious mental illness experience health challenges yielding alarming morbidity rates (Mai et al., 2011 and 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 and 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.