Putting Bias Aside

By Megan Pinder, PA-C

In the years leading up to the COVID-19 pandemic, the prevalence of mental health and substance use disorders was already on the rise. The World Health Organization estimates a 13% increase in the prevalence of mental health disorders in the decade leading up to 2017. (1)  However, since the pandemic, the prevalence of these disorders has greatly increased due to stressors surrounding this unprecedented time. (2)  Now more than ever, it is essential that providers can connect with patients, recognize signs of mental health and substance use disorders, and holistically approach treatment of these conditions.

There are many barriers preventing patients who have mental health and substance use disorders from receiving care, including lack of providers, lack of resources, and provider bias and lack of empathy. These barriers lead to poor health outcomes for patients. Studies show that patients with co-occurring mental illness have higher mortality rates from comorbid conditions than people who do not have a mental illness. (3) Patients with mental health disorders also have lower life expectancies than the general population. (4) In this article, we will discuss how bias and stigma affect health outcomes for patients with mental illness and substance use disorders, and identify some of the different types of bias and stigma that may affect the care that healthcare providers give to their patients. In a second article, called “Approach to Limiting Bias for Patients with Mental Health and Substance Use Disorders,” we will discuss realistic ways that providers can work together to improve the care these patients receive.

Before we begin our discussion, let’s start by defining a few terms that will be referenced going forward:

  1. Bias: an attitude or belief that is prejudicial in favor of or against a particular group. (6)
  2. Explicit bias (conscious bias): preferences, beliefs, and attitudes of which people are generally consciously aware, endorsed, and can be identified and communicated. (8)
  3. Implicit bias (unconscious bias): unconscious mental processes that lead to associations and reactions that are automatic and without intention. (5) They develop over time through life experiences and tend to be based on stereotypes.
  4. Cognitive bias: a systematic error in the way individuals reason due to a subjective perception of reality. It involves how we interpret information based on our beliefs and experiences. (7) It is based in the dual process theory which accounts for two ways that our brain makes decisions. The first is an automatic process using past experiences. The second is more rule-based and analytical. Our brain naturally takes “shortcuts” to make daily decisions. However, with these shortcuts, cognitive bias can occur.
  5. Stereotype: a widely held but fixed and oversimplified image or idea of a particular type of person or thing. (6)
  6. Stigma: a mark of disgrace associated with a particular circumstance, quality, or person. (6)

Explicit and Implicit Bias

Both explicit and implicit bias are well-known in the general lexicon and are included in a lot of conversation and research regarding race, gender, and sexual minority discrimination. In the healthcare setting, explicit and implicit biases are detrimental to patient care. Studies show explicit biases are a predictor of more negative patient prognoses. (8) Many studies also show that when providers self-report low explicit bias, implicit bias can still be a factor in their clinical decisions. (9)

Although this article will primarily focus on general mental health stigma and bias, it is important to acknowledge that implicit bias about factors such as socioeconomic status, race, and gender/sexual minorities can exacerbate the disparity that we see in mental health patients.

Cognitive bias

There are many different types of cognitive biases that may apply to providers and potentially influence how we care for patients with mental health and substance use disorders. The following list is not exhaustive, but includes a few common examples that have been researched:

  1. Premature closure occurs when a presumed diagnosis is accepted before it has been completely established. (3) For example, a patient may present with palpitations and shortness of breath. Because the EKG may show no abnormalities, the diagnosis of “anxiety” is given rather than completing the appropriate diagnostic workup. Remember that many of the diagnoses in the DSM V are diagnoses of exclusion. This means that an appropriate assessment of the chief complaint and related symptoms should be thoroughly explored prior to giving these diagnoses. Symptoms associated with anxiety disorders, for example, can be confused with many other conditions, such as hyperthyroidism, arrhythmias, pheochromocytoma, and other illnesses. Additionally, to establish a diagnosis of an anxiety disorder, the patient must meet the other criteria outlined in the DSM V.
  2. Anchoring bias occurs when one relies heavily on information that is discovered early in the clinical reasoning process. (11) With this bias, a clinician may continue to rank a hypothesis high despite conflicting evidence received later in the process. For example, a patient may present with altered mental status and hallucinations. Initially, a schizophrenia spectrum disorder is ranked higher on the differential. However, despite conflicting evidence such as negative mental health history, positive neurological deficits, and other signs of physical illness, the schizophrenia spectrum disorder remains highest on the differential because of the hallucinations. This type of bias may, again, lead to inappropriate work-up based on flawed clinical reasoning.
  3. Diagnostic Overshadowing is a term that describes a phenomenon where individuals with intellectual disabilities and mental illnesses are assessed less accurately due to the tendency of clinicians to attribute symptoms to a patient’s intellectual disability or comorbid mental illness. (3, 12) An example of diagnostic overshadowing would be a patient with a history of major depressive disorder (MDD) presenting to a clinic with signs and symptoms of torn meniscus. When the provider realizes the patient has MDD, diagnostic overshadowing would occur if the provider attributed the patient’s pain to their mental health condition rather than further investigating the signs in a way that they normally would for other patients. This can manifest as misdiagnosis, inappropriately changing the treatment plan, and increased burden on the patient with clinical outcomes (including more cost, decreased quality of life, and higher mortality rates). (13, 29)

Stigma

Stigma is a barrier to care that can affect not only the type of care patients receive, but also their access to care and outcomes. The literature involving mental health stigma explores the different types of stigma that may affect patients, including structural stigma, interpersonal stigma, and intrapersonal stigma. Structural stigma occurs at an institutional level. It could be embedded in our processes in the hospital/clinic setting or in how patients are allowed to receive care for mental health via insurance. Interpersonal stigma relates to prejudicial attitudes and behaviors that can affect people with mental illness. An example of this is stigma in the healthcare setting from providers. This can be reflected in some of the “negative” attitudes and beliefs that some healthcare providers may have about patients. Intrapersonal stigma refers to self-stigma, which is commonly cited as a reason that patients may not seek care. (14, 15)

Among healthcare providers, there have been multiple studies demonstrating either equal or more negative stereotypes of people with mental illness than the general population. (15, 19) This trend persists even for mental health care providers.  (15, 16) While psychiatrists tend to have positive views about people with mental illness, they continue to have more desire to socially distance from individuals with mental illness outside of the healthcare setting. (16, 17) A study comparing the views that healthcare providers have about patients with schizophrenia and depression (16, 18) showed providers have an increased desire to socially distance themselves from individuals with schizophrenia compared with depression, demonstrating that some diagnoses can come with more stigma than others.

Schizophrenia is not the only diagnosis that may be more stigmatized. Personality disorders also come with a lot of stigma. Specifically, borderline personality disorder (BPD) has long been known as a disorder that is very stigmatized, especially in the healthcare setting. (20, 22) Studies have shown that providers sometimes have negative viewpoints and use negative language to describe patients carrying this diagnosis. (20, 21) Some behavior exhibited by patients is viewed as “manipulative,” “attention-seeking” and within the patient’s control, rather than a symptom of their disorder. (23) Suicide attempts are often viewed as “attention-seeking” rather than a sign of crisis. (22,23)

There is also structural stigma associated with BPD. This includes the inability to bill for some services if the diagnosis is a personality disorder, and distancing of providers from these patients to create gaps in treatment options. (20, 22) Decreased funding and research for BPD is another type of stigma that has far-reaching effects. These different stigmatizations of borderline personality disorder have led to effects like decreased access to mental healthcare for patients and decreased understanding of the disorder and treatments available. (19)

Another highly stigmatized group is patients who have substance use disorders. Many studies have shown that health professionals can have negative attitudes towards patients with substance use disorders. (25) For example, some providers describe encounters with patients as being challenging or unsafe. (31) Additionally, some providers have the perception that the illness is controllable and that patients have caused their symptoms. (27) There is evidence that bias can be transmitted through language used in the medical record(24)  and a recent study demonstrated that the majority of patients with substance use disorders had at least one note written that contained stigmatizing language. (26)

The stigma experienced by patients with substance use disorders can lead to negative outcomes, including decreased adherence to treatment plans due to patients’ perceived bias, alterations to the treatment plans by the provider, and providers taking a more punitive approach instead of a treatment-oriented approach to care. Stigma on the structural level can result in underfunding for substance treatment programs, restrictive treatment policies, and policies that limit access to evidence-based treatments. (28)

Understanding the types of biases and stigma that patients with mental health and substance use disorders face in healthcare settings is the first step to ensuring these patients receive the care they need and deserve. To learn more about the additional steps providers can take to mitigate bias and stigma in healthcare, read our article, “Approach to Limiting Bias for Patients with Mental Health and Substance Use Disorders.”

Works Cited:
  1. https://www.who.int/health-topics/mental-health#tab=tab_2
  2. WHO – https://www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide
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  29. Geiss, M, Chamberlain, J, Edmonson, D; Diagnostic Overshadowing of the Psychiatric Population in the Emergency Department: Physiological Factors Identified for an Early Warning System

 

Megan Pinder graduated from the Wake Forest Department of PA Studies in 2017. Since that time, she has worked as a practicing PA in multiple psychiatry settings. She is currently on faculty at the Wake Forest PA program and works for an outpatient psychiatry clinic in Winston-Salem, North Carolina.