The Stigma of Mental Illness in Primary Health Care Physicians Research Paper

Introduction

Mental illness refers to all detectable mental dysfunctions that are characterized by atypical cognition, mood, or manners that lead to suffering and impaired function (Winer, Morris-Patterson, Smart, Bijan, & Katz, 2013). Stigma, on the other hand, is defined as a symbol of disgrace or disrepute; a stain or mark of blame (Pope, 2011). It manifests as prejudices against mentally ill patients. Although stigma is a damaging situation, the alienation thereof is much worse. Stigma may be categorized as self-stigma or perceived stigma. Self-stigma includes areas such as personal, social, hereditary, medical, and treatment of illness (Yang & Link, 2015). On the other hand, perceived stigma denotes how patients view the stigma that impacts the ability to cope with the emotional and physical effects of the disorder. This paper explores if the mental health care providers feel the social stigma experienced by their patients and if so what are the repercussions or importance of that. If that is the case, a suitable scale – with items related exactly to the role of primary care physician – to measure attitudes towards these patients will also be discussed. Therefore, the paper is confined to the various aspects of self-stigma.

Background information

Mentally ill people experience health challenges that lead to high morbidity rates and premature death compared to sane cohorts. This situation may be due to health system inadequacies like the lack of integrated care services or inadequate health insurance coverage. However, studies have also implicated poor decision-making by some physicians as another source of worsening health outcomes among these patients (Ayalon, Karkabi, Bleichman, Fleischmann, & Goldfracht, 2016). Even though the quality and efficiency of mental health care and services have improved over the past decade, therapeutic approaches have not been able to minimize stigma associated with these disorders in society as well as among physicians.

Persons with mental disorders are stigmatised by the society and even by the health care givers. In this case, stigma manifests as a partiality in treatment or in patient-centred care delivery due to preconceived notions and beliefs about mental illness. Corrigan et al. (2016) noted that during the dispensation of health care to patients, physicians discriminated the patients with mental disorders in areas like referring patients for mammography, inpatient admission after diabetic crisis, and cardiac catheterisation. These patients have less regular preventive services and are barred from receiving optimal treatment based on the principles of care. That is unfortunate since stigma is one of the risk factors associated with poor mental health outcomes (Corrigan et al., 2016). It accounts for treatment seeking delays and diminishes the chances of mentally ill patient receiving adequate care.

Mentally ill patients may fail to benefit from primary health care services if they realise that the care givers have prejudices over them. Shrivastava, Johnson, and Bureau (2012), observed that “prevalent stigma is the likely cause of direct disability and indirect economic implications’ (p.82). As such, these patients will not comply with the medication and psychosocial treatment, which increases the chances of costly recrudescence and re-hospitalisation. Thus, stigma can be a result of reduced trust in the very institutions and persons who the patients rely on as the ultimate source of help and hope in their situation.

Causes of Stigma

Stigma originates from several sources that operate synergistically and may cause deleterious impacts on a person’s life. First of all, the traditional practice of separating mental health management system from the normal healthcare could intensify stigma. Other factors such as the “lack of education, perception, or awareness and the nature and complications of the mental illness, for instance, odd behaviours and violence”, are also culpable (Shrivastava et al., 2012, p. 83). For example, a patient with schizophrenia is likely to experience high rates of segregation due to a lack of awareness about the condition, the nature of the disease itself, behavioural signs associated with it, and drug related complications.

Negative views towards mental illnesses also contribute to stigma. Examples may include treating mentally ill persons as outcasts, superstitious beliefs about mental disorders, and indifference towards people with mental illness (Shim & Rust, 2013). The other factors implicated in poor mental health stigma include inadequate mental healthcare, fear of working with persons with mental ailments, and the general unwillingness to provide mental health care (Shim & Rust, 2013). From the stance of the patients themselves, stigma is perceived to emanate from the attitudes in the general population, co-workers, and family members.

Stigma among Physicians

Health trainees and graduate health care providers are vital targets for assessment and for likely involvement in interventions to address stigma and promote more broadminded, tolerant, and positive views towards mentally ill patients (Stefanovics et al., 2016). Majority of past studies have verified that the mental health providers hold more optimistic views about mental illness than the lay public does (Stefanovics et al., 2016). However, in other studies, medics have shown more negative attitudes than the public does, a very unfortunate situation given that the physicians are accountable for providing care and for enlightening the general population about mental illness (Shim & Rust, 2013).

Provider stigma bears a significant influence on the health care decisions of patients with mental disorders. Probably, perceptions about the ability of these patients to adhere to treatment connect between physician stigma and the health care decisions made. Those medics with stigmatising outlooks may believe that mentally ill patients are unable to comply with certain types of treatment recommendations. If so, such providers may be unwilling to offer those kinds of treatment to the patients. Further, a physician’s familiarity with mental illness may lessen their endorsing of the stigma of mental illness. Thus, the provider’s discipline may moderate the stigma’s effects on treatment outcome. In other words, it is anticipated that nurses and physicians with the mental health training should show less stigma against mentally ill-patients than the primary care providers do.

However, evidence points to the contrary, as mental health physicians may approve stigma equal or greater than that shown by other medical professions. In an effort to validate the impact of mental health stigma on treatment decisions, Corrigan et al. (2016) did a sample survey on 166 physicians (42.2% from the primary care and the rest from mental health practice) in which the participants filled in data on stigma characteristics, expected treatment compliance, and resultant health decisions about a male schizophrenic person that was seeking treatment for arthritic back pains. They found out that providers who approve stigmatising views about mental disorders were very pessimistic about the ability of mentally ill patients to adhere to treatment (Corrigan et al., 2016). Interestingly, professional training did not seem to determine the level of stigmatisation accorded to the patient (Corrigan et al., 2016). These findings suggest that stigma exists among both the primary care and mental health providers and that there should be integrated efforts to target these groups in order to lessen the gaps in clinical practice.

Indeed, there is a large inequality in the medical care of patients with severe mental ailments as compared to people without these conditions. Pope (2011) noted that in these persons, “many medical comorbidities are often missed and more than half of their chronic medical conditions remain undiagnosed” (p. 29). Despite the fact that people with mental disorders have high rates of physical ailments, evidence points to the fact that many of them go undetected. The reason is that health complaints by mentally ill patients are held as psychosomatic.

The quality, not quantity, of contact between the physicians and the patients is of significance when dealing with patients with mental ailments, particularly when interactions occur on inpatient psychiatric units. Evidence points to the fact that physicians who work primarily in inpatient psychiatric hospital locations where the patients are severely ill experience an increased social distance between them and the patients (Stefanovics et al., 2016). In cultures and settings where caring for the patients with mental disorders is chiefly the responsibility of the families of the patients, the primary care providers have increased stigma of these disorders due to reduced socialisation and normalising factors. Stefanovics et al. (2016) observed that the low status accorded to mental health workers in some communities, e.g., China, makes them to be stigmatised and reluctant to work in the psychiatric profession.

On the other extreme, the phenomenon of physicians identifying with their patients causes parallel emotional experiences that can lead to social distancing between the health care providers and the patients. Cases of physicians experiencing mental perturbation when dealing with patients who suffer from anxiety, depression, and fear are common. Knowledge of episodes of such negative emotional reactions is important because treating patients with mental ailments serves nothing except to widen the gap between primary givers and the patients. Other ways through which stigmatisation occurs are lack of social responsibility, empathy, and compassion for the mentally ill patients.

Importance

Exploring the existence of stigma among general physicians is important as patients are more inclined to “seek mental health treatment in primary health care setting instead of psychiatric settings due to the stigma associated with the mental health diagnoses” (Yin et al., 2014, p. 114). Moreover, patients first present to primary care, which is the first point contact with the healthcare system. Thus, there is a need for a bi-directional combination of the primary health care into public mental health centers and other specialty behavioural health settings. In addition, efforts to include prevention plans into the primary health care system could serve to minimise stigma linked to the detection and treatment of these disorders.

The importance of combining behavioural health and primary care can be comprehended from the following aims: first, to promote the patient experience, i.e., satisfaction and quality of care, second, to improve the health of the masses, and third, to minimise the cost of health care (Yin et al., 2014). Within the primary health care set up, effective screening for behavioural health problems is necessary in order to encourage patients and develop the confidence and willingness to open up and share individual mental anxieties. In fact, many joint care approaches have revealed that many mental health patients can be effectively engaged within the primary care setting. Therefore, effective physician communication is critical in addressing the healthcare needs of mentally ill patients.

The Scale

As documented in literature, efforts to measure attitudes towards people with mental illnesses have been through the use of stigma components. In particular, stereotypes such as ‘people with mental illness are potentially violent’, ‘people with mental illness are unlikely to recover’, and the desire for social distance are common (Kassam, Papish, Modgill, & Patten, 2012). Similarly, stigma can also be measured by considering emotional responses towards these patients. In addition, disclosing that one has mental illness can be an indicator of stigma that is related to mental disorders (Kassam et al., 2012). The important parameter to consider while deciding on the suitable scale to use while measuring mental illness stigma among primary health care physicians is disclosure, as it is a clear indicator of whether the respondent holds stigmatising views towards mental ailments.

Those who are free to disclose their mental health status do not consider mental illness as a condition to be ashamed of and are less stigmatising. A better way of measuring stigma is necessary, as stigma among health care givers varies from other types of stigmas held by other groups. For instance, people with mental disorders have poorer physical health, a situation partly attributed to physicians wrongly associating the physical signs felt by the patient to the mental disorder itself. Whereas a comprehensive assessment gives detailed patient information, a brief questionnaire can provide a concise picture of the problem.

The affiliate stigma scale is appropriate for measuring mental illness stigma among primary caregivers due to the following reasons: first, its psychometric features have been surveyed using the Rasch analysis and the classical test theory, and second, the facts show that it is valid, feasible , and applicable to various populations, including people with intellectual disabilities, people with dementia, schizophrenics, and those with mood swings (Chang et al., 2015). It is a 22- item scale that measures “the caregivers’ stress, burden, and positive perceptions in caring for the consumer” (Chang, Su, & Lin, 2016, p. 116). The items are graded on a 4-point Likert scale that has three domains: 7 cognitive items, 7 affective items, and 8 items on behavior (Chang et al., 2016). Under this scale, a higher score would indicate a higher level of stigma. It has good internal consistency, person separation reliability, and predictive as well as concurrent validity. This makes it a robust tool for measuring stigma among mental healthcare providers.

Conclusion

Stigma among primary health care physicians exists. This fact is important to consider, especially in the current medical practice where there has been a tendency to integrate the mental health care into the primary health care system. The affiliate stigma scale provides a better foundation for more validation and as a device for use in the evaluation programs intended to minimise mental illness associated with stigma among the general physicians. The reduction in this stigma will certainly translate into better patient outcomes and reduce patient mortality as well as the economic burdens involved.

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