Psychiatric Rehabilitation Journal 2014, Vol. 37, No. 4, 297–303
In the public domain http://dx.doi.org/10.1037/prj0000095
Healthcare Providers’ Attitudes Toward Persons With Schizophrenia Dinesh Mittal
Patrick Corrigan
Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, and University of Arkansas for Medical Sciences
Illinois Institute of Technology
Michelle D. Sherman
Lakshminarayana Chekuri
University of Minnesota
University of Arkansas for Medical Sciences
Xiaotong Han and Christina Reaves
Snigdha Mukherjee
Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, and University of Arkansas for Medical Sciences
Louisiana Public Health Institute, New Orleans, Louisiana
Scott Morris
Greer Sullivan
Illinois Institute of Technology
Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, and University of Arkansas for Medical Sciences
Objective: This study compared the attitudes of mental health and primary care providers toward persons with schizophrenia at 5 Veterans Affairs (VA) facilities. Method: This study utilized a cross-sectional anonymous survey, including clinical vignettes describing identical patient scenarios for a hypothetical patient with and without schizophrenia, to examine the differences in attitudes of primary care and mental health providers. The survey was distributed in 3 waves from August 2011 to April 2012. Participants included 351 VA providers from 5 VA medical centers, including 205 mental health providers (psychiatrists, psychologists, and mental health nurses) and 146 primary care providers (nurses and physicians). Providers’ attitudes were assessed on 3 domains, including social distance, stereotyping, and attribution of mental illness. Results: Primary care providers had significantly more negative attitudes toward the vignette patient with schizophrenia compared with the patient without schizophrenia on 2 of 3 attitude measures (stereotyping and attribution of mental illness); however, this difference was not observed for mental health providers on the 2 measures. Conclusions and Implication for Practice: Primary care providers’ negative attitudes toward individuals with schizophrenia represent a potential target for interventions to reduce disparities in care for individuals with schizophrenia. Keywords: schizophrenia, serious mental illness, stigma, provider attitudes, vignette study Supplemental materials: http://dx.doi.org/10.1037/prj0000095.supp
This article was published Online First October 13, 2014. Dinesh Mittal, MD, VA South Central Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, and Department of Psychiatry Division of Health Services Research, University of Arkansas for Medical Sciences; Patrick Corrigan, PsyD, College of Psychology, Illinois Institute of Technology; Michelle D. Sherman, PhD, Department of Family Social Science, University of Minnesota; Lakshminarayana Chekuri, MD, Department of Psychiatry, Division of Health Services Research, University of Arkansas for Medical Sciences; Xiaotong Han, MS, VA South Central Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, and Department of Psychiatry, Division of Health Services Research, University of Arkansas for Medical Sciences; Christina Reaves, MPH, VA South Central Mental Illness Research, Education, and Clinical Center, Cen-
tral Arkansas Veterans Healthcare System, and Department of Psychiatry, Division of Health Services Research and Translational Research Institute, University of Arkansas for Medical Sciences; Snigdha Mukherjee, PhD, Division of Evaluation and Research, Louisiana Public Health Institute, New Orleans, Louisiana; Scott Morris, PhD, College of Psychology, Illinois Institute of Technology; Greer Sullivan, MD, MSPH, VA South Central Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, and Translational Research Institute, University of Arkansas for Medical Sciences. Correspondence concerning this article should be addressed to Dinesh Mittal, MD, Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, Building 58 (152/NLR), North Little Rock, AR 72114. E-mail: [email protected] 297
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Negative attitudes of primary care providers and mental health providers may contribute to disparities in physical healthcare for persons with serious mental illness (SMI) such as schizophrenia (De Hert et al., 2011; Druss, Bradford, Rosenheck, Radford, & Krumholz, 2000; Koroukian, Bakaki, Golchin, Tyler, & Loue, 2012; Li, Cai, & Cram, 2011; Lord, Malone, & Mitchell, 2010; Mitchell, Lord, & Malone, 2012; Thornicroft, Brohan, Rose, Sartorius, & Leese, 2009). Relative to those without mental illness, persons with SMI have higher mortality (Kilbourne, Ignacio, Kim, & Blow, 2009) and physical comorbidity (Jeste, Gladsjo, Lindamer, & Lacro, 1996), and receive suboptimal physical and preventive healthcare. (De Hert et al., 2011; Druss, Rosenheck, Desai, & Perlin, 2002; Kilbourne, Welsh, McCarthy, Post, & Blow, 2008; Li et al., 2011; Lord et al., 2010; Mitchell & Lord, 2010; Viron & Stern, 2010). For example, individuals with comorbid SMI are substantially less likely to receive cardiovascular revascularization procedures (Druss et al., 2000), women with mental illness are less likely to receive mammography (Koroukian et al., 2012), and patients with schizophrenia who are obese are less likely to be referred for weight management programs (Mittal et al., 2013). However, some studies found quality of care for people with SMI was comparable with or better than care for persons without SMI (Leung, Zhang, Lin, & Clark, 2011). Although the reasons for these differences are complex, healthcare providers’ negative attitudes and behaviors and lower expectations toward persons with SMI have been suggested as one factor (Caldwell & Jorm, 2001; De Hert et al., 2011; Druss et al., 2000; Graber et al., 2000; Hugo, 2001; Jorm, Korten, Jacomb, Christensen, & Henderson, 1999; Kilbourne et al., 2008; Mitchell et al., 2012; Mittal et al., 2013). Most studies comparing healthcare professionals’ attitudes toward people with mental illness with those of the general public have found few differences on standard stigma measures such as desire for social distance (Lauber, Nordt, Braunschweig, & Rossler, 2006; Nordt, Rossler, & Lauber, 2006; Schulze, 2007) and endorsement of negative stereotypes (Magliano, Fiorillo, De Rosa, Malangone, & Maj, 2004; Nordt et al., 2006). A few studies reported that healthcare professionals had more positive views than the public regarding prognosis, psychiatric treatment and patients’ civil rights (Lauber, Nordt, Falcato, & Rössler, 2004; Nordt et al., 2006), whereas other studies (Caldwell & Jorm, 2001; Hugo, 2001; Jorm et al., 1999; Magliano et al., 2004; Nordt et al., 2006), found that mental health providers espouse more negative attitudes than the general public in that they stereotype persons with mental illness more and desire greater social distance. Research comparing attitudes of primary care providers with mental health professionals is especially sparse. Overall, findings suggest that primary care providers, relative to mental health providers, have a more negative view (prognosis and dangerousness) of persons with schizophrenia (Bjorkman, Angelman, & Jonsson, 2008; Caldwell & Jorm, 2001; Hori, Richards, Kawamoto, & Kunugi, 2011; Hugo, 2001). Because a majority of these studies reported attitudes of European and Australian providers and only a few of the studies focused on attitudes held by U.S. healthcare providers, (Kua, Parker, Lee, & Jorm, 2000; Nordt et al., 2006; Wilson & Read, 2001) we assessed the attitudes of VA primary care (primary care nurses and physicians) and mental health providers (mental health nurses, psychiatrists, and psychologists) toward persons diagnosed
with schizophrenia. We hypothesized that healthcare providers would have more negative attitudes toward patients with schizophrenia than toward patients without schizophrenia, and that the effect of patient diagnosis of schizophrenia on attitudes would be moderated by the type of provider. Specifically, we hypothesized that primary care providers would have more negative attitudes toward patients with schizophrenia than toward patients without schizophrenia, but mental health providers’ attitudes would not differ across the two patient types.
Method The data for the current study were collected as part of a larger study examining provider attitudes toward patients with schizophrenia (Mittal et al., 2013). Between August 2011 and April 2012, we surveyed 351 healthcare providers (67 mental health nurses, 62 psychiatrists, 76 psychologists, 91 primary care nurses, and 55 primary care physicians), employed by five Veterans Affairs (VA) hospitals in the southeast and south central areas of the United States. Each participant completed a survey that included a vignette describing a patient, followed by a series of demographic and attitudinal measures. The surveys were identical except that one vignette included the diagnosis of schizophrenia and the other did not. The vignette was intended to depict a person who had been functioning well socially and vocationally for several years (see Supplement 1). Each provider completed only one of the two surveys (hypothetical patient with or without schizophrenia). The study was approved by the VA Central Institutional Review Board (IRB). The IRB allowed the waiver of the documentation of the informed consent to maximize the privacy of the participants. Providers who volunteered to complete the survey were given an information sheet describing all aspects of the informed consent. No incentive was offered. Surveys were distributed during regularly scheduled staff meetings, some with single type of provider and some with mixed provider groups. Research assistants (RAs) from each site requested surveys from the coordinating site based on the estimated number of attendees at these staff meetings. Surveys were returned using preaddressed, postage-paid envelopes anonymously to the site study coordinator. When the coordinating site sent surveys to sites RAs, the surveys were packaged with alternating versions of surveys (i.e., different vignette version). RAs were instructed to distribute the surveys from the packaged stack so that roughly equal numbers of each survey version were distributed. This system also ensured an essentially random distribution among providers. As the coordinating site received completed surveys, they tracked the response rate for each of the four provider groups (primary care physicians and nurses and psychiatrists and psychiatric nurses) and by the two survey versions. If significantly more or less of one survey version was returned from a site, we weighted the next round of surveys sent to the site with more or less of that version. Similarly, recruiting targets were adjusted over time to compensate for uneven response rates from the different provider groups. Later, we added psychologists to the study and collected data in a similar manner. In all, 710 surveys were distributed to volunteer respondents and 358 were returned. We excluded seven surveys from the analysis because of missing provider group.
HEALTHCARE PROVIDERS’ ATTITUDES
Measures We measured stigmatizing attitudes and beliefs using the characteristic scale (Olmsted & Durham, 1976), attribution questionnaire (Corrigan et al., 2002), and a social distance scale (The National Data Program for the Sciences & University of Chicago, 2013). Characteristic scale. Provider stereotyping was measured using a semantics differential scale (characteristic scale; Olmsted & Durham, 1976) in which respondents rated the qualities of the hypothetical patient on a 7-point scale of quality pairs, such as dangerous–safe (see Table 1 for items). The nine items were summed to create an overall scale representing the “stereotype characteristics scale.” Higher scores denote more negative attitudes. Attribution questionnaire. We used eight of the original nine items on the attribution questionnaire (AQ-9; Corrigan et al., 2002) to assess affective behavioral and cognitive reactions to a vignette on a 9-point response scale (1 ⫽ not at all, 9 ⫽ very much). The ninth question was not applicable to our study. Exploratory factor analysis identified six items as defining a single factor, and the confirmatory factor analysis confirmed an adequate fit (see Table 1 for items). The six items were summed to create an overall scale. Higher scores denote a more negative attribution.
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Social distance scale. We measured desire for social distance using five items with a 4-point response scale. Items were drawn from the General Social Survey (The National Data Program for the Sciences & University of Chicago, 2013) and summed to create the social distance scale (see Table 1 for items). A higher score on this scale denotes greater desire for social distance and therefore a more negative attitude. Covariates. Several potential confounding variables were measured and included in the analysis as covariates. Covariates included provider years in clinical practice, data collection site (with a total of five), and demographic variables including provider age (⬍30, 31– 40, 41–50, 51– 60, and ⬎60), gender and race (White vs. non-White).
Data Analysis The majority of variables had some missing values. Therefore multiple imputations (Rubin, 1976) were conducted using the SAS MI procedure. Analyses were repeated for each of five imputed dataset and then combined using the SAS MIANALYZE procedure. Descriptive statistics were calculated for all variables. Vignette type (schizophrenia vs. no schizophrenia) was the independent variable and provider group (primary care providers, which included primary care nurses and physicians, and mental health providers,
Table 1 Summary Measures Construct Social distance
Measure
Items
Bogardus Social Distance Scale
Assuming this patient was not a patient of yours, how willing would you be to move next door to this patient? Assuming this patient was not a patient of yours, how willing would you be to spend an evening socializing with this patient? Assuming this patient was not a patient of yours, how willing would you be to make friends with this patient? Assuming this patient was not a patient of yours, how willing would you be to have this patient start working closely with you on a job? Assuming this patient was not a patient of yours, how willing would you be to have this patient marry into your family? Valuable (1)–Worthless (7) Clean (1)–Dirty (7) Sincere (1)–Insincere (7) Safe (1)–Dangerous (7) Warm (1)–Cold (7) Wise (1)–Foolish (7) Strong (1)–Weak (7) Predictable (1)–Unpredictable (7) Tense (1)–Relaxed (7) I would think that it was [the patient’s] own fault that he is in the present condition. I would think that [the patient] is dangerous. I would think that [the patient] should be forced into treatment with his doctor even if he does not want treatment. I would be angry with [the patient]. I would be scared of [the patient]. I would try to stay away from [the patient].
Stereotypes
Characteristic scale
Attribution of Mental Illness
Attribution Questionnaire (AQ-9)
Range of scores
Alpha reliability
5–20
.86
1–7
9–63
.83
1–9
6–54
.76
Item scale 1–4 1 ⫽ Definitely willing 4 ⫽ Definitely unwilling
1 ⫽ Not at all 9 ⫽ Very much
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which included mental health nurses, psychiatrist, and psychologist) was the moderator, along with the interaction between vignette type and provider group as hypothesized. Covariates included provider gender, age, and race; provider years in clinical practice; and site. The dependent variables included three measures of provider attitudes: social distance, stereotype characteristics scale, and attribution of mental illness. Because each outcome represented a distinct construct, each was examined in a separate analysis. For each dependent variable, we first visually inspected its histogram to determine if the variable was approximately normally distributed. For social distance and the stereotype characteristics scale, where the normality assumption was met, a general linear model was fit. For attribution of mental illness, the distribution was positively skewed and we used a generalized linear model with a log link and gamma distribution. Predicted means (LSMEANS) from each of the three models were calculated for each vignette type and provider group with the continuous covariates set at their mean values and categorical covariates set at one divided by number of the groups. SAS® Version 9.3 was used.
Results The majority of our sample was White (63%), female (65%), and on average, had approximately 17 years of clinical practice. Demographic and clinical characteristics of the two provider groups are reported in Table 2, with significant differences found between the two provider groups for all variables in the table except for gender and age. Results from regression models examining the association of each provider attitude measure with vignette type and provider group are presented in Table 3. Predicted means (LSMEANS) from each of the three models are presented for each of the
vignette type and provider group in Table 4. There was a significant interaction between the provider group and the vignette type for the stereotype characteristics scale (t ⫽ ⫺2.70, p ⫽ .007), indicating that the effect of the vignette was different for primary care providers and mental health providers. Specifically, only primary care providers had significantly more negative stereotypes toward a patient with schizophrenia than toward a patient without schizophrenia (mean difference ⫽ 5.06, p ⬍ .001). This pattern was not observed for mental health providers. The interaction between vignette type and provider group was also significant for the attribution of mental illness (t ⫽ ⫺1.97, p ⫽ .049), and the pattern was similar to that found for the stereotype characteristics scale. Specifically, only primary care providers had more negative attributions about a patient with schizophrenia than about a patient without schizophrenia (mean difference ⫽ 2.14, p ⬍ .01). In contrast, the difference between the vignettes on attributions was not significant for mental health providers. For the Social Distance Scale, the interaction between vignette type and provider group was not significant (t ⫽ ⫺0.11, p ⫽ .91). This implies that the vignette type effect was consistent for the two provider groups. We then excluded the interaction between vignette type and provider group from the model and examined the main effect of vignette type (data not shown). A significant main effect was found for vignette type (t ⫽ 2.37, p ⫽ .02). All provider groups desired more social distance from patients with schizophrenia (LSMEAN ⫽ 11.27) than from patients without schizophrenia (LSMEAN ⫽ 10.44). For all three dependent variables, we examined the vignette effect for the provider subgroups within the primary care (primary care nurses and primary care physicians) and mental health (mental health nurses, psychologists, and psychiatrists) groups.
Table 2 Descriptive Statistics by Provider Group
Variable Vignetteⴱ Nonschizophrenia Schizophrenia Gender Female Male Age Less than 30 years old Between 31 and 40 years old Between 41 and 50 years old Between 51 and 60 years old Over 60 years old Whiteⴱ Years in clinical practice (mean/SD)ⴱ Provider attitudes Social distance (mean/SD), range ⫽ 5–20ⴱ Provider stereotyping (mean/SD), range ⫽ 9–63ⴱ Attribution of mental illness (mean/SD), range ⫽ 6–54ⴱ
Primary care providers N (%)
Mental health providers N (%)
Total
146 (41.6)
205 (58.4)
351 (100)
76 (52.05) 70 (47.95)
83 (40.49) 122 (59.51)
159 (45.30) 192 (54.70)
97 (66.44) 49 (33.56)
132 (64.39) 73 (35.61)
229 (65.24) 122 (34.76)
6 (4.11) 31 (21.23) 35 (23.97) 52 (35.62) 22 (15.07) 50.82% 19.00 (17.37)
13 (6.34) 61 (29.76) 46 (22.44) 60 (29.27) 25 (12.20) 71.12% 15.76 (15.11)
19 (5.41) 92 (26.21) 81 (23.08) 112 (31.91) 47 (13.39) 62.68% 17.10 (11.49)
11.59 (4.92) 28.64 (14.00) 11.00 (9.42)
10.62 (4.29) 26.49 (9.88) 9.18 (5.32)
11.02 (3.21) 27.39 (8.25) 9.94 (5.07)
Note. For those variables with multiple imputation used, the exact frequencies cannot be obtained, so only percentages were presented. Those variables started with “White.” ⴱ p ⬍ .05 for the bivariate analysis between the two groups of providers and each variable above.
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Table 3 Regression Models for Relationship of Vignette Type and Provider Attitudes (n ⫽ 351) Provider attitudes Parameter (SE) Social distance Vignette type Schizophrenia vs. nonschizophrenia Provider group Mental health vs. primary care Vignette typeⴱprovider group
Stereotyping
0.88 (0.51)
5.06 (1.31)ⴱⴱ
⫺0.81 (0.51) ⫺0.08 (0.73)
0.40 (1.28) ⫺4.67 (1.73)ⴱⴱ
Attribution (log link with gamma distribution) 0.18 (0.07)ⴱⴱ ⫺0.09 (0.06) ⫺0.17 (0.09)ⴱ
Note. All the models included the following covariates: site, gender, age, race, and years in clinical practice. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01.
On the stereotype characteristic scale, both primary care physicians (p ⬍ .05) and primary care nurses (p ⬍ .05) expressed more negative stereotypes toward the individual with schizophrenia than toward the individual without schizophrenia; the difference was not significant for any of the mental health providers. On attribution of mental illness scale, only primary care nurses made more negative attributions toward the individual with schizophrenia than toward the individual without schizophrenia (p ⬍ .05); the difference was not significant for primary care physicians or any of the mental health providers. For the social distance model, both primary care physicians and psychiatrists showed more social distance toward the individual with schizophrenia than toward individual without schizophrenia (p ⬍ .05 for both). The difference was not significant for primary care nurses, mental health nurses, or psychologists.
Discussion Consistent with our hypothesis, primary care providers reported a significantly more negative attitude toward individuals with schizophrenia compared with those without schizophrenia on two of the three attitudinal variables (stereotyping and attribution of mental illness). In contrast, these two attitude scores did not significantly differ across the two vignettes for mental health providers. These findings of primary care providers having more negative views of individuals with schizophrenia are consistent with the existing literature (Bjorkman et al., 2008; Caldwell & Jorm, 2001; Hori et al., 2011; Hugo, 2001). On social distance however, both provider groups showed similar patterns regarding vignette type, with both wanting greater social distance from individuals with schizophrenia than from individuals without
Table 4 Predicted Means (LSMEANS) From Regression Models for Each Vignette Type and Provider Group Provider attitudes Social distance
Provider group Schizophrenia Nonschizophrenia
Mental health Primary care Provider stereotyping Mental health Primary careⴱ Attribution Mental health Primary careⴱ ⴱ
10.83 11.72 26.80 31.08 9.91 12.86
p ⬍ .01 between schizophrenia and nonschizophrenia.
10.03 10.84 26.41 26.02 9.79 10.72
schizophrenia which is consistent with the findings of Caldwell and Jorm (Caldwell & Jorm, 2001). Why do primary care providers have more negative attitudes toward individuals with schizophrenia compared with individuals without schizophrenia? This finding may be understood based on existing conceptual frameworks for public stigma. Classic labeling theory (Scheff, 1966) posits that negative stereotypes are triggered when a person is labeled as mentally ill. Holding a negative belief does not necessarily result in any unacceptable behavior (Jussim, Nelson, Manis, & Soffin, 1995). Only those individuals who endorse and validate such negative stereotypes are prone to prejudice which could lead to discriminatory behaviors (Corrigan, Markowitz, Watson, Rowan, & Kubjak, 2003). The attribution model described by Weiner (1995) and the cognitive-affective models tested by Jussim and others (Jussim et al., 1995) further expand this complex interplay between stereotyping, prejudice, and discriminatory behavioral responses. According to Weiner (1995) the stereotyping-prejudice-discrimination pathway is influenced by beliefs about cause, controllability, and individual responsibility. The nature of such beliefs (e.g., attributing the cause to underlying biology/individual choice) would elicit affective reactions such as anger or pity which could influence behavioral responses (help vs. punishment; Corrigan et al., 2003). Primary care providers may endorse more negative attitudes toward individuals with schizophrenia because they have less training about mental illness than mental health providers, less exposure to the recovery model that emphasizes strengths rather than disabilities among individuals with mental illness (Davidson, Lawless, & Leary, 2005), less contact with patients with schizophrenia, and likely less exposure to recent research indicating growing rates of recovery from schizophrenia (Lambert et al., 2008). Results from our subgroup analysis add strength to these postulations. For instance, primary care physicians and nurses surveyed in this study reported significantly higher negative stereotypes toward the individual with schizophrenia. Also primary care nurses had significant higher negative attributions for schizophrenia. Previous research clearly indicates that greater contact with individuals with SMI tends to reduce stigmatizing views (Couture & Penn, 2003). Findings from this study suggest that primary care physicians and nurses may need focused interventions to help modify their negative stereotypes and misattributions for schizophrenia. Familiarity with mental illness and contact with an individual with mental illness who has achieved a substantial degree of
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recovery and is able to describe the story of struggles and recovery from mental illness can reduce prejudice and discrimination (Corrigan, 2011; Corrigan, Edwards, Green, Diwan, & Penn, 2001; Corrigan & Watson, 2002) Whether targeting negative stereotypes and attributions would result in minimizing the disparities in delivery of suboptimal physical healthcare to persons with schizophrenia is worth exploring in future studies. It is interesting to note that the subgroup analysis from this study revealed that both primary care physicians and psychiatrists desired more social distance from individuals with schizophrenia. Similar concerns were identified by Stuber, Rocha, Christian, and Link (2014) when they compared attitudes of mental health professionals with those from the general public. Although an increase in familiarity with individuals with mental illness may have helped in mitigating some of their negative stereotypes and attitudes among mental health providers (items on the characteristic scale and attribution questionnaire), a tendency to social distance appears to have persisted despite greater familiarity with patients with schizophrenia. This may be the result of relatively greater exposure to sicker patients with schizophrenia that can lead to negative generalizations toward all patients with schizophrenia (Cohen & Cohen, 1984). Pescosolido, Medina, Martin, and Long (2013) refer to larger cultural beliefs, attitudes, and opinions about mental illness as a “backbone” of prevailing myths among the providers and general public. Historically, medical textbooks describe patients with schizophrenia having a progressively deteriorating course with little hope of remission (Sadock & Sadock, 2007). Contrasting this information with newer research, Zipursky et al. concluded from their review that only 25% of patients with schizophrenia experience deteriorating course, while others demonstrate significant ability to recover (Zipursky, Reilly, & Murray, 2013). Interventions that combine both educational- and contact-based approaches with providers who have achieved substantial recovery from mental illness may be especially valuable to promote affirming attitudes among providers.
Limitations Because the current study examined providers working in VA, the findings may not generalize to providers working in other settings. VA tends to provide an integrated system of care to a greater extent than other systems, and this may lead practitioners to interact with individuals with schizophrenia differently than in non-VA settings. At the same time, VA represents the training site for many physicians in the community. Therefore, it would not be surprising to find similar attitudes expressed in other healthcare settings. Further, the generalizability of the study findings may be limited by the suboptimal response rate, with only 50% of the distributed surveys returned. However, 50% rates are typical for organizational survey research (Baruch & Holtom, 2008). Notwithstanding study limitations, these results point to the need to preferentially tailor interventions toward primary care providers to meet their unique needs. Effective interventions exist to reduce negative attitudes about persons with schizophrenia in the general population (Corrigan, Morris, Michaels, Rafacz, & Rüsch, 2012); however, our review of the literature did not find interventions tailored specifically for healthcare providers. Furthermore, to further explore how biological and environmental etiological factors influence provider attitudes, future research efforts may explore the differences in providers’ attitudes toward mental health diagnostic categories that have
a strong biological predisposition such as schizophrenia as opposed to those more strongly determined by environmental factor such as posttraumatic stress disorder. Lastly, studies that focus on attitudes of providers with lived experience of mental illness toward individuals with schizophrenia represent another area of research that could enhance the literature.
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Received March 6, 2014 Revision received July 1, 2014 Accepted August 5, 2014 䡲
In the public domain http://dx.doi.org/10.1037/prj0000095
Healthcare Providers’ Attitudes Toward Persons With Schizophrenia Dinesh Mittal
Patrick Corrigan
Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, and University of Arkansas for Medical Sciences
Illinois Institute of Technology
Michelle D. Sherman
Lakshminarayana Chekuri
University of Minnesota
University of Arkansas for Medical Sciences
Xiaotong Han and Christina Reaves
Snigdha Mukherjee
Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, and University of Arkansas for Medical Sciences
Louisiana Public Health Institute, New Orleans, Louisiana
Scott Morris
Greer Sullivan
Illinois Institute of Technology
Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, and University of Arkansas for Medical Sciences
Objective: This study compared the attitudes of mental health and primary care providers toward persons with schizophrenia at 5 Veterans Affairs (VA) facilities. Method: This study utilized a cross-sectional anonymous survey, including clinical vignettes describing identical patient scenarios for a hypothetical patient with and without schizophrenia, to examine the differences in attitudes of primary care and mental health providers. The survey was distributed in 3 waves from August 2011 to April 2012. Participants included 351 VA providers from 5 VA medical centers, including 205 mental health providers (psychiatrists, psychologists, and mental health nurses) and 146 primary care providers (nurses and physicians). Providers’ attitudes were assessed on 3 domains, including social distance, stereotyping, and attribution of mental illness. Results: Primary care providers had significantly more negative attitudes toward the vignette patient with schizophrenia compared with the patient without schizophrenia on 2 of 3 attitude measures (stereotyping and attribution of mental illness); however, this difference was not observed for mental health providers on the 2 measures. Conclusions and Implication for Practice: Primary care providers’ negative attitudes toward individuals with schizophrenia represent a potential target for interventions to reduce disparities in care for individuals with schizophrenia. Keywords: schizophrenia, serious mental illness, stigma, provider attitudes, vignette study Supplemental materials: http://dx.doi.org/10.1037/prj0000095.supp
This article was published Online First October 13, 2014. Dinesh Mittal, MD, VA South Central Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, Arkansas, and Department of Psychiatry Division of Health Services Research, University of Arkansas for Medical Sciences; Patrick Corrigan, PsyD, College of Psychology, Illinois Institute of Technology; Michelle D. Sherman, PhD, Department of Family Social Science, University of Minnesota; Lakshminarayana Chekuri, MD, Department of Psychiatry, Division of Health Services Research, University of Arkansas for Medical Sciences; Xiaotong Han, MS, VA South Central Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, and Department of Psychiatry, Division of Health Services Research, University of Arkansas for Medical Sciences; Christina Reaves, MPH, VA South Central Mental Illness Research, Education, and Clinical Center, Cen-
tral Arkansas Veterans Healthcare System, and Department of Psychiatry, Division of Health Services Research and Translational Research Institute, University of Arkansas for Medical Sciences; Snigdha Mukherjee, PhD, Division of Evaluation and Research, Louisiana Public Health Institute, New Orleans, Louisiana; Scott Morris, PhD, College of Psychology, Illinois Institute of Technology; Greer Sullivan, MD, MSPH, VA South Central Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, and Translational Research Institute, University of Arkansas for Medical Sciences. Correspondence concerning this article should be addressed to Dinesh Mittal, MD, Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, Building 58 (152/NLR), North Little Rock, AR 72114. E-mail: [email protected] 297
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Negative attitudes of primary care providers and mental health providers may contribute to disparities in physical healthcare for persons with serious mental illness (SMI) such as schizophrenia (De Hert et al., 2011; Druss, Bradford, Rosenheck, Radford, & Krumholz, 2000; Koroukian, Bakaki, Golchin, Tyler, & Loue, 2012; Li, Cai, & Cram, 2011; Lord, Malone, & Mitchell, 2010; Mitchell, Lord, & Malone, 2012; Thornicroft, Brohan, Rose, Sartorius, & Leese, 2009). Relative to those without mental illness, persons with SMI have higher mortality (Kilbourne, Ignacio, Kim, & Blow, 2009) and physical comorbidity (Jeste, Gladsjo, Lindamer, & Lacro, 1996), and receive suboptimal physical and preventive healthcare. (De Hert et al., 2011; Druss, Rosenheck, Desai, & Perlin, 2002; Kilbourne, Welsh, McCarthy, Post, & Blow, 2008; Li et al., 2011; Lord et al., 2010; Mitchell & Lord, 2010; Viron & Stern, 2010). For example, individuals with comorbid SMI are substantially less likely to receive cardiovascular revascularization procedures (Druss et al., 2000), women with mental illness are less likely to receive mammography (Koroukian et al., 2012), and patients with schizophrenia who are obese are less likely to be referred for weight management programs (Mittal et al., 2013). However, some studies found quality of care for people with SMI was comparable with or better than care for persons without SMI (Leung, Zhang, Lin, & Clark, 2011). Although the reasons for these differences are complex, healthcare providers’ negative attitudes and behaviors and lower expectations toward persons with SMI have been suggested as one factor (Caldwell & Jorm, 2001; De Hert et al., 2011; Druss et al., 2000; Graber et al., 2000; Hugo, 2001; Jorm, Korten, Jacomb, Christensen, & Henderson, 1999; Kilbourne et al., 2008; Mitchell et al., 2012; Mittal et al., 2013). Most studies comparing healthcare professionals’ attitudes toward people with mental illness with those of the general public have found few differences on standard stigma measures such as desire for social distance (Lauber, Nordt, Braunschweig, & Rossler, 2006; Nordt, Rossler, & Lauber, 2006; Schulze, 2007) and endorsement of negative stereotypes (Magliano, Fiorillo, De Rosa, Malangone, & Maj, 2004; Nordt et al., 2006). A few studies reported that healthcare professionals had more positive views than the public regarding prognosis, psychiatric treatment and patients’ civil rights (Lauber, Nordt, Falcato, & Rössler, 2004; Nordt et al., 2006), whereas other studies (Caldwell & Jorm, 2001; Hugo, 2001; Jorm et al., 1999; Magliano et al., 2004; Nordt et al., 2006), found that mental health providers espouse more negative attitudes than the general public in that they stereotype persons with mental illness more and desire greater social distance. Research comparing attitudes of primary care providers with mental health professionals is especially sparse. Overall, findings suggest that primary care providers, relative to mental health providers, have a more negative view (prognosis and dangerousness) of persons with schizophrenia (Bjorkman, Angelman, & Jonsson, 2008; Caldwell & Jorm, 2001; Hori, Richards, Kawamoto, & Kunugi, 2011; Hugo, 2001). Because a majority of these studies reported attitudes of European and Australian providers and only a few of the studies focused on attitudes held by U.S. healthcare providers, (Kua, Parker, Lee, & Jorm, 2000; Nordt et al., 2006; Wilson & Read, 2001) we assessed the attitudes of VA primary care (primary care nurses and physicians) and mental health providers (mental health nurses, psychiatrists, and psychologists) toward persons diagnosed
with schizophrenia. We hypothesized that healthcare providers would have more negative attitudes toward patients with schizophrenia than toward patients without schizophrenia, and that the effect of patient diagnosis of schizophrenia on attitudes would be moderated by the type of provider. Specifically, we hypothesized that primary care providers would have more negative attitudes toward patients with schizophrenia than toward patients without schizophrenia, but mental health providers’ attitudes would not differ across the two patient types.
Method The data for the current study were collected as part of a larger study examining provider attitudes toward patients with schizophrenia (Mittal et al., 2013). Between August 2011 and April 2012, we surveyed 351 healthcare providers (67 mental health nurses, 62 psychiatrists, 76 psychologists, 91 primary care nurses, and 55 primary care physicians), employed by five Veterans Affairs (VA) hospitals in the southeast and south central areas of the United States. Each participant completed a survey that included a vignette describing a patient, followed by a series of demographic and attitudinal measures. The surveys were identical except that one vignette included the diagnosis of schizophrenia and the other did not. The vignette was intended to depict a person who had been functioning well socially and vocationally for several years (see Supplement 1). Each provider completed only one of the two surveys (hypothetical patient with or without schizophrenia). The study was approved by the VA Central Institutional Review Board (IRB). The IRB allowed the waiver of the documentation of the informed consent to maximize the privacy of the participants. Providers who volunteered to complete the survey were given an information sheet describing all aspects of the informed consent. No incentive was offered. Surveys were distributed during regularly scheduled staff meetings, some with single type of provider and some with mixed provider groups. Research assistants (RAs) from each site requested surveys from the coordinating site based on the estimated number of attendees at these staff meetings. Surveys were returned using preaddressed, postage-paid envelopes anonymously to the site study coordinator. When the coordinating site sent surveys to sites RAs, the surveys were packaged with alternating versions of surveys (i.e., different vignette version). RAs were instructed to distribute the surveys from the packaged stack so that roughly equal numbers of each survey version were distributed. This system also ensured an essentially random distribution among providers. As the coordinating site received completed surveys, they tracked the response rate for each of the four provider groups (primary care physicians and nurses and psychiatrists and psychiatric nurses) and by the two survey versions. If significantly more or less of one survey version was returned from a site, we weighted the next round of surveys sent to the site with more or less of that version. Similarly, recruiting targets were adjusted over time to compensate for uneven response rates from the different provider groups. Later, we added psychologists to the study and collected data in a similar manner. In all, 710 surveys were distributed to volunteer respondents and 358 were returned. We excluded seven surveys from the analysis because of missing provider group.
HEALTHCARE PROVIDERS’ ATTITUDES
Measures We measured stigmatizing attitudes and beliefs using the characteristic scale (Olmsted & Durham, 1976), attribution questionnaire (Corrigan et al., 2002), and a social distance scale (The National Data Program for the Sciences & University of Chicago, 2013). Characteristic scale. Provider stereotyping was measured using a semantics differential scale (characteristic scale; Olmsted & Durham, 1976) in which respondents rated the qualities of the hypothetical patient on a 7-point scale of quality pairs, such as dangerous–safe (see Table 1 for items). The nine items were summed to create an overall scale representing the “stereotype characteristics scale.” Higher scores denote more negative attitudes. Attribution questionnaire. We used eight of the original nine items on the attribution questionnaire (AQ-9; Corrigan et al., 2002) to assess affective behavioral and cognitive reactions to a vignette on a 9-point response scale (1 ⫽ not at all, 9 ⫽ very much). The ninth question was not applicable to our study. Exploratory factor analysis identified six items as defining a single factor, and the confirmatory factor analysis confirmed an adequate fit (see Table 1 for items). The six items were summed to create an overall scale. Higher scores denote a more negative attribution.
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Social distance scale. We measured desire for social distance using five items with a 4-point response scale. Items were drawn from the General Social Survey (The National Data Program for the Sciences & University of Chicago, 2013) and summed to create the social distance scale (see Table 1 for items). A higher score on this scale denotes greater desire for social distance and therefore a more negative attitude. Covariates. Several potential confounding variables were measured and included in the analysis as covariates. Covariates included provider years in clinical practice, data collection site (with a total of five), and demographic variables including provider age (⬍30, 31– 40, 41–50, 51– 60, and ⬎60), gender and race (White vs. non-White).
Data Analysis The majority of variables had some missing values. Therefore multiple imputations (Rubin, 1976) were conducted using the SAS MI procedure. Analyses were repeated for each of five imputed dataset and then combined using the SAS MIANALYZE procedure. Descriptive statistics were calculated for all variables. Vignette type (schizophrenia vs. no schizophrenia) was the independent variable and provider group (primary care providers, which included primary care nurses and physicians, and mental health providers,
Table 1 Summary Measures Construct Social distance
Measure
Items
Bogardus Social Distance Scale
Assuming this patient was not a patient of yours, how willing would you be to move next door to this patient? Assuming this patient was not a patient of yours, how willing would you be to spend an evening socializing with this patient? Assuming this patient was not a patient of yours, how willing would you be to make friends with this patient? Assuming this patient was not a patient of yours, how willing would you be to have this patient start working closely with you on a job? Assuming this patient was not a patient of yours, how willing would you be to have this patient marry into your family? Valuable (1)–Worthless (7) Clean (1)–Dirty (7) Sincere (1)–Insincere (7) Safe (1)–Dangerous (7) Warm (1)–Cold (7) Wise (1)–Foolish (7) Strong (1)–Weak (7) Predictable (1)–Unpredictable (7) Tense (1)–Relaxed (7) I would think that it was [the patient’s] own fault that he is in the present condition. I would think that [the patient] is dangerous. I would think that [the patient] should be forced into treatment with his doctor even if he does not want treatment. I would be angry with [the patient]. I would be scared of [the patient]. I would try to stay away from [the patient].
Stereotypes
Characteristic scale
Attribution of Mental Illness
Attribution Questionnaire (AQ-9)
Range of scores
Alpha reliability
5–20
.86
1–7
9–63
.83
1–9
6–54
.76
Item scale 1–4 1 ⫽ Definitely willing 4 ⫽ Definitely unwilling
1 ⫽ Not at all 9 ⫽ Very much
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which included mental health nurses, psychiatrist, and psychologist) was the moderator, along with the interaction between vignette type and provider group as hypothesized. Covariates included provider gender, age, and race; provider years in clinical practice; and site. The dependent variables included three measures of provider attitudes: social distance, stereotype characteristics scale, and attribution of mental illness. Because each outcome represented a distinct construct, each was examined in a separate analysis. For each dependent variable, we first visually inspected its histogram to determine if the variable was approximately normally distributed. For social distance and the stereotype characteristics scale, where the normality assumption was met, a general linear model was fit. For attribution of mental illness, the distribution was positively skewed and we used a generalized linear model with a log link and gamma distribution. Predicted means (LSMEANS) from each of the three models were calculated for each vignette type and provider group with the continuous covariates set at their mean values and categorical covariates set at one divided by number of the groups. SAS® Version 9.3 was used.
Results The majority of our sample was White (63%), female (65%), and on average, had approximately 17 years of clinical practice. Demographic and clinical characteristics of the two provider groups are reported in Table 2, with significant differences found between the two provider groups for all variables in the table except for gender and age. Results from regression models examining the association of each provider attitude measure with vignette type and provider group are presented in Table 3. Predicted means (LSMEANS) from each of the three models are presented for each of the
vignette type and provider group in Table 4. There was a significant interaction between the provider group and the vignette type for the stereotype characteristics scale (t ⫽ ⫺2.70, p ⫽ .007), indicating that the effect of the vignette was different for primary care providers and mental health providers. Specifically, only primary care providers had significantly more negative stereotypes toward a patient with schizophrenia than toward a patient without schizophrenia (mean difference ⫽ 5.06, p ⬍ .001). This pattern was not observed for mental health providers. The interaction between vignette type and provider group was also significant for the attribution of mental illness (t ⫽ ⫺1.97, p ⫽ .049), and the pattern was similar to that found for the stereotype characteristics scale. Specifically, only primary care providers had more negative attributions about a patient with schizophrenia than about a patient without schizophrenia (mean difference ⫽ 2.14, p ⬍ .01). In contrast, the difference between the vignettes on attributions was not significant for mental health providers. For the Social Distance Scale, the interaction between vignette type and provider group was not significant (t ⫽ ⫺0.11, p ⫽ .91). This implies that the vignette type effect was consistent for the two provider groups. We then excluded the interaction between vignette type and provider group from the model and examined the main effect of vignette type (data not shown). A significant main effect was found for vignette type (t ⫽ 2.37, p ⫽ .02). All provider groups desired more social distance from patients with schizophrenia (LSMEAN ⫽ 11.27) than from patients without schizophrenia (LSMEAN ⫽ 10.44). For all three dependent variables, we examined the vignette effect for the provider subgroups within the primary care (primary care nurses and primary care physicians) and mental health (mental health nurses, psychologists, and psychiatrists) groups.
Table 2 Descriptive Statistics by Provider Group
Variable Vignetteⴱ Nonschizophrenia Schizophrenia Gender Female Male Age Less than 30 years old Between 31 and 40 years old Between 41 and 50 years old Between 51 and 60 years old Over 60 years old Whiteⴱ Years in clinical practice (mean/SD)ⴱ Provider attitudes Social distance (mean/SD), range ⫽ 5–20ⴱ Provider stereotyping (mean/SD), range ⫽ 9–63ⴱ Attribution of mental illness (mean/SD), range ⫽ 6–54ⴱ
Primary care providers N (%)
Mental health providers N (%)
Total
146 (41.6)
205 (58.4)
351 (100)
76 (52.05) 70 (47.95)
83 (40.49) 122 (59.51)
159 (45.30) 192 (54.70)
97 (66.44) 49 (33.56)
132 (64.39) 73 (35.61)
229 (65.24) 122 (34.76)
6 (4.11) 31 (21.23) 35 (23.97) 52 (35.62) 22 (15.07) 50.82% 19.00 (17.37)
13 (6.34) 61 (29.76) 46 (22.44) 60 (29.27) 25 (12.20) 71.12% 15.76 (15.11)
19 (5.41) 92 (26.21) 81 (23.08) 112 (31.91) 47 (13.39) 62.68% 17.10 (11.49)
11.59 (4.92) 28.64 (14.00) 11.00 (9.42)
10.62 (4.29) 26.49 (9.88) 9.18 (5.32)
11.02 (3.21) 27.39 (8.25) 9.94 (5.07)
Note. For those variables with multiple imputation used, the exact frequencies cannot be obtained, so only percentages were presented. Those variables started with “White.” ⴱ p ⬍ .05 for the bivariate analysis between the two groups of providers and each variable above.
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Table 3 Regression Models for Relationship of Vignette Type and Provider Attitudes (n ⫽ 351) Provider attitudes Parameter (SE) Social distance Vignette type Schizophrenia vs. nonschizophrenia Provider group Mental health vs. primary care Vignette typeⴱprovider group
Stereotyping
0.88 (0.51)
5.06 (1.31)ⴱⴱ
⫺0.81 (0.51) ⫺0.08 (0.73)
0.40 (1.28) ⫺4.67 (1.73)ⴱⴱ
Attribution (log link with gamma distribution) 0.18 (0.07)ⴱⴱ ⫺0.09 (0.06) ⫺0.17 (0.09)ⴱ
Note. All the models included the following covariates: site, gender, age, race, and years in clinical practice. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01.
On the stereotype characteristic scale, both primary care physicians (p ⬍ .05) and primary care nurses (p ⬍ .05) expressed more negative stereotypes toward the individual with schizophrenia than toward the individual without schizophrenia; the difference was not significant for any of the mental health providers. On attribution of mental illness scale, only primary care nurses made more negative attributions toward the individual with schizophrenia than toward the individual without schizophrenia (p ⬍ .05); the difference was not significant for primary care physicians or any of the mental health providers. For the social distance model, both primary care physicians and psychiatrists showed more social distance toward the individual with schizophrenia than toward individual without schizophrenia (p ⬍ .05 for both). The difference was not significant for primary care nurses, mental health nurses, or psychologists.
Discussion Consistent with our hypothesis, primary care providers reported a significantly more negative attitude toward individuals with schizophrenia compared with those without schizophrenia on two of the three attitudinal variables (stereotyping and attribution of mental illness). In contrast, these two attitude scores did not significantly differ across the two vignettes for mental health providers. These findings of primary care providers having more negative views of individuals with schizophrenia are consistent with the existing literature (Bjorkman et al., 2008; Caldwell & Jorm, 2001; Hori et al., 2011; Hugo, 2001). On social distance however, both provider groups showed similar patterns regarding vignette type, with both wanting greater social distance from individuals with schizophrenia than from individuals without
Table 4 Predicted Means (LSMEANS) From Regression Models for Each Vignette Type and Provider Group Provider attitudes Social distance
Provider group Schizophrenia Nonschizophrenia
Mental health Primary care Provider stereotyping Mental health Primary careⴱ Attribution Mental health Primary careⴱ ⴱ
10.83 11.72 26.80 31.08 9.91 12.86
p ⬍ .01 between schizophrenia and nonschizophrenia.
10.03 10.84 26.41 26.02 9.79 10.72
schizophrenia which is consistent with the findings of Caldwell and Jorm (Caldwell & Jorm, 2001). Why do primary care providers have more negative attitudes toward individuals with schizophrenia compared with individuals without schizophrenia? This finding may be understood based on existing conceptual frameworks for public stigma. Classic labeling theory (Scheff, 1966) posits that negative stereotypes are triggered when a person is labeled as mentally ill. Holding a negative belief does not necessarily result in any unacceptable behavior (Jussim, Nelson, Manis, & Soffin, 1995). Only those individuals who endorse and validate such negative stereotypes are prone to prejudice which could lead to discriminatory behaviors (Corrigan, Markowitz, Watson, Rowan, & Kubjak, 2003). The attribution model described by Weiner (1995) and the cognitive-affective models tested by Jussim and others (Jussim et al., 1995) further expand this complex interplay between stereotyping, prejudice, and discriminatory behavioral responses. According to Weiner (1995) the stereotyping-prejudice-discrimination pathway is influenced by beliefs about cause, controllability, and individual responsibility. The nature of such beliefs (e.g., attributing the cause to underlying biology/individual choice) would elicit affective reactions such as anger or pity which could influence behavioral responses (help vs. punishment; Corrigan et al., 2003). Primary care providers may endorse more negative attitudes toward individuals with schizophrenia because they have less training about mental illness than mental health providers, less exposure to the recovery model that emphasizes strengths rather than disabilities among individuals with mental illness (Davidson, Lawless, & Leary, 2005), less contact with patients with schizophrenia, and likely less exposure to recent research indicating growing rates of recovery from schizophrenia (Lambert et al., 2008). Results from our subgroup analysis add strength to these postulations. For instance, primary care physicians and nurses surveyed in this study reported significantly higher negative stereotypes toward the individual with schizophrenia. Also primary care nurses had significant higher negative attributions for schizophrenia. Previous research clearly indicates that greater contact with individuals with SMI tends to reduce stigmatizing views (Couture & Penn, 2003). Findings from this study suggest that primary care physicians and nurses may need focused interventions to help modify their negative stereotypes and misattributions for schizophrenia. Familiarity with mental illness and contact with an individual with mental illness who has achieved a substantial degree of
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recovery and is able to describe the story of struggles and recovery from mental illness can reduce prejudice and discrimination (Corrigan, 2011; Corrigan, Edwards, Green, Diwan, & Penn, 2001; Corrigan & Watson, 2002) Whether targeting negative stereotypes and attributions would result in minimizing the disparities in delivery of suboptimal physical healthcare to persons with schizophrenia is worth exploring in future studies. It is interesting to note that the subgroup analysis from this study revealed that both primary care physicians and psychiatrists desired more social distance from individuals with schizophrenia. Similar concerns were identified by Stuber, Rocha, Christian, and Link (2014) when they compared attitudes of mental health professionals with those from the general public. Although an increase in familiarity with individuals with mental illness may have helped in mitigating some of their negative stereotypes and attitudes among mental health providers (items on the characteristic scale and attribution questionnaire), a tendency to social distance appears to have persisted despite greater familiarity with patients with schizophrenia. This may be the result of relatively greater exposure to sicker patients with schizophrenia that can lead to negative generalizations toward all patients with schizophrenia (Cohen & Cohen, 1984). Pescosolido, Medina, Martin, and Long (2013) refer to larger cultural beliefs, attitudes, and opinions about mental illness as a “backbone” of prevailing myths among the providers and general public. Historically, medical textbooks describe patients with schizophrenia having a progressively deteriorating course with little hope of remission (Sadock & Sadock, 2007). Contrasting this information with newer research, Zipursky et al. concluded from their review that only 25% of patients with schizophrenia experience deteriorating course, while others demonstrate significant ability to recover (Zipursky, Reilly, & Murray, 2013). Interventions that combine both educational- and contact-based approaches with providers who have achieved substantial recovery from mental illness may be especially valuable to promote affirming attitudes among providers.
Limitations Because the current study examined providers working in VA, the findings may not generalize to providers working in other settings. VA tends to provide an integrated system of care to a greater extent than other systems, and this may lead practitioners to interact with individuals with schizophrenia differently than in non-VA settings. At the same time, VA represents the training site for many physicians in the community. Therefore, it would not be surprising to find similar attitudes expressed in other healthcare settings. Further, the generalizability of the study findings may be limited by the suboptimal response rate, with only 50% of the distributed surveys returned. However, 50% rates are typical for organizational survey research (Baruch & Holtom, 2008). Notwithstanding study limitations, these results point to the need to preferentially tailor interventions toward primary care providers to meet their unique needs. Effective interventions exist to reduce negative attitudes about persons with schizophrenia in the general population (Corrigan, Morris, Michaels, Rafacz, & Rüsch, 2012); however, our review of the literature did not find interventions tailored specifically for healthcare providers. Furthermore, to further explore how biological and environmental etiological factors influence provider attitudes, future research efforts may explore the differences in providers’ attitudes toward mental health diagnostic categories that have
a strong biological predisposition such as schizophrenia as opposed to those more strongly determined by environmental factor such as posttraumatic stress disorder. Lastly, studies that focus on attitudes of providers with lived experience of mental illness toward individuals with schizophrenia represent another area of research that could enhance the literature.
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Received March 6, 2014 Revision received July 1, 2014 Accepted August 5, 2014 䡲
