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  • The Medical Provider Bias of the Psychiatric Patient

    There has been so much going on in the last week in terms of my physical health, it has been overpowering my need to protect my mental health. I fell apart physically, rather abruptly and unexpectedly. Testing has proven inconclusive thus far, which is both encouraging and discouraging. I am encouraged to know there is no serious ailment, however discouraged that my symptoms remain vague and without cause. With my husband consistently at my side, and a dear friend who stood up and staunchly advocated for my needs we were able to come up with a plan to move forward, so I will be fine as always. I'm a tough bird. 

    What I wanted to call your attention to was a guest post I wrote a year ago for another website that I linked below and am republishing: the topic of feeling that our physical concerns are not taken seriously when a provider sees in the EHR that they are dealing with a primary psychiatric diagnosis before they meet you. There is a very real bias that exists and the more we ae aware of it and talk about it, the better our care can and will be. 

    http://www.everythingbutthecat.net/#!Guest-Blog-Medical-Provider-Bias-of-the-Psychiatric-Patient/c1kyp/55a39e840cf21636d2fcd246 (first published July 23, 2015)

    A patient presents to their local emergency department at the prodding of their spouse in the midst of experiencing about 36 hours of mid-sternal chest tightness with an inability take a deep breath. It is not relieved with antacids or aspirin. The patient feels worse when moving around. They are checked in to the emergency department, and EKG is done and they are sent back to the waiting room to wait. And wait. And wait.  After a few hours, a polite inquiry is made as to when the patient might be seen knowing chest pain is usually considered to be a serious malady. They are told the ECG was normal and that they are waiting for a doctor to come speak with them. Frustrated, the patient leaves and a two days later seeks help with the primary care provider (PCP) who diagnoses them with costochondritis, which is an inflammation of the cartilage connecting the sternum to the rib cage and the pain can often mimic that of a heart attack.  It is easily treated with a two-week course of a non-steroid anti-inflammatory medication. The medical record shows the patient was seen for the primary problem of anxiety, secondary problem of chest discomfort. 

    A patient presents to a neurologist who specializes in the treatment of migraines at the behest of their other providers for better management of their migraines. On the day of the appointment, they are experiencing a migraine, having gait difficulty and vomiting in the waiting room, with a prolonged waiting time on the day of the appointment.  The neurologist told the patient that their migraines were made up and being used as a method to get attention. The patient was further told that these migraines were all in their head and not real.  They left without medical care. 

    Outrageous right? In today’s day and age of medicine where patient satisfaction rules that day how dare someone’s chest pain be ignored, then find out they are viewed by providers as anxious despite an actual medical condition they were diagnosed with and how could a neurologist tell a patient vomiting from migraine that this was a made-up attention-seeking headache? What if I told you both of the above patient’s charts carried a diagnosis of bipolar disorder. In the age of electronic medical records, providers are fairly savvy on a patient’s medical condition and past histories before ever seeing or interviewing a patient. Are you still outraged? I hope so. Hold onto it for a moment. 

    I was intrigued by this bias of a seemingly different standard of medical care as it appeared it was being offered to a patient with a pre-existing psychiatric diagnosis versus a patient without one.  For example, the chest pain differential diagnosis (once EKG ruled out changes concerning for heart attack) is still long and warrants work-up. Fortunately for our patient, they were okay. Imagine however if they returned say 24 hours later in extremis. It is still baffling how when at no time they were anxious, they were calm and stated the facts of what was happening to them, their PCP still found a primary episode diagnosis of anxiety necessary, not the costochondritis the patient was prescribed treatment for. The migraine patient was greeted by the neurologist with the words “Oh, I see you’re a bipolar.” While that is not exactly politically correct, it should have raised red flags for the neurologist that this patient has headaches since migraines are a proven co-morbid condition, not suggest that the patient was confabulating a disorder and wasting their time. Did the patient “make-up” the vomit in the waiting room trash can too? 

    I know these two anecdotes do not even begin to scratch the surface of bias psychiatric patients experience while trying to obtain medical care. I did a literature review to attempt to grasp the extent of the problem. Not entirely unsurprisingly I was not able to find much. However I did learn a lot of information.

    In a 2013 study, Maina, Bechon, Rigardetto and Salvi noted that those with bipolar disorder have worse physical health and life expectancy reduced by approximately 30% compared to the general population (Note: that number is higher than I have previously seen). They found patients with bipolar disorder are more likely to have cardiovascular conditions, hypertension, diabetes, hypothyroidism, respiratory illness, liver dysfunction and peptic ulcers. 55% of the patients they examined had a co-morbid condition. The most common co-morbid conditions were either endocrine or cardiovascular.  64% of patients who had an endocrine disorder experienced metabolic syndrome. The biggest risk factors they found for predicting the risk of a co-morbid condition were female gender and duration of untreated illness. It was noted that individuals with bipolar disorder are more likely to demonstrate “risky” behaviors health-wise in terms of diet, poor exercise habits, sub-optimal self care, limited access to health care and perhaps unwillingness to obtain health care during periods of depression. It was also noted that the medications used to treat bipolar disorder are lifetime medications and place the patient at risk for obesity, metabolic syndrome and thus cardiovascular disease and diabetes.  (Maina G, Bechon E, Rigardetto S, Salvi V. General Medical Conditions Are Associated with Delay to Treatment in Patients with Bipolar Disorder. Psychosomatics. 2013:54-437-442.)

    I looked at a 2013 study from Crump, Sundquist K, Winkleby, and Sundquist J, which knowing bipolar disorder is associated with increased mortality sought to examine what effects the disorder has on the individuals physical health over a 7 year period. Their study found that for the individuals identified as having bipolar disorder over 60% were middle-aged, the majority were women, they were more likely to use alcohol or other illicit substances and have lower educational or income levels.  They found that these patients had three times the amount of outpatient visits and two times as many hospital admissions on an annual basis. The diagnoses these patient were more at risk for was influenza or pneumonia, COPD, diabetes, cardiovascular disease – specifically mentioning stroke. When mortality was examined, it was found that women, on average, passed away 9 years earlier than other women and men, on average, passed away 8.5 years earlier than other men. This represents a 2.3 and 2.0 fold increase in mortality. It also calls to attention the notion that those with bipolar disorder are less likely to receive primary medical care, thus in essence preventative medicine for many of these disorders. Modifiable behaviors are also noted, such as, obesity, smoking and substance abuse. (Crump C, Sundquist K, Winkleby M, Sundquist J. Comorbidities and Mortality in Bipolar Disorder: A Swedish National Cohort Study. JAMA Psychiatry. 2013;70(9):931-939.

    The final study I want to call attention to is from 2014 by Gras, Swart, Sloof, van Weeghel et al looking at stigmatizing attitudes healthcare professionals may hold toward psychiatric patients. They acknowledge upfront their study was limited by a bias toward providers likely wanting to provide a socially appropriate answer. They sought to look at the beliefs held by general medical professionals (GPs), general mental health care professionals  (MHCs) and forensic psychiatric professionals (FPs). They hypothesized that the GPs would hold the most stigmatizing beliefs; the MHCs would hold the most accepting and the FPS would be in the middle.  They found that all three groups held a “moderately positive attitude” and that their hypothesis was correct. It was noted that only between 26-38% of the providers across all three groups admitted having personal experience with mental illness. (Gras L, Swart M, Sloof C, van Weeghel J, et al. Differential stigmatizing attitudes of healthcare professionals towards psychiatry and patients with mental health problems: something to worry about? A pilot study. Soc Psychiatry Psychiatr Epidemiol (2015) 50:299-306)

    It is worth noting that bias exists, and that primary care providers have been shown to hold a more stigmatizing attitude than other providers. It could be hypothesized that same said attitude carries over to providers of a non-psychiatric specialty, however given a paucity of data available in my literature review, we don’t know that answer.

    Patients with a psychiatric diagnosis deserve better in our care and need to stand up for ourselves. We deserve the same standard of care for our healthcare needs as anyone else. We ask for and expect parity with our insurance and it is reasonable that the very same parity would extend to our medical care. The data clearly shows the collective we hold a higher risk of cardiovascular disease, endocrine disorders, stroke, and risky modifiable behaviors. There is no reason for any single one of us to hold increased mortality versus the general population if our care providers sit down and pay attention. I did not even get a chance to discuss the increase lifetime risk of suicide that an individual with bipolar disorder carries over the general population. 

    Why don’t we empower our care providers to provide us with the very same standard of care that a non-psychiatric patient would receive? In an increasing era of patient satisfaction and concierge care, speak up and talk to your providers. Encourage them to listen to you. Would a non-psychiatric patient be told their medical ailment is made up? Would a non-psychiatric patient be seen for a physical complaint but end up with the primary visit complaint a diagnosis straight out of the DSM. If the answer is NO, then stand up and speak up.