Does a Physician's Attitude toward a Patient with Mental Illness Affect Clinical Management of Diabetes? Results from a Mixed‐Method Study

Although disparities in health and health care often are associated with demographic characteristics such as race and ethnicity, people with mental illness also experience systematic obstacles to optimal health (DHHS 2012). High rates of diabetes and cardiovascular disease contribute to premature mortality in patients with serious mental illness (SMI), and low rates of cardiometabolic risk factor detection (Motsinger et al. 2006; Kilbourne et al. 2007) have prompted recommendations for widespread screening, particularly for patients prescribed atypical antipsychotics (Consensus Statement 2004; Dinan 2004; Lambert and Chapman 2004; Marder et al. 2004). Three factors may contribute to patients with SMI experiencing poor outcomes for diabetes. First, access to regular health care can be hindered by system factors, such as lack of insurance parity for physical and mental health. Second, patient behaviors resulting from symptoms of SMI (e.g., amotivation, cognitive deficits) (Felker, Yazel, and Short 1996; Corrigan 2004) can lower ability to self-manage glucose levels and make lifestyle changes. Third, variation in provider decisions has been shown to contribute to differences in quality of care for diabetes overall (Shackelton et al. 2009; von dem Knesebeck et al. 2010; Marceau et al. 2011; McKinlay, Marceau, and Piccolo 2012) and for patients with mental illness in particular. Focusing on quality of care, research has found that diabetes patients with SMI were less likely than those without SMI to be prescribed lipid-lowering and hypertension medications (Kreyenbuhl et al. 2006). Although Veterans Health Administration studies found comparable diabetes care for people with and without SMI (Desai et al. 2002; Krein et al. 2006), results from community-based clinics revealed that people with SMI were less likely to receive the full range of diabetes services (Goldberg et al. 2007), and the nationwide Clinical Antipsychotic Trials of Intervention Effectiveness showed a high rate of nontreatment for diabetes (30.2 percent) (Nasrallah et al. 2006). Reasons for disparate management may include distrust, a belief that somatic complaints are psychological (Graber et al. 2000), or response to stigma associated with SMI (Bunce et al. 1982; Penn and Martin 1998). Stigma is a mark of difference embodied in social interactions (Goffman 1963; Pescosolido et al. 2008) and structured by power relations (Scambler 2009). Stigma can lead to conscious or unintentional discrimination by invoking explicit or automatic attitudes (Rusch et al. 2011), stereotypes, and prejudice that can shape behavior (Smedley, Stith, and Nelson 2003). Although one may expect that physicians would be less susceptible to this process because of increased education about and contact with people with stigmatizing illnesses, research is mixed on whether these factors reduce the effects of stigma (Pescosolido et al. 2008; Corrigan et al. 2012). Research has also shown that physicians are not immune to the common practice of using stereotypes to make sense of vast amounts of information in short periods of time (Smedley, Stith, and Nelson 2003; Welch et al. 2012). To better understand the provider contribution to disparate care for people with SMI, we examine two questions: Do primary care physician (PCP) attitudes toward patients differ by stigmatizing mental health comorbidity, controlling for other patient, provider, and organizational characteristics? Do differences in attitudes attributable to mental health comorbidity influence management of patients with diabetes?