Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

• Compare the effectiveness of strategies to reduce stigma, prejudice, and discrimination among individuals with serious mental illness.

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

• Compare the effectiveness of strategies to reduce stigma, prejudice, and discrimination against people with SMI and to encourage their social inclusion.

– It is possible that these should be viewed as distinct issues. While social exclusion may relate to stigma, prejudice or discrimination, it may also result from lack of motivation, lack of desire for social contact or other factors that may accompany serious mental illness. This bullet point should consider the effects of stigmatization due to serious mental illness and co-occurring conditions (e.g. substance use, personality disorder) within the health care system. The effects of other co-occurring factors on discrimination by clinicians also need to be assessed. For example, is stigmatization by medical personnel and worsening of delivered care more common when serious mental illness and obesity co-exist or when serious mental illness and low socioeconomic status occur together?)

• Compare the effectiveness of alternatives to interventions using force or involuntary approaches (e.g. seclusion and restraint) in people with SMI.

– One nominator noted it is not clear how this statement fits in with the theme of stigma, prejudice and discrimination. The apparent implication is that such approaches are necessarily discriminatory or the result of stigma or prejudice. Although it is important to develop alternatives to involuntary interventions and delineate the situations in which a particular approach is likely to be most useful, there may still be situations in which involuntary treatment is needed to maintain the safety of patients and others.

– Alternatives to seclusion and restraint need to be specified. It would also be useful to see whether such alternatives influence positive or negative outcomes in addition to effectiveness per se (e.g., patient satisfaction, perception of the therapeutic alliance, treatment adherence, subsequent avoidance of mental health contacts, rates of patient injury, ra

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Persons with Serious Mental Illness (SMI)

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

• Those with co-occurring disorders
• Specific cultural groups
• See previous comments on subgroups of interest

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

• Social inclusion of adults with SMI
• Improved quality of life for patients with SMI, including normative success in education, relationships, employment, and housing
• Enhanced physical health and decreased morbidity and mortality due to physical illness may occur (if there are reductions in discriminatory attitudes and behaviors of non-mental health medical professionals).
• Reductions in psychiatric symptoms may also be observed. For example, self-esteem may improve and apparent ideas of reference, demoralization, anger, depression and/or anxiety may be reduced if individuals feel less stigmatized.
• Diagnoses may be more accurate and the appropriateness of treatment planning may be improved by reducing stigmas among health professionals. For example, unrecognized stigmas can result in inaccurate diagnoses (e.g., young African American males being more likely diagnosed as having schizophrenia) or may result in a tendency to provide medications or seclusion/restraint more readily than more conservative interventions.

Describe any health-related risks, side effects, or harms that you are concerned about.

Efforts to enhance social inclusion may be disconcerting and produce anxiety for individuals who are amotivational, highly anxious or suspicious as part of their syndrome of illness. To avoid symptom exacerbations, It may be necessary to pursue more gradual efforts at social inclusion or postpone such efforts until symptoms are better controlled. Patient preferences should always be considered. Similarly, some individuals may be unable to tolerate housing in group settings with distinct responsibilities (e.g, cooking for the group), mandatory requirements (e.g., attend a treatment program daily) or restrictions (e.g., prohibition on alcohol use, even in rare social situations). Efforts to reduce stigma and prejudice at a community level could also have potential unintended consequences. For example, drawing attention to the problem may lead groups of individuals to escalate verbal and other attacks on individuals with serious illness. Raising awareness of the deficits in community housing for those with mental illness could similarly lead to a backlash of "not-in-my-backyard."

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Depression and other mental health disorders
• Diabetes mellitus
• Functional limitations and disability
• Infectious diseases, including HIV/AIDS
• Obesity
• Substance abuse

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

More than 30 percent of the US population suffers from a mental illness each year.1 With or without insurance, it is more difficult to find a mental health provider in rural areas, and there is some evidence that rural residents may be less likely to seek such services due to stigma and fear that their privacy will not be protected. Even with mental health parity, mental health carveouts are common and there are often differential requirements for pre-approvals and medical necessity determinations for mental health treatment compared to other treatments. In addition, not all policies even include mental health coverage.

The result of privacy concerns is that individuals may be less likely to seek care and/or may be less open in speaking with mental health professionals when they do seek care. With the rapid growth of electronic medical records, the linkage between privacy concerns and fear of discrimination is becoming even more essential to address. Those with serious mental illness can receive very significant benefits from enhanced coordination of care and availability of medical information in decision support applications (e.g., drug interaction checking). However, increases in the potential for stigma and patient concerns about being stigmatized need to be addressed. It is important to know the comparative effectiveness of technological approaches to granular privacy protections (e.g., use of personal health records to set information sharing constraints, patient-controlled encryption) and whether such approaches can be understood by and implemented in the care of those with serious mental illness. Most current approaches to privacy in electronic records are all-or-nothing (i.e., opt-in vs. opt-out) and are limited to adding protections for psychiatric records. But they do not address patient’s desire to share some but not all information or the fact that mental health related information is present in charts of primary care physicians and other non-me

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

Differences in the availability of particular treatment approaches is a commonly reported reason that clinicians do not follow evidence based recommendations regarding care. This observation also appears to be true in the care of individuals with serious mental illness. Reducing discrepancies in available care due to stigma and discrimination could enhance the use of evidence-based approaches with patients.

Issues of stigma and discrimination also arise frequently in day-to-day clinical practice in efforts to get social supports (e.g., housing) and needed medical care for our patients. Discrimination in medical care can take a number of forms. Medical professionals may harbor the same biases against those with mental illnesses as are present in the community. They may spend less time with mentally ill individuals, take patient concerns less seriously, be less likely to do an appropriate physical examination, less likely to order indicated diagnostic tests and more likely to want to shift the care of the patient to other health professionals rather than providing continuity of care. Even with standardized patients (i.e., patient scenarios portrayed by actors for purposes of teaching and examination), medical students were less likely to show appropriate examination and diagnostic skills when the standardized patient portrayed a physically or intellectually disabled individually (Brown et al., Academic Medicine Sept 2010). Anecdotally, in our medical students’ standardized patient examinations, they appear frightened of and are less attentive to the standardized “patient” who has schizophrenia and who presents with abdominal pain. Interventions to reduce stigmatization of mental illness among health professionals could greatly enhance the medical care of those with serious mental illness and reduce morbidity and mortality. There are also increasing concerns expressed about the privacy of electronic health records and the potential for discrimination if such

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

See answers to previous questions for details.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

Describe the timeframe in which an answer to your question is needed.

As soon as possible. This topic was prioritized during a series of stakeholder meetings focused on SMI, held July-August 2010.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Although all subgroups are important for inclusion (see item 3 above), the issues of stigma, discrimination, and prejudice against persons with serious mental illness appear to be of particular importance in rural areas. See previous comments for additional details. Additional discussion of the issues in rural settings are reviewed in Roberts et al. Psychiatr Serv. 1999 Apr;50(4):497-503.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

The Practice Guidelines project of the American Psychiatric Association was asked for the name of someone to participate; my name was submitted.