Implicit Bias in Mental Healthcare and the Plight of the Black Patient

According to CBS News, March 2020 was the first March in nearly two decades that the United States had not experienced a school shooting , likely due to the widespread school closures brought on by the current coronavirus pandemic. This absence of school shootings during this time also means that we were  spared the endless news media debates about the role of mental illness in the development of gun violence. 

A simple google scholar search of the phrase “mental illness and violence” produces about 1,240,000 results and suggests that there is a historical association of violence with mental illness, an association that often results in the biased perception that individuals living with mental illness are inherently more violent than the average person . The existence of this bias in the general population is to some degree not surprising as mental illnesses are traditionally stigmatized conditions. What is surprising, however, is the prevalence of similar biases amongst mental health professionals (i.e. psychiatrists, psychologists, psychiatric nurses…etc.). Previous research has shown that mental health professionals also hold biases against their clients . 

 The existence of bias amongst health care providers towards their mentally ill patients has an impact on the kinds of treatment plans and recommendations they provide. The effects of which, may be seen in low rates of patient engagement with mental health services. Such bias against the mentally ill, when combined with racial bias, can be disastrous for Black patients. 

Healthcare workers also harbor implicit biases

Compared to physical health, mental health issues are considered to be a taboo subject in almost every part of the world. Consequently, individuals struggling with mental illnesses rarely feel comfortable talking about or seeking help for their issues. When they do eventually seek help, they may encounter bias from their healthcare provider. For example, the bias  represents a tendency for mental health professionals to view individuals with certain psychiatric diagnoses (i.e. schizophrenia) as more violent than the general public and individuals with diagnoses that are perceived to be of a milder quality (i.e. major depression). 

In a study using vignettes that described individuals meeting the DSM-IV criteria for major depression and schizophrenia, researchers found that more than a third of mental health professionals expressed an unwillingness to work with a coworker who was diagnosed with schizophrenia. Additionally, another one-third of these providers expressed beliefs that the schizophrenic individual is more likely to be violent towards others . They also found that although mental health professionals have a more positive attitude towards individuals with mental illnesses compared to the general American public, providers’ desires for social distance from clients and co-workers with schizophrenia highlight the concerning reality that even providers who work within the mental health realm harbor implicit biases towards their clients. Furthermore, although the researchers argued that perhaps the reason why some providers would perceive schizophrenic individuals as more dangerous is due to their likelihood of having firsthand experience with untreated and symptomatic patients, the fact that providers’ beliefs of violence from schizophrenic patients are on par with that of the general public is alarming and raises the question of how these implicit biases impact treatment recommendations. 

Implicit biases cloud caregiver judgments  

This question was the subject of a study by Corrigan and colleagues in which they examined the effect that stigmatizing mental health beliefs held by healthcare providers had on their treatment recommendations. The study featured 166 health care providers of which 42% worked in primary care and 58% in mental health practice. The providers were presented with a vignette of a male schizophrenic patient who came in for lower back pain due to arthritis and had to decide between two treatment recommendations (refer the patient to a specialist or refill the prescription). The researchers found that providers (either in primary or mental health care) who held more implicit biases towards the patient were more likely to believe that he would not adhere to his treatment. As a result of this belief, they were subsequently less likely to either refer the patient to a specialist or to write the patient a prescription to obtain a refill . 

The importance of this finding is that there is no research basis for the belief that a schizophrenic patient is less likely to adhere to medication. Research on the adherence rates of schizophrenic patients found that these patients were no more likely to engage in nonadherence than the general public. Therefore, the providers’ refusal to refill the prescription of the patient in the above vignette stems solely from an implicit bias that schizophrenic patients were by nature poor medication adherents. Likewise, a study by Graber and colleagues found that family physicians tend to engage in diagnostic overshadowing. That is, the reluctance to believe that a patient who had previously been diagnosed with depression could be experiencing new physical symptoms  having nothing to do with their pre-existing mental illness. Ultimately, these studies show that the existence of an implicit bias held against mentally ill patients clouds and shapes the treatment recommendations that a provider is likely to make.  

Implicit bias reduces engagement in already vulnerable and underserved Black patients

Sociodemographic factors, like gender and race  make some patients more vulnerable to the implicit biases that providers hold against mentally ill patients. For example, although rates of depression in Black patients are comparable to that of the general population, only 8.7% of Black patients received treatment for mental health concerns compared to 16% of white adults . Research by Yesenia Merino and colleagues shows that the implicit biases that mental health professionals hold can affect how the provider views certain behaviors. For example, a provider may perceive a Black man’s vigilance in everyday life to be a sign of paranoid schizophrenia without taking into account the lived experience of the individual and the fact that this behavior may be a result of growing up in a society where Black men are disproportionately targeted by law enforcement officials. Indeed, even with the standardized diagnostic criteria of the DSM-V, Black individuals are disproportionately more likely to be over-diagnosed with psychotic disorders and underdiagnosed with affective disorders like depression when compared to their white counterparts. The result of these misdiagnoses is often either a delay in care or a failure to refer patients to the appropriate care. 

The effects of these biases on patient engagement are many and varied, with the most prominently studied ones being that Black patients often express dissatisfaction with their care. Added to this is a tendency to experience microaggressions from providers during the care process while also typically being prescribed older antipsychotics that have many nasty side effects . According to Lonnie Snowden, these negative experiences when seeking care may then cause members of minority groups to “question the benefit of seeking mental health services, which may decrease treatment adherence”. 

Lastly, the negative experiences brought on as a result of provider implicit biases may extend beyond the individual to their broader community resulting in the perpetuation of  what Merino and colleagues call “social norms that discourage treatment-seeking for psychiatric problems”. These findings thus show that not only are providers’ treatment recommendations impacted by their implicit biases, Black patients’ engagements with mental health services are also hampered by the existence of provider implicit bias. Healthcare workers can begin to rectify the problem by taking the Implicit Association Test to become aware of their implicit biases and taking purposeful steps to examine the sources influencing their treatment recommendations for Black patients. Reducing provider implicit bias in mental healthcare thus has the potential to increase patient engagement with mental health services while also reducing the rates of mental health disparities that exist in the United States and globally. 

References 

Black and African American Communities and Mental Health. (2020). Mental Health America. https://www.mhanational.org/issues/black-and-african-american-communities-and-mental-health

Corrigan, P. W., Angell, B., Davidson, L., Marcus, S. C., Salzer, M. S., Kottsieper, P., Larson, J. E., Mahoney, C. A., O’Connell, M. J., & Stanhope, V. (2012). From Adherence to Self-Determination: Evolution of a Treatment Paradigm for People With Serious Mental Illnesses. Psychiatric Services, 63(2), 169–173. https://doi.org/10.1176/appi.ps.201100065

Corrigan, P. W., Mittal, D., Reaves, C. M., Haynes, T. F., Han, X., Morris, S., & Sullivan, G. (2014). Mental health stigma and primary health care decisions. Psychiatry Research, 218(1), 35–38. https://doi.org/10.1016/j.psychres.2014.04.028

FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: A systematic review. BMC Medical Ethics, 18(1), 19. https://doi.org/10.1186/s12910-017-0179-8

Graber, M. A., Bergus, G., Dawson, J. D., Wood, G. B., Levy, B. T., & Levin, I. (2000). Effect of a patient’s psychiatric history on physicians’ estimation of probability of disease. Journal of General Internal Medicine, 15(3), 204–206. https://doi.org/10.1046/j.1525-1497.2000.04399.x

Harris, J. I., Leskela, J., Lakhan, S., Usset, T., DeVries, M., Mittal, D., & Boyd, J. (2019). Developing Organizational Interventions to Address Stigma Among Mental Health Providers: A Pilot Study. Community Mental Health Journal, 55(6), 924–931. https://doi.org/10.1007/s10597-019-00393-w

Lewis, S. (2020). March 2020 was the first March without a school shooting in the U.S. since 2002. Retrieved April 24, 2020, from https://www.cbsnews.com/news/coronavirus-first-march-without-school-shooting-since-2002-united-states/

Merino, Y., Adams, L., & Hall, W. J. (2018). Implicit Bias and Mental Health Professionals: Priorities and Directions for Research. Psychiatric Services, 69(6), 723–725. https://doi.org/10.1176/appi.ps.201700294

Mulvey, E. P. (1994). Assessing the Evidence of a Link Between Mental Illness and Violence. Psychiatric Services, 45(7), 663–668. https://doi.org/10.1176/ps.45.7.663

Snowden, L. R. (2003). Bias in Mental Health Assessment and Intervention: Theory and Evidence. American Journal of Public Health, 93(2), 239–243. https://dx.doi.org/10.2105%2Fajph.93.2.239

Stuber, J. P., Rocha, A., Christian, A., & Link, B. G. (2014). Conceptions of mental illness: Attitudes of mental health professionals and the general public. Psychiatric Services (Washington, D.C.), 65(4), 490–497. https://doi.org/10.1176/appi.ps.201300136

Nihmotallahi Adebayo is a Nigerian-Jamaican Master of Science in Health Communication candidate at Northwestern University and a T37 Research Trainee at the Center for Health Equity Transformation. Her interests are in global mental health advocacy, health equity and making STEM education accessible to all. In her spare time, she enjoys reading, cooking and watching Netflix shows.

(c) 2020 Nihmotallahi Adebayo