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The Role of Bias in Clinical Decision-Making of People with Serious Mental Illness and Medical Co-morbidities: a Scoping Review

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Abstract 

The aim of this review was to examine the evidence for the impact of explicit and implicit biases against mental illness on the clinical decision-making of primary care physicians, medical students, and nurses when they are providing care to individuals with serious mental illness for cardiovascular disease, diabetes, and cancer. Studies were identified by searching MEDLINE, EBSCO host, and PsychINFO. A total of 18 studies published between 1996 and 2020 were reviewed and summarized. The studies were divided into two groups—studies that used a simulation or vignette methodology and those with a qualitative approach (interviews and focus groups). Of the simulation/vignette studies that allowed participants to report what they would have done in various clinical scenarios, there were roughly equal numbers of neutral or negative clinical decisions that represented 80% of the relevant behavioral results. Only 21% of the findings demonstrated a clinical decision that was favorable towards people with mental illness. Of the qualitative studies, all of the studies reported behaviors (either self-reported or observed) that were likely to be biased against people with mental illness, while 3 of the studies reported mixed results. Healthcare provider bias against individuals with mental illness does exist and impacts clinical decisions negatively. Much more empirical work needs to be done to determine the full extent and impact of the problem, including how these decisions affect the lives of individuals with mental illness.

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Authors and Affiliations

  1. Department of Psychiatry, LSU School of Medicine, 5246 Brittany Drive, Rm 340, Baton Rouge, Baton Rouge, LA, 70808, USA

    Kathleen A. Crapanzano MD MACM, Stephen Deweese MD, Diem Pham MD, Thanh Le PhD, Thanh Le PhD & Rebecca Hammarlund PhD

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  1. Kathleen A. Crapanzano MD MACM
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  2. Stephen Deweese MD
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  3. Diem Pham MD
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Correspondence to Kathleen A. Crapanzano MD MACM.

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Appendices

Appendix A – PubMed Search

  1. 1.

    "mental disorders"[All Fields]

  2. 2.

    "mental disorder"[All Fields]

  3. 3.

    "mental illnesses"[All Fields]

  4. 4.

    "mental illness"[All Fields]

  5. 5.

    "psychiatric"[All Fields]

  6. 6.

    "psychological"[All Fields]

  7. 7.

    "mentally ill"[All Fields]

  8. 8.

    "mental health"[All Fields]

  9. 9.

    "psychotic disorders"[All Fields]

  10. 10.

    "psychotic disorder"[All Fields]

  11. 11.

    "schizophrenia"[MeSH Terms] OR "schizophrenia"[All Fields]

  12. 12.

    "schizoaffective" [All Fields]

  13. 13.

    "psychosis"[All Fields]

  14. 14.

    "psychoses"[All Fields]

  15. 15.

    "bipolar disorder"[All Fields]

  16. 16.

    "bipolar and related disorders"[All Fields]

  17. 17.

    "mania"[All Fields]

  18. 18.

    "manias"[All Fields]

  19. 19.

    "manic"[All Fields]

  20. 20.

    "bipolar depression"[All Fields]

  21. 21.

    "depression"[All Fields]

  22. 22.

    "depressive disorder"[MeSH Terms]

  23. 23.

    "depressive"[All Fields] AND "disorder"[All Fields]

  24. 24.

    "depressive disorder"[All Fields]

  25. 25.

    "depression"[All Fields]

  26. 26.

    "depression"[MeSH Terms]

  27. 27.

    "depressive disorder, major"[All Fields]

  28. 28.

    "depressive neurosis"[All Fields]

  29. 29.

    "depressive neuroses"[All Fields]

  30. 30.

    "melancholia"[All Fields]

  31. 31.

    "dysthymic disorder"[All Fields]

  32. 32.

    "mood disorder"[All Fields]

  33. 33.

    "mood disorders"[All Fields]

  34. 34.

    "affective disorder"[All Fields]

  35. 35.

    "affective disorders"[All Fields]

  36. 36.

    OR 2 OR 3 OR 4 … OR 35

  37. 37.

    "physical health"[All Fields]

  38. 38.

    "physical disease"[All Fields]

  39. 39.

    "physical diseases"[All Fields]

  40. 40.

    "physical symptom"[All Fields]

  41. 41.

    "physical symptoms"[All Fields]

  42. 42.

    "psychosomatic"[All Fields]

  43. 43.

    "psychogenic"[All Fields]

  44. 44.

    "diabetes mellitus, Type 2"[All Fields]

  45. 45.

    "diabetes mellitus"[All Fields]

  46. 46.

    "type 2 diabetes"[All Fields]

  47. 47.

    "heart diseases"[All Fields].

  48. 48.

    "heart disease"[All Fields]

  49. 49.

    "prehypertension"[All Fields]

  50. 50.

    "hypertension"[All Fields]

  51. 51.

    "heart attack"[All Fields]

  52. 52.

    "heart attacks"[All Fields]

  53. 53.

    "myocardial ischemia"[All Fields]

  54. 54.

    "myocardial infarction"[All Fields]

  55. 55.

    "myocardial infarctions"[All Fields]

  56. 56.

    "coronary artery disease"[All Fields]

  57. 57.

    "coronary occlusion"[All Fields]

  58. 58.

    "neoplasms"[All Fields]

  59. 59.

    "malignant neoplasm"[All Fields]

  60. 60.

    "malignant neoplasms"[All Fields]

  61. 61.

    "cancer"[All Fields]

  62. 62.

    "cancers"[All Fields]

  63. 63.

    "malignancy"[All Fields]

  64. 64.

    "malignancies"[All Fields]

  65. 65.

    37 OR 38 OR 39 … OR 64

  66. 66.

    "attitude of health personnel"[All Fields]

  67. 67.

    "health personnel attitude"[All Fields]

  68. 68.

    "health personnel attitudes"[All Fields]

  69. 69.

    "provider attitude"[All Fields]

  70. 70.

    "provider attitudes"[All Fields]

  71. 71.

    "providers attitude"[All Fields]

  72. 72.

    "providers attitudes"[All Fields]

  73. 73.

    "physician attitude"[All Fields]

  74. 74.

    "physician attitudes"[All Fields]

  75. 75.

    "physicians attitude"[All Fields]

  76. 76.

    "physicians attitudes"[All Fields]

  77. 77.

    "nurse attitude"[All Fields]

  78. 78.

    "nurse attitudes"[All Fields]

  79. 79.

    "nurses attitude"[All Fields]

  80. 80.

    "nurses attitudes"[All Fields]

  81. 81.

    "provider perception"[All Fields]

  82. 82.

    "provider perceptions"[All Fields]

  83. 83.

    "providers perception"[All Fields]

  84. 84.

    "providers perceptions"[All Fields]

  85. 85.

    "physician perception"[All Fields]

  86. 86.

    "physician perceptions"[All Fields]

  87. 87.

    "physicians perception"[All Fields]

  88. 88.

    "physicians perceptions"[All Fields]

  89. 89.

    "nurse perception"[All Fields]

  90. 90.

    "nurse perceptions"[All Fields]

  91. 91.

    "nurses perception"[All Fields]

  92. 92.

    "nurses perceptions"[All Fields]

  93. 93.

    "provider bias"[All Fields]

  94. 94.

    "provider biases"[All Fields]

  95. 95.

    "physician bias"[All Fields]

  96. 96.

    "physician biases"[All Fields]

  97. 97.

    "prejudice"[All Fields] OR "implicit attitude"[All Fields]

  98. 98.

    "implicit attitudes"[All Fields]

  99. 99.

    "explicit attitude"[All Fields]

  100. 100.

     "explicit attitudes"[All Fields]

  101. 101.

      "attentional bias"[All Fields]

  102. 102.

      "attentional biases"[All Fields]

  103. 103.

      "cognitive bias"[All Fields]

  104. 104.

      "cognitive biases"[All Fields]

  105. 105.

      104. 66 OR 67 OR 68 … OR 104

  106. 106.

      ("1990/01/01"[PDAT]: "3000/12/31"[PDAT]) AND "humans"[MeSH Terms] AND English[lang]

  107. 107.

      36 AND 65 AND 104 AND 105

Appendix B – PsychINFO Search

  1. 1.

    "mental disorders"

  2. 2.

    "mental disorder"

  3. 3.

    "mental illnesses"

  4. 4.

    "mental illness"

  5. 5.

    "psychiatric"

  6. 6.

    "psychological"

  7. 7.

    "mentally ill"

  8. 8.

    "mental health"

  9. 9.

    "psychotic disorders"

  10. 10.

    “psychotic disorder”

  11. 11.

    schizophrenia

  12. 12.

    schizoaffective

  13. 13.

    “psychosis”

  14. 14.

    “psychoses”

  15. 15.

    “bipolar disorder”

  16. 16.

    “bipolar and related disorders”

  17. 17.

    “mania”

  18. 18.

    “manias”

  19. 19.

    “manic”

  20. 20.

    “bipolar depression”

  21. 21.

    "depression"

  22. 22.

    depression

  23. 23.

    "depressive disorder, major”

  24. 24.

    “depressive neurosis”

  25. 25.

    “depressive neuroses”

  26. 26.

    “melancholia”

  27. 27.

    "dysthymic disorder"

  28. 28.

    “mood disorder”

  29. 29.

    “mood disorders”

  30. 30.

    “affective disorder”

  31. 31.

    “affective disorders”)

  32. 32.

    32. 1 OR 2 OR 3 … OR 31

  33. 33.

    "physical health"

  34. 34.

    "physical disease"

  35. 35.

    "physical diseases"

  36. 36.

    "physical symptom"

  37. 37.

    "physical symptoms"

  38. 38.

    "psychosomatic"

  39. 39.

    "psychogenic"

  40. 40.

    “diabetes mellitus, Type 2”

  41. 41.

    “diabetes mellitus”

  42. 42.

    “type 2 diabetes”

  43. 43.

    “heart diseases”

  44. 44.

    “heart disease”

  45. 45.

    “prehypertension”

  46. 46.

    “hypertension”

  47. 47.

    “heart attack”

  48. 48.

    “heart attacks”

  49. 49.

    “myocardial ischemia”

  50. 50.

    “myocardial infarction”

  51. 51.

    “myocardial infarctions”

  52. 52.

    “coronary artery disease”

  53. 53.

    “coronary occlusion”

  54. 54.

    “neoplasms”

  55. 55.

    “malignant neoplasm”

  56. 56.

    “malignant neoplasms”

  57. 57.

    “cancer”

  58. 58.

    “cancers”

  59. 59.

    “malignancy”

  60. 60.

    “malignancies”

  61. 61.

    61. 33 OR 34 OR 35 … OR 60

  62. 62.

    “attitude of health personnel”

  63. 63.

    “health personnel attitude”

  64. 64.

    “health personnel attitudes”

  65. 65.

    “provider attitude”

  66. 66.

    “provider attitudes”

  67. 67.

    “providers attitude”.

  68. 68.

    “providers attitudes”

  69. 69.

    “physician attitude”

  70. 70.

    “physician attitudes”

  71. 71.

    “physicians attitude”

  72. 72.

    “physicians attitudes”

  73. 73.

    “nurse attitude”

  74. 74.

    “nurse attitudes”

  75. 75.

    “nurses attitude”

  76. 76.

    “nurses attitudes”

  77. 77.

    “provider perception”

  78. 78.

    “provider perceptions”

  79. 79.

    “providers perception”

  80. 80.

    “providers perceptions”

  81. 81.

    “physician perception”

  82. 82.

    “physician perceptions”

  83. 83.

    “physicians perception”

  84. 84.

    “physicians perceptions”

  85. 85.

    “nurse perception”

  86. 86.

    “nurse perceptions”

  87. 87.

    “nurses perception”

  88. 88.

    “nurses perceptions”

  89. 89.

    “provider bias”

  90. 90.

    “provider biases”

  91. 91.

    “providers bias”

  92. 92.

    “providers biases”

  93. 93.

    “physician bias”

  94. 94.

    “physician biases”

  95. 95.

    “physicians bias”

  96. 96.

    “physicians biases”

  97. 97.

    “prejudice”

  98. 98.

    “implicit attitude”

  99. 99.

    “implicit attitudes”

  100. 100.

      “explicit attitude”

  101. 101.

      “explicit attitudes”

  102. 102.

      “attentional bias”

  103. 103.

      “attentional biases”

  104. 104.

      “cognitive bias”

  105. 105.

      105.“cognitive biases”

  106. 106.

      106. 62 OR 63 OR 64 OR … 105

  107. 107.

      107. 32 AND 61 AND 106

Limiters: Boolean/Phrase, English, Research Article, January 1990-September 2019, Peer Reviewed, Journal Article.

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Crapanzano, K.A., Deweese, S., Pham, D. et al. The Role of Bias in Clinical Decision-Making of People with Serious Mental Illness and Medical Co-morbidities: a Scoping Review. J Behav Health Serv Res 50, 236–262 (2023). https://doi.org/10.1007/s11414-022-09829-w

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