It’s not in my head: a qualitative analysis of experiences of discrimination in people with mental health and substance use conditions seeking physical healthcare

Abstract

IntroductionClinician bias contributes to lower quality healthcare and poorer health outcomes in people with mental health and substance use conditions (MHSUC). Discrimination can lead to physical conditions being overlooked (diagnostic overshadowing) or substandard treatment being offered to people with MHSUC. This research aimed to utilise experiences of people with MHSUC to identify discrimination by clinicians, including the role of clinician’s beliefs and assumptions in physical health service provision.MethodsWe surveyed people with MHSUC who accessed physical healthcare services. Of 354 eligible participants, 253 responded to open-ended questions about experiences of those services. Thematic descriptive analysis of survey responses was completed using existing stigma frameworks and inductive coding.ResultsOne dominant theme from survey responses was that diagnostic overshadowing by clinicians was driven by clinician mistrust. Another theme was that clinicians assumed respondent’s physical symptoms, including pain, were caused by MHSUC. This influenced decisions not to initiate investigations or treatment. Respondents perceived that clinicians focused on mental health over physical health, contributing to suboptimal care.DiscussionDiscrimination based on MHSUC leads to poor quality care. Health systems and clinicians need to focus quality improvement processes on access to and delivery of equitable physical healthcare to people with MHSUC, address stereotypes about people with MHSUC and improve integration of mental and physical healthcare.

Dealing With Discrimination in Physical Health Care Services: Strategies of People With Mental Health and Substance Use Conditions

“…These results will be published separately. 30 For this secondary analysis, 2 phases of coding were completed of participants' responses to open-ended questions. The first phase involved structural coding, 31 where participants' survey responses were grouped using an existing stigma framework that defined public and self-stigma into components of stereotype, prejudice, and discrimination.…”

“…(26-35, F) Some people commuted long distances to reach preferred and trusted providers, valuing non-discriminatory care over the inconvenience of travel: I chose to stay with my current GP even though the location is inconvenient because they are very supportive and understanding of my health issues. (36-45,F) Changing providers was not always possible for people who had limited options and fear of being judged or labeled could prevent change: I've wanted to change practitioners, but I've generally just stuck it out… to avoid any appearance of being 'noncompliant' or 'doctor shopping' (26)(27)(28)(29)(30)(31)(32)(33)(34)(35)…”