Crapanzano et al.1 address an important concern that medicine as a profession is only beginning to acknowledge and moves the field in a direction towards increasing awareness and unbiased treatment. The majority of the regrettably sparse literature on the subject addresses implicit racial and ethnic assumptions in medical student2 and physician3 contributions to healthcare disparities and racial and ethnic stigmatization. Similarly, there is a paucity of empirical research on implicit biases regarding mental illness and the resulting negative impact on care of this vulnerable population.4
Crapanzano found that internal medicine residents were more likely than their psychiatric colleagues to view depression negatively and to associate depression with being untreatable. These biases could have considerable health implications as more than half of visits to primary care physicians for somatic concerns involve anxiety or depression.5 Such implicit assumptions would likely adversely affect quality mental health treatment. This compelling study is an important first step in mitigating this heretofore unseen potential harm.
The study leaves a number of important questions unanswered. Firstly, the authors looked at resident’s implicit attitudes to words that indicate depressive affect, not the clinical entity of depression. This points to a larger potential concern, as many more patients present to primary care physicians with depressed mood than do those with a discrete psychiatric diagnosis. Is being sad, regardless of diagnosis, a potential hazard with respect to treatment?
Also left unanswered is an assessment of implicit bias against anything providers feel insufficiently trained to treat. Does the data reflect a true bias against depression or does it reflect a feeling of lack of proficiency? It is easy—and probably correct, to assume some prejudice and negative stigmatization toward mental illness, though this might be partially confounded by feelings of therapeutic inadequacy.
For making us more aware of implicit bias, the authors are to be applauded.
References
Crapanzano K, Fisher D, Hammarlund R, Hsieh EP, May W. An exploration of residents’ implicit biases towards depression—a pilot study. J Gen Intern Med. https://doi.org/10.1007/s11606-018-4593-5.
van Ryn M, Hardeman R, Phelan SM et al. Medical school experiences associated with change in implicit racial bias among 3547 students: a medical student changes study report. J Gen Intern Med. 2015;30:1748. https://doi.org/10.1007/s11606-015-3447-7.
Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate healthcare disparities. J Gen Intern Med. 2013;28:1504. https://doi.org/10.1007/s11606-013-2441-1.
Dabby L, Tranulis C, Kirmayer LJ. Explicit and implicit attitudes of Canadian psychiatrists toward people with mental Illness. Can J Psychiatr. 2015;60(10):451–459. https://doi.org/10.1177/070674371506001006.
Kroenke K. The interface between physical and psychological symptoms. Primary Care Companion J Clin Psychiatry. 2003;5(suppl 7):11–18.
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Furman, A.C. Capsule Commentary on Crapanzano et al., An Exploration of Residents’ Implicit Biases Towards Depression—a Pilot Study. J GEN INTERN MED 33, 2189 (2018). https://doi.org/10.1007/s11606-018-4644-y
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DOI: https://doi.org/10.1007/s11606-018-4644-y