Stigmatizing attitudes of primary care professionals towards people with mental disorders: A systematic review

Abstract

Objective

To examine stigmatizing attitudes towards people with mental disorders among primary care professionals and to identify potential factors related to stigmatizing attitudes through a systematic review.

Methods

A systematic literature search was conducted in Medline, Lilacs, IBECS, Index Psicologia, CUMED, MedCarib, Sec. Est. Saúde SP, WHOLIS, Hanseníase, LIS-Localizador de Informação em Saúde, PAHO, CVSO-Regional, and Latindex, through the Virtual Health Library portal (http://www.bireme.br website) through to June 2017. The articles included in the review were summarized through a narrative synthesis.

Results

After applying eligibility criteria, 11 articles, out of 19.109 references identified, were included in the review. Primary care physicians do present stigmatizing attitudes towards patients with mental disorders and show more negative attitudes towards patients with schizophrenia than towards those with depression. Older and more experience doctors have more stigmatizing attitudes towards people with mental illness compared with younger and less-experienced doctors. Health-care providers who endorse more stigmatizing attitudes towards mental illness were likely to be more pessimistic about the patient’s adherence to treatment.

Conclusions

Stigmatizing attitudes towards people with mental disorders are common among physicians in primary care settings, particularly among older and more experienced doctors. Stigmatizing attitudes can act as an important barrier for patients to receive the treatment they need. The primary care physicians feel they need better preparation, training, and information to deal with and to treat mental illness, such as a user friendly and pragmatic classification system that addresses the high prevalence of mental disorders in primary care and community settings.

Keywords

stigma stigmatizing attitudes primary care mental disorders

Introduction

Mental, neurological, and substance use disorders (MNSD) exact a high toll, accounting for 13% of the total global burden of disease.¹ The burden of disease attributable to MNSD increased by 41% between 1990 and 2010. MNSD accounts for one in every 10 disability adjusted life years² and affects disproportionally low- and middle-income countries .² Individuals with major depression and schizophrenia have a 40% to 60% greater chance of dying prematurely than the general population, owing to physical health problems that are often left untreated (e.g., cancer, cardiovascular diseases, diabetes, and HIV infection).²

It is widely known that people with mental disorders commonly present in primary care and that disorders such as depression, alcohol abuse, and epilepsy can be treated by primary care professionals.³ For instance, Ansseau et al.⁴ in a survey performed in Belgium found that, in the year prior to the study, 31% of adult patients in primary care services had affective disorders, 19% had some type of anxiety disorder, 18% had some type of somatoform disorder, and 10% had disorders related to use of alcohol, and other studies estimate that 24% of patients who present to primary care physicians (PCP) have a well-defined ICD-10 mental disorder.⁵ Scientific evidence shows that, worldwide, 69% of patients with mental disorders in primary care settings present to physicians with physical symptoms and that in many of those patients, the physical symptoms or physical illness remain undetected.⁵

It is recommended that common mental disorders be treated in primary care settings. However, a number of obstacles hinder PCPs’ ability to identify and to treat mental disorders. First, it has been shown that PCP have limited ability to diagnose a mental disorder because the training required for developing this ability is not routinely available in general medical undergraduate courses and medical training.⁶ Lack of training leads to difficulties in dealing with metal health problems, and to the maintenance of misconceptions about mental disorders.^6,7 Another important obstacle is the stigma or prejudice that primary care providers may have in relation to patients with mental disorders.^8–13

Stigma is defined as a process involving labeling, separation, stereotype endorsement, prejudice, and discrimination in a context in which social, economic, or political power is exercised to the detriment of members of a social group.¹⁴ It comprises three related dimensions, which, when combined are a powerful driver of social exclusion: (a) lack of knowledge (ignorance and misinformation), (b) negative attitudes (prejudice), and (c) excluding or avoiding behavior’s (discrimination).^12,15–18

Stigmatizing attitudes may influence how PCPs diagnose and treat individuals with mental disorders.¹⁹ Thus, although individuals with mental disorders may seek treatment more frequently from primary care than from specialized services, in part to avoid the labeling related to psychiatric treatment, they may also face stigma in primary care.²⁰

Health professionals who work in primary health-care services and support stigmatizing attitudes toward people with mental disorders are more pessimistic about their adherence to treatment, both for mental illness and physical illness. Stigma can lead professionals to make clinical decisions based on mistaken assumptions or against clinical standards or guidelines.¹³ In this context, unreceptive attitudes of professionals who perpetuate stigmatizing beliefs tend to distance people with mental disorders even more from the health care they need.^20,21

The main aim of this study examined stigmatizing attitudes towards people with mental disorders among PCPs and to identify potential factors related to stigmatizing attitudes through a systematic review.

Methods and procedures

We performed a systematic review of the scientific literature through the Biblioteca Virtual em Saúde (Virtual Health Library)—BVS. The BVS automatically runs searches in the following databases: Medline, Lilacs, PubMed, IBECS, Lilacs, Index Psicologia – Periódicos técnicos-científicos, CUMED, CidSaúde-Cidades saudáveis, MedCarib, BDENF-Enfermagem, Sec. Est. Saúde SP, WHOLIS, BBO-Odontologia, Hanseníase, HomeoIndex-Homeopatia, LIS-Localizador de Informação em Saúde, PAHO, CVSO-Regional, and Latindex. Additionally, reference lists of included studies and reviews were checked for potentially relevant articles not identified through the electronic search. We used the following search terms: stigma-related terms AND primary care AND mental health-related terms as follows:

((tw:(stigma*)) OR (tw:(discriminat*)) OR (tw:(prejudice*)) OR (tw:(social distance*)) OR (tw:(stereotyp*)) OR (tw:(attitude*)) OR (tw:(behav*))) AND (tw:(primary care)) AND ((tw:(mental disorder*)) OR (tw:(mental illness*)) OR (tw:(mental disease*)) OR (tw:(mental disabilit*)) OR (tw:(psychiatr* disorder*)) OR (tw:(psychiatry* illness*)) OR (tw:(psychiatry* disease*)) OR (tw:(psychiatry* diagnos*))).

Titles and abstracts were screened, and full reports of potentially relevant studies were obtained. Two authors (AORV and DJV) independently assessed the reports for eligibility, with discrepancies resolved by discussion with a third author (WSR).

We included quantitative studies which assessed stigmatizing attitudes towards mental health problems, mental health symptoms, or mental disorders, among PCPs in English, Spanish, and Portuguese. Articles were excluded based on the following exclusion criteria: (1) if they referred to non-data-based studies (e.g., editorials, commentaries, opinion papers, and review papers) and (2) if stigmatizing attitudes were assessed among non-physician primary care professionals, such as nurses, technicians, social workers, and other professionals, among mental health professionals, or in the general population. Data on study design, sample characteristics, and findings were extracted independently by two authors (AORV and DJV). Because of heterogeneity between studies, which hindered a statistical synthesis of their results, we summarized evidence from articles included in the review through a narrative synthesis.²²

Results

The database search identified 19.109 non-duplicate references. After reviewing titles and abstracts, 15 articles were identified as potentially relevant and were assessed against eligibility criteria. Eleven studies fulfilled inclusion criteria (Figure 1) and are summarized in Table 1 .

Figure 1.

The number of articles found to be included in the review.²³

Table 1.

Summary of Included Articles by Categories.

	Objectives	Method and sample	Covariates	Results
Country: United States and Canada.Year of publication: 1993Study date: 1993	To examine the relation between primary care clinicians’ attitudes, beliefs, and training and their perceptions of the importance and frequency of depression.	A 56-item questionnaire was mailed to 226 clinicians in the Ambulatory Sentinel Practice Network Inc. (ASPN), a primary care research network.	Demographic variables, attitudes of the primary care practices, beliefs, training, treatment.	Results of path analysis indicate that clinician training in depression, beliefs about the burden and discomfort associated with diagnosing and treating depression, perceptions of their patients’ discomfort, and self-efficacy in diagnosing and treating depression are all significantly related to clinician perceptions of whether depression was an important and frequent primary care problem. Further analysis indicates that actual prevalence of depression accounted for little variability in clinicians’ beliefs and attitudes about depression.
Country: Brazil. Year of publication: 1996 Study date: 1994	To assess the attitudes towards depression among general practitioners working in primary health care centers in Brazil.	Cross sectional study. All general practitioners working in the city of Campinas were invited to complete the Depression Attitude Questionnaire (DAQ) (N=110); 78 (71%) of them completed the DAQ.	Demographic variables, attitudes of the general practitioners.	Forty-two percent of participants considered it “difficult to differentiate whether patients are presenting with unhappiness or a clinical depressive disorder that needs treatment”; 47% of them agreed or strongly agreed that “the majority of depression seen in general practice originates from patients’ recent misfortunes.” The statement “I feel comfortable in dealing with depressed patients’ needs” was endorsed by 57% of respondents, 46% agreed that “Working with depressed patients is heavy going,” and 27% felt it is not “rewarding to spend time looking after depressed patients.”
Country: Spain. Year of publication: 1999 Study date: 1999	To assess primary care physicians’ attitudes towards excessive alcohol consumption and to identify potential predictors of physicians’ stigmatizing attitudes.	The study applied a structured, anonymous, self-administered survey, consisting of socio-demographic- and labor-related variables, as well as a Likert-scale questionnaire on attitudes. Total sample comprised 486 medical professionals (except pediatricians) working in primary care in the Murcia region were invited to answer the questionnaire; 227 (46.70%) agreed to participate.	Demographic variables, attitudes of the general practitioners, labor variables.	They presented skepticism (68.9%) when treating patients with problems caused by inadequate intake of alcohol and indifference in their work with patients with alcohol problems, although they agreed (72.9%) they should continue training on the subject of alcohol abuse. It was found that older medical professionals were less likely to work with individuals with alcohol problems.
Country: Finland. Year of publication: August 2000Study date: May 2000	To identify barriers to healthcare providers carrying out competent brief interventions to help heavy drinkers to reduce their drinking.	A questionnaire on attitudes, skills, knowledge, training needs and suggestions for implementation of brief interventions was mailed to all nurses and physicians working in primary health care in two Finnish cities. One hundred and sixty-seven primary health care nurses and 84 physicians returned the questionnaire.	Demographic variables, attitudes of the physicians, knowledge, skills and beliefs.	The physicians were readier than the nurses to discuss alcohol with their patients and more of them thought that detection and treating of early phase alcohol abusers was appropriate to their everyday work. Physicians were more familiar than nurses with the content of brief interventions. The nurses expressed a greater need for training than the physicians. “More practical training” was most often their first choice (50%; 103/205). It was also most often among their three choices (90%; 184/205). The respondents also expressed a need for more information about brief intervention studies; 27% (56/205) gave this as their first choice and 63% (130/205) placed it among their three choices. Personal training and lectures were also often among the three most important choices (49%; 100/205 and 36%; 74/205, respectively).
Country: Israel. Year of publication: 2007Study date: 2002	To examines the knowledge, attitudes and barriers of primary care physicians toward providing care for depression and anxiety in their practices.	They constructed a questionnaire with face validity. The main domains of the questionnaire are as follows: (A) attitudes and knowledge and competence, (B) barriers toward depression and anxiety care, and (C) definition of measures to improve the care of these disorders in primary care practice. They sent the questionnaire to 99 primary care physicians (PCPs) from 14 primary care clinics in the southern district of CHS in the Beersheba region. All the clinics in the region, 14 altogether, were approached. All the clinics were urban.	Demographic variables, attitudes of the primary care physicians, knowledges, barriers.	80.6% of the participants agreed with the statement that depression and anxiety are frequent problems in primary care and they should be treated in primary care clinics, but 37.3% reported to have little interest in treating mental disorders, 47.7% thought depression and anxiety should be treated in mental health clinics; 43.3% of the participants declared that they experienced a personal difficulty in taking care of patients with depression and anxiety, and 85% identified time constraint as a major barrier to care of depression and anxiety in primary care; 80.6% of the physicians would like to improve their knowledge in diagnosis and treatment of depression and anxiety, 83.6% would like to improve their skills and 80.6% would like to receive personal counseling from psychiatrists (outreach visits) concerning their patients.
Country: Switzerland. Year of publication: 2005Study date: 2001	To obtain information about the number of patients in the early and chronic stages of schizophrenia seen in general practice; the needs and attitudes of GPs, their diagnostic knowledge concerning early phases of schizophrenia and their knowledge and practice concerning treatment of patients with first-episode and multi-episode schizophrenia.	Questionnaires were sent to 3978 GPs in a first wave in April 2001. The same questionnaire was sent 8 months later to the same GPs. Owing the retirement and the refusal to participate of some GPs, the second sample consisted of 3830 GPs. The questionnaire was anonymous with 23-items consisted of four demographic items, and 19 (partly multi-item) questions which assessed six dimensions to analyze.	Demographic variables, attitudes of the primary care physicians, knowledges, needs and treatment.	A total of 1089 GPs responded to the survey. A fifth of GPs (230; 21%) reported no problems when treating patients with established schizophrenia; 608 (56%) judged the patients’ behavior to be problematic but continued care in their practice, and 144 (13%) preferred to refer patients because of their problematic behavior. In addition, the more GPs considered the patient’s behavior to be problematic, the more often they referred them to specialists and did not seek collaboration. Early psychosis had a low prevalence in general practice, and GPs expressed a wish for specialized, low threshold referral services. Diagnostic and treatment knowledge showed inconsistencies. Most GPs said they would treat first-episode schizophrenia with antipsychotics, but only a third recommended maintenance treatment after a first episode of schizophrenia that would conform with international recommendations.
Country: Brazil. Year of publication: 2009Study date: 2007	Reports on the views of Primary Health Care (PHC) providers in Southeast Brazil on the use of alcohol and other drugs which reflect stigma, moralization, or negative judgment.	Non-controlled exploratory study, with an intentionally defined sample. Attitudes toward the use of alcohol and other drugs were evaluated in comparison to Hansen’s disease, obesity, depression, schizophrenia, HIV/AIDS, and tobacco use. Six hundred and nine PHC professionals in active public health care service took part in the study: 369 (60.6%) served in municipalities in the Zone da Mata region of the State of Minas Gerais, and the other 240 (39.4%) in Ribeirão Preto in the State of São Paulo, Brazil.	Demographic variables, Medical condition (Tobacco use, Marijuana/Cocaine dependence/Alcoholism/HIV-AIDS/Obesity/Depression/Hansen´s Disease/Schizophrenia).	Regarding attitudes towards alcohol addiction, primary care physicians had the lowest scores, meaning less negative attitudes, when compared to other health professionals. There was a similar trend when comparing the professionals’ views of different health conditions: primary care physicians had the lowest prevalence of negative attitudes about marijuana/cocaine dependence. No differences were observed regarding difficulties in dealing with patients in relation to the length of work history in PHC, age or gender of professionals. The study found a positive and statistically significant correlation between primary care physicians and the other professionals age and moral judgment towards alcoholics (increased age, increased moralization).
Country: Australia. Year of publication: 1999Study date: 1999	Compare the Australian public’s attitudes towards people who have been treated for a mental disorder with the attitudes of general practitioners (GPs), psychiatrists and clinical psychologists	Cross sectional study. The survey was posted to all psychiatrists in Australia, a sample of general practitioners (GPs) listed on the national register of medical practitioners (the Medicare Provider File), and all members of the College of Clinical Psychologists. The questionnaire was based on a vignette of a person suffering from a mental disorder. A household survey was carried out with a nationally representative sample of 2031 Australian adults aged 18 to 74 years in August 1995. This sample represented a response rate of 85%.	Demographic variables, attitudes of the general practitioners.	For the depression vignette, the public rated positive outcomes as more likely and negative outcomes as less likely than did the physicians and the psychiatrists. Clinical psychologists also rated positive outcomes as more likely and negative outcomes as less likely than did physicians; clinical psychologists and physicians rated negative outcomes as less likely than did psychiatrists. For the schizophrenia vignette, the general population rated positive outcomes as more likely and negative outcomes as less likely than did all three professional groups. For the schizophrenia vignette, the general population was less likely to believe there would be discrimination than the physicians and the other two professional groups. There was general agreement that discrimination was more likely for schizophrenia than depression. For physicians, there was a significant effect of age group on ratings of negative outcomes for schizophrenia, with younger physicians making more negative ratings, although post hoc Scheffe tests found no differences between pairs of age groups at the p<0.01. Female physicians, who tended to be younger psychiatrists rated negative outcomes as more likely for both depression and schizophrenia.
Country: Hong Kong. Year of publication: 2013Study date: 2009–2010	Describe the attitudes of primary care physicians towards mental health patients in Hong Kong, especially to examine the doctors’ views on schizophrenia and depression, and the influence of their demographic variables.	Cross sectional study. Questionnaire developed by the research team was sent to members of Hong Kong College of Family Physicians. Potential respondents were allocated on equal basis to one of the two sets of questionnaire, set 1 for clinical vignette of schizophrenia and set 2 for depression. (Response rate of 37% (500 of 1360).)	Sex, Work setting, Work sector, Type of practice, Relative/friend with mental disorders, Years since graduation, Type of mental illness.	The authors found that primary care doctors in Hong Kong had more negative attitudes towards patients with schizophrenia than depression. Also the results showed that primary care doctors were more willing to treat patients with depression (71.5%) than schizophrenia (40%). They were less likely to feel comfortable to deal with the needs of patients with schizophrenia (37.0%) than of patients with depression (60.9%). The more experienced doctors were more likely to refer patients with schizophrenia or depression to specialized treatment because they considered it annoying to deal with such patients. Experienced doctors showed more negative attitudes towards patients with mental disorders in general than the less experienced ones. These results suggest that clinical experience accumulated through years of practice may not strengthen medical practitioners’ confidence and attitudes in managing psychiatric patients.
Country: United States. Year of publication: 2014Study date: 2011–2012	Evaluate completed measures of stigma characteristics, expected adherence, and subsequent health decisions (referral to a specialist and refill pain prescription) about a male patient with schizophrenia who was seeking help for low back pain due to arthritis.	Cross sectional study. Research participants completed one of two vignettes of a patient (described more fully below) who varied based on presence or absence of a diagnosis of schizophrenia. Nurses, physicians, and psychologists from mental health and primary care clinics were recruited from five VA hospitals in the southeast and southwest areas; 166 health-care providers (42.2% primary care, 57.8% mental health practice) from the Veteran’s Affairs (VA).	Sex, age, ethnicity, professional discipline.	The study showed that health care providers who stigmatized mental illness were more likely to be pessimistic about the patient’s adherence to treatment. Stigma was greater among those providers who were relatively less comfortable with using mental health services themselves.
Country: United States. Year of publication: 2014Study date: 2011–2012	This study compared the attitudes of mental health and primary care providers toward persons with schizophrenia at 5 Veterans Affairs (VA) facilities.	This study utilized a cross-sectional anonymous survey, including clinical vignettes describing identical patient scenarios for a hypothetical patient with and without schizophrenia, to examine the differences in attitudes of primary care and mental health providers. Participants included 351 VA providers from 5 VA medical centers, including 205 mental health providers (psychiatrists, psychologists, and mental health nurses) and 146 primary care providers (nurses and physicians).	Covariates included provider years in clinical practice, data collection site, demographic variables including provider age, gender and race.	The results revealed, on the stereotype characteristic scale, that both primary care physicians and primary care nurses expressed more negative stereotypes toward the individual with schizophrenia than the individual with depression in the questionnaire and the two clinical vignettes. For the social distance model, both primary care physicians and psychiatrists showed more social distance toward the individual with schizophrenia than the individual with depression.

All the 11 studies included in the review used a cross-sectional design to assess stigmatizing attitudes towards mental disorders through questionnaires developed by the authors in six studies and one study using a standardized scale. Two studies were conducted in Brazil,^24,25 two in the United States,^19,26 one in Australia,¹⁰ one in Hong Kong,²⁷ one in Spain,²⁸ one from Finland,²⁹ one from United States and Canada,³⁰ one from Israel,³¹ and one from Switzerland.³²

Three studies included in the review assessed attitudes towards depression and anxiety among general practitioners working in primary care.^24,30,31 All the studies considered that depression is a frequent problem in primary care. One of the studies²⁴ found that 42% of physicians considered it “difficult to differentiate whether patients are presenting with unhappiness or a clinical depressive disorder that needs treatment”; that 47% of professionals agreed or strongly agreed that most of depressive symptoms “originates from patients’ recent misfortunes”; that 46% and 27% of physicians, respectively, considered it to be “heavy going” and “not rewarding” to work with depressed patients. However, 57% of respondents reported feeling “comfortable in dealing with the need of depressive patients.” Despite the consideration that depression is a problem that should be treated in primary care, in the study from Israel³¹ almost the 50% of the sample stated that the preferential locus for treatment of depression and anxiety are mental health clinics, 80.6% of the physicians agreed that there is under-diagnosis and under-treatment of depression and anxiety in primary care; and 37.3% stated that they have no interest in treating depression and anxiety in primary care. Coinciding with this, in the third study,³⁰ the PCPs who think their patients feel uncomfortable with their broaching issues about depression see depression as less important in primary care. Moreover, PCPs are more likely to feel satisfied if their self-efficacy for diagnosing, treating, and managing depression is high.

Three articles assessed PCP’s views, knowledge’s, beliefs, and attitudes (including stereotypes and moral attributions) towards alcohol consumption and drugs dependence.^25,28,29 Whereas one of the studies²⁵ found that PCP had the lowest scores, meaning less negative attitudes towards alcohol addiction and towards marijuana/cocaine dependence, when compared to other health professionals, the other study²⁸ found that 69.9% of PCP presented skepticism when treating patients with problems caused by alcohol misuse and presented indifference in their work with patients with alcohol-related disorders. The third study²⁹ found that 87% of PCPs “have positive attitudes towards discussing alcohol with patients,” and that 81% of them “thought that detection and treating of early phase alcohol abusers was appropriate to their everyday work.”

Two articles^26,32 evaluated stigmatizing attitudes toward schizophrenia, by assessing stigma characteristics, physician’s needs and expectations about patients’ adherence to treatment, and subsequent health decisions (referral to a specialist and refill pain prescription). The first study²⁶ showed that physicians who stigmatized mental illness were more likely to be pessimistic about the patient’s adherence to treatment.²⁶ In the other study,³² 21% of PCPs reported no problems when treating patients with schizophrenia, 56% kept treating schizophrenic patients, even though they considered patients’ behavior to be problematic, and 13% preferred to refer patients for considering their behavior to be problematic. The study also showed that the more PCPs considered the patients behavior to be problematic, the more often they referred them to specialists.

Three studies compared PCP’s attitudes towards patients with schizophrenia with their attitudes towards patients with depression.^10,19,27 PCP’s stigmatizing attitudes were greater towards patients with schizophrenia than towards patients with depression. PCPs were more willing to treat patients with depression than schizophrenia, and they were less likely to feel comfortable to deal with the needs of patients with schizophrenia than of patients with depression.

Four^10,25,27,28 of the articles included in the review assessed factors that might be associated with physicians’ stigmatizing attitudes towards mental disorders. Two studies^25,27 found a statistically significant association between age and stigmatizing attitudes, meaning that older physicians presented higher moralization towards alcohol-related disorders²⁵ and lower willingness to work with patients with alcohol problems.²⁸ Another study, however, found results in the opposite direction when the younger physicians presented higher levels of stigma than the older one.¹⁰ Alongside with age, training is another factor that might impact PCPs attitudes and clinical practice. PCPs with more training in depression, for example, felt significantly more comfortable dealing with depressed patient, when compared to PCPs with no or little training.³⁰ Moreover, a major proportion of PCPs (59.7% indicated lack of knowledge in diagnosis and treatment) referred/appointed lack of training as a major barrier for treating patients with depression and anxiety, and, therefore, referred/appointed the need of training for improving their skills to treat patients with mental health problems (83.6% of the PCPs).³¹ Also, stigma was greater among those providers who were relatively less comfortable with using mental health services themselves.²⁶

Five^{24,28,30–32} articles include in their results the impact of the training in the attitudes and clinical practice of the PCPs. In one of the studies,³¹ almost 60% of the sample indicated the lack of knowledge in diagnosis and treatment as barriers to care people with depression and anxiety. On the other hand, those PCPs with more training in depression experienced significantly less discomfort while addressing in that those with little or no training.³⁰ The need of more training is a common conclusion by the PCPs in order to improve their skills to treat people with mental disorders.^24,28,32

When compared the stigmatizing attitudes from PCPs with mental health professionals or general population, one study¹⁰ found that the public rated positive outcomes as more likely and negative outcomes as less likely than did the physicians and psychiatrists for depression patients. Also, regarding patients with schizophrenia, the general population rated positive outcomes as more likely and negative outcomes as less likely than did all three professional groups, and the general population was less likely to believe there would be discrimination against patients than the physicians did.

Discussion

The results of this systematic review show that stigmatizing attitudes towards patients with mental disorders are common among physicians in primary care settings, and that many physicians do not feel comfortable to deal with patients with mental disorders. Stigmatization towards schizophrenia was found to be significantly higher than towards depression,^10,27,33 and PCPs’ views were more negative about a patient with schizophrenia than an otherwise identical patient with depression.³⁴ These findings of primary care providers having more negative views of individuals with schizophrenia are consistent with other studies which considered stigmatizing attitudes among others primary care professionals like nurses, social workers, and mental health professionals.^35–38

Our results also show that physicians have more negative attitudes towards mental illness when compared to other professionals and to the general population. Studies comparing such groups found that physicians had the highest levels of stigmatizing attitudes, followed by other primary care professionals, mental health professionals, and the general population.^10,19,25,26

The literature suggests that stigmatizing attitudes among physicians are associated with a lack of adequate training regarding treatment and identification of mental disorders.^39–41 Research has repeatedly identified deficiencies in both the identification and management of depressive illness in general practice.^42–45

There is evidence that physicians stigmatizing attitudes towards mental disorders might be an important barrier for people with mental health problems to receive the treatment they need.^19,26 Negative attitudes of primary care providers and mental health providers may contribute to disparities in physical health care for persons with serious mental illness such as schizophrenia.^41,46–50 One of the most important negative attitudes was the erroneous attribution of the signs and symptoms of physical illness to concurrent mental disorders, as it may result in physical ailments being undertreated due to the so-called “medical bias” or “diagnostic overshadowing” related to providers’ negative attitudes.⁵¹

As most depressed patients seek treatment in primary care settings, and these patients are frequently undertreated, it is important to identify ways to increase the effectiveness of primary care clinicians in managing depression. Interventions need to consider the context of the primary care setting and consider barriers to treatment including lack of adequate time, training, competing agendas, and lack of adequate reimbursement. Ineffective treatment leads to patient and physician frustration due to lack of progress.⁵² Thus, primary health-care providers represent a potential target for interventions to reduce disparities in care for individuals with depression, schizophrenia, and in clinical care in general.^27,28,53

The main limitation of the study was the search strategy, which may have led to publication bias as potential sources of gray literature were not included. However, the search was conducted in the main medical databases, using terms which have been previously used in the literature on stigma, and references of the studies selected were carefully screened to find further studies.⁵⁴ Another limitation was the heterogeneity between studies—particularly regarding the assessment of stigma. Such heterogeneity limits the possibility of combining and synthesizing findings of different articles. Additionally, it was not possible to combine studies’ results in a statistical synthesis (meta-analysis) given the heterogeneity in analysis strategies and results from individual articles. For this reason, we decided to summarize the results of articles included in the review through a narrative synthesis. Another important limitation is that most of the results in the review are based on a single study, which have important implications when interpreting and generalizing our results.

The main conclusion of this review is that stigmatizing attitudes towards people with mental disorders are common among primary care professionals, and that professionals need more training and adequate tools to deal with mental disorders, such as a user friendly and pragmatic classification system that addresses the high prevalence of mental disorders in primary care and community settings.⁵⁵ The reduction of stigma among health professionals is important to reduce barriers to treatment faced by people with mental disorders and, thus, to increase their access to optimal care, which would lead to improvement in their mental health status and well-being.

Footnotes

Acknowledgments

Angel O Rojas Vistorte is receiving a scholarship from CAPES foundation of the Brazilian Ministry of Education for his doctorate training in the Department of Psychiatry, Federal University of São Paulo. Denisse Jaen is also funded by Capes for her doctorate training. Jair de Jesus Mari is an I-A senior researcher from the National Brazilian Council (CNPq). Sara Evans-Lacko and Wagner Silva Ribeiro are funded by the European Research Council under the European Union’s Seventh Framework Programme (FP7/2007-2013)/ERC grant agreement number (337673).

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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