Do patients with psychiatric histories receive less aggressive care for somatic illnesses? Researchers at the University of Iowa say yes, but the reasons are more complex than simple discrimination.

The investigators mailed a questionnaire to 300 Iowa family physicians asking them what treatment action they would prescribe for two hypothetical patients: a 43-year-old woman with symptoms suggestive of subarachnoid hemorrhage and a 62-year-old man with symptoms suggestive of a serious disorder, such as an aortic aneurysm.

The physicians were asked to evaluate these two patients in terms of having "no past history," "a history of major depressive disorder and a number of recent social stressors," or a "long history of somatic complaints without obvious organic etiology."

For each of these scenarios the physicians were asked these questions: Would they order more tests for the man? for the woman? Would they diagnose the woman as having subarachnoid hemorrhage? Would they diagnose the man as having a serious problem?

The findings showed that the physicians were significantly less likely to order more tests for the man and woman who had the psychiatric history of major depression than for the patients who did not. Furthermore, they were significantly less likely to diagnose the woman psychiatric patient as having subarachnoid hemorrhage and significantly less likely to diagnose the man psychiatric patient as having a "serious problem."

The patients with a history of somatic complaints were even less likely than those with a history of depression to receive more tests or to be diagnosed as having subarachnoid hemorrhage (woman) or a "serious problem" (man).

Although the researchers did not study why the physicians made the decisions that they had, investigator George Bergus, M.D., offered some insight into when physicians were influenced by patients’ psychiatric history.

"Physicians’ decision making is a two-step process: first, physicians judge the probability of disease. Then they make treatment decisions," said Bergus, a family physician and an associate professor of family medicine and psychiatry and codirector of the Combined Family Practice/Psychiatry Residency Program at the University of Iowa.

"In other words, if physicians judge that the probability of disease is above a threshold, they’ll do one thing; below, they’ll do another thing. In our study we found that the estimates of disease probability and likelihood of ordering more tests were highly correlated. This suggests that the physicians probably responded differently to the psychiatric patients because they viewed them as less likely to have serious medical disease. In other words, their psychiatric history impacted the first step. It did not seem to impact the second step."

Thus, to improve the medical care of psychiatric patients, physicians’ probability judgments need to improve, Bergus advised. This can be done through training, hands-on experience, and education, he said.

The study was published in the March Journal of General Internal Medicine.