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PubMed2000

A proposed national policy on health care workers living with HIV/AIDS and other blood-borne pathogens.

In 1991, scientific uncertainty about the risk of transmission of human immunodeficiency virus or hepatitis B virus (hepatitis B e antigen [HBeAg]-positive) led the Centers for Disease Control and Prevention to recommend that infected health care workers (HCWs) be reviewed by an expert panel and inform patients of their serologic status before engaging in exposure-prone procedures. The data demonstrate that risks of transmission in the health care setting are exceedingly low, suggesting that the national policy should be reformed. Implementation of the current national policy at the local level poses significant human rights burdens on HCWs, but does not improve patient safety. A new national policy should focus on the management of the workplace environment and injury prevention by creating a program to prevent blood-borne pathogen transmission; by encouraging infected HCWs to promote their own health and well-being; by discontinuing expert review panels and special restrictions for exposure-prone procedures, which stigmatize HCWs; by discontinuing mandatory disclosure of a HCW's infection status in low-level risk procedures; and by imposing practice restrictions to avert significant risks to patients. Inclusion of these principles would achieve high levels of patient safety without discrimination and invasion of privacy. JAMA. 2000;284:1965-1970.

Blood-Borne Pathogens↗
PubMed2003

Use of race and ethnicity in biomedical publication.

Researchers, clinicians, and policy makers face 3 challenges in writing about race and ethnicity: accounting for the limitations of race/ethnicity data; distinguishing between race/ethnicity as a risk factor or as a risk marker; and finding a way to write about race/ethnicity that does not stigmatize and does not imply a we/they dichotomy between health professionals and populations of color. Journals play an important role in setting standards for research and policy literature. The authors outline guidelines that might be used when race and ethnicity are addressed in biomedical publications.

Bias↗
PubMed2004

Etiology of pruritic papular eruption with HIV infection in Uganda.

CONTEXT: A frequent cause of human immunodeficiency virus (HIV)-related morbidity in sub-Saharan Africa is a commonly occurring, intensely pruritic skin rash. The resulting scars are disfiguring and stigmatizing. Despite the substantial prevalence of pruritic papular eruption (PPE) among HIV-infected Africans, the cause has been elusive. OBJECTIVE: To determine the etiology of PPE occurring in HIV-infected individuals. DESIGN, SETTING, AND PATIENTS: Cross-sectional study of HIV-infected patients with active PPE from clinics in Uganda conducted from May 19 through June 6, 2003. Enrollment occurred in the month preceding May 19. Each participant was clinically examined by 2 dermatologists, had laboratory studies performed, was administered an epidemiologic questionnaire, and had a skin biopsy of a new lesion evaluated by a dermatopathologist. MAIN OUTCOME MEASURES: Histological characteristics of new pruritic lesions. Other assessments included CD4 cell count, eosinophil count, and physician-assessed rash severity. RESULTS: Of 109 patients meeting inclusion criteria, 102 (93.6%) completed the study. The CD4 cell counts in this study population were generally low (median, 46/microL) and inversely related to increasing rash severity (median CD4 cell counts: 122 for mild, 41 for moderate, and 9 for severe; P<.001 for trend). Eighty-six patients (84%; 95% confidence interval, 77%-91%) had biopsy findings characteristic of arthropod bites. Patients with arthropod bites on biopsy had significantly higher peripheral eosinophil counts (median, 330 vs 180/microL; P = .02) and had a trend toward lower CD4 cell counts (median, 40 vs 99/microL; P = .07) than those without histological evidence of arthropod bites. CONCLUSIONS: Pruritic papular eruption occurring in HIV-infected individuals may be a reaction to arthropod bites. We hypothesize that this condition reflects an altered and exaggerated immune response to arthropod antigens in a subset of susceptible HIV-infected patients.

Adult↗
PubMed2005

Influence of patients' requests for direct-to-consumer advertised antidepressants: a randomized controlled trial.

CONTEXT: Direct-to-consumer (DTC) advertising of prescription drugs in the United States is both ubiquitous and controversial. Critics charge that it leads to overprescribing, while proponents counter that it helps avert underuse of effective treatments, especially for conditions that are poorly recognized or stigmatized. OBJECTIVE: To ascertain the effects of patients' DTC-related requests on physicians' initial treatment decisions in patients with depressive symptoms. DESIGN: Randomized trial using standardized patients (SPs). Six SP roles were created by crossing 2 conditions (major depression or adjustment disorder with depressed mood) with 3 request types (brand-specific, general, or none). SETTING: Offices of primary care physicians in Sacramento, Calif; San Francisco, Calif; and Rochester, NY, between May 2003 and May 2004. PARTICIPANTS: One hundred fifty-two family physicians and general internists recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%. INTERVENTIONS: The SPs were randomly assigned to make 298 unannounced visits, with assignments constrained so physicians saw 1 SP with major depression and 1 with adjustment disorder. The SPs made a brand-specific drug request, a general drug request, or no request (control condition) in approximately one third of visits. MAIN OUTCOME MEASURES: Data on prescribing, mental health referral, and primary care follow-up obtained from SP written reports, visit audiorecordings, chart review, and analysis of written prescriptions and drug samples. The effects of request type on prescribing were evaluated using contingency tables and confirmed in generalized linear mixed models that accounted for clustering and adjusted for site, physician, and visit characteristics. RESULTS: Standardized patient role fidelity was excellent, and the suspicion rate that physicians had seen an SP was 13%. In major depression, rates of antidepressant prescribing were 53%, 76%, and 31% for SPs making brand-specific, general, and no requests, respectively (P<.001). In adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10%, respectively (P<.001). The results were confirmed in multivariate models. Minimally acceptable initial care (any combination of an antidepressant, mental health referral, or follow-up within 2 weeks) was offered to 98% of SPs in the major depression role making a general request, 90% of those making a brand-specific request, and 56% of those making no request (P<.001). CONCLUSIONS: Patients' requests have a profound effect on physician prescribing in major depression and adjustment disorder. Direct-to-consumer advertising may have competing effects on quality, potentially both averting underuse and promoting overuse.

Adjustment Disorders↗
PubMed2000

Q-switch laser and tattoo pigments: first results of the chemical and photophysical analysis of 41 compounds.

BACKGROUND AND OBJECTIVE: In the Western world, there are at least 20-30 million people with tattoos. Improved self-image and social stigmatization are the main reasons for removing tattoos from skin. Q-switched lasers are applied to destroy the tattoo compounds in the skin. The treatment of tattoos containing ink often gives excellent results, whereas the results of treatments for coloured tattoos are not predictable and usually are worse. The chemical structure and the absorption spectra of the tattoo pigments are usually unknown. However, the efficacy of the treatment by using light of different Q-switched lasers (wavelengths 510, 532, 694, 755, 1064 nm) is correlated to both the chemical structure of the tattooed compounds yielding specific absorption spectra and the laser wavelength used. STUDY DESIGN/MATERIALS AND METHODS: A structural and spectroscopic analysis of 41 coloured pigments was performed. RESULTS: The 41 substances were identified, and they consist of 16 individual chemicals of different structured well-known industrial organic pigments. The absorption spectra of the 16 pigments were measured quantitatively. CONCLUSION: The results of the present analysis explain to some extent the outcome of clinical studies regarding laser therapy of coloured tattoos. Because the laser energy used produces a high temperature in the azo or polycyclic pigments, it is necessary to investigate whether that change causes possibly toxic or cancerogenic compounds.

Coloring Agents↗
PubMed2000

Food refusal and insanity: sitophobia and anorexia nervosa in Victorian asylums.

Although anorexia nervosa emerged as a new syndrome in the second half of the 19th century, this clinical picture seemed to be unknown in the psychiatric hospitals or asylums. In asylum medicine, the commonly used concept of sitophobia to designate food refusal in the insane covered a wide variety of mental disturbances and cannot be plainly equated with anorexia nervosa. A major difference is the occurrence of hallucinations and delusions specifically centered around religion and digestion. Most probably, anorectic patients were not treated in asylums, but at home, in the doctor's office, or in general hospitals. This pattern may be partly attributed to the fact that both patients and doctors were focusing on symptoms of self-starvation like emaciation, constipation, and amenorrhea, which were primarily interpreted as referring to somatic diseases. Additionally, wealthy families probably preferred private care in water-cure establishments, sanatoria, and rest homes to the stigmatizing referral of their anorectic daughter to an asylum. Hence, the fact that late 19th-century institutionalized psychiatry was only incidentally confronted with anorexia nervosa may explain its lack of interest in the emerging syndrome.

Feeding Behavior↗
PubMed1998

Patterns of spirituality in persons with advanced HIV disease.

This study was conducted to explicate the role of spirituality in dealing with the many struggles of advanced HIV disease. The research question that guided the study was: How is spiritual meaning structured in advanced stages of HIV disease? Published articles have lacked sound conceptions of spirituality that would allow it to be described apart from religion as a concept within humanistic science. Qualitative methodological assumptions were derived from interpretive interactionism. The spiritual experiences of 10 men and women in advanced-stage (symptomatic) HIV disease who self-identified that they had either spiritual or religious experiences that had helped them cope with HIV disease were interpreted. Data were collapsed, over three iterations, into three major themes to build the meaning of spirituality in HIV. Extracted themes were: purpose in life emerges from stigmatization; opportunities for meaning arise from a disease without a cure; and after suffering, spirituality frames the life.

Adaptation, Psychological↗
PubMed1998

Rationing organs using psychosocial and lifestyle criteria.

The role of patient psychosocial and lifestyle characteristics in decisions about the allocation of scarce health care resources has not been examined. In this national survey using the Criteria for Selection of Transplant Recipient (CSTR) Scale, organ transplant coordinators (N = 559) identified the psychosocial and lifestyle criteria they believe should be considered in patient selection/rejection for organ transplant. Using factor analysis to reduce the data, six factors were identified: current lifestyle/psychiatric problems, family/socioeconomic issues, habits, controlled lifestyle/psychiatric issues, cost, and stigmatized conditions. Patients who were in prison for a serious crime, used cocaine, had AIDS, or were HIV positive (criteria making up the Stigma factor), were more likely to be labeled for exclusion from transplant than those with other psychosocial/lifestyle characteristics. When transplant coordinators perceived that patients' psychosocial and lifestyle problems were under control or corrected, they were more likely to consider them for a transplant. For all but the cost factor, criteria were most stringent for heart transplants. Although over 90% of the coordinators assessed patients and participated in patient selection for transplant, master's prepared nurses were more likely than nurses with other educational preparation to be involved in organ recipient selection. These findings can serve as a prototype for how decisions are made for allocating other scarce health care resources.

Adult↗
PubMed1999

Employment of individuals with mental disabilities: business response to the ADA's challenge.

This research examines the response of the business community to the Americans with Disabilities Act (ADA) with specific focus on the employment of those with mental disabilities. The ADA is viewed as an important "rational myth" in that it represents both a legal and normative demand with which businesses are expected to comply. Yet employers' responses will be influenced by their attitudes toward persons with mental disabilities as well as their concern with legal sanction for discriminatory behaviors. A telephone survey was completed in a southern metropolitan area with a random sample of 117 businesses in order to access the knowledge employers have about the ADA (and its inclusion of those with mental disabilities), the compliance with the ADA, the employment practices, and the role played by stigma in the employment of individuals with mental disabilities. In terms of specific practices which indicated compliance with the ADA, a little over one-third of the companies which were surveyed by telephone had a Title 1 implementation plan, 15% had specific policies for hiring those with mental disabilities, and 37.6% had indeed hired such an individual. The role of coercive and normative rationales for compliance to the ADA was examined. It was found that receiving formal information about the ADA, threat of legal sanction, and previous employment of those with mental disabilities were all significant predictors of compliance with the ADA. Stigmatizing attitudes did not predict compliance, though employers did view those with mental disabilities with more discomfort than other types of employees.

Cooperative Behavior↗
PubMed2000

Commentary: listening to the message.

The first-person accounts of c/s/x experiences with the mental health system have several common threads that run through them. These are: (1) labels are stigmatizing; (2) pathology-based models are destructive: (3) it is important to value individuality; (4) alternative treatments are valuable: (5) peer support and self-help are important; (6) therapist training must be reconsidered; and (7) services should be recovery-oriented. In order to be as helpful as possible, mental health professionals must enter into creative partnerships with those in the c/s/x movement, and must consider incorporating these issues in their own functioning and in the training of future professionals.

Community Participation↗
PubMedDate not supplied

To tell or not to tell: patterns of disclosure among men with prostate cancer.

This paper draws on the results of a longitudinal, qualitative study of men with prostate cancer (treated with prostatectomy) and their spouses. Interviews were conducted separately and simultaneously with men and their spouses, at three points in time (pre-surgery, 8-10 weeks post-surgery and 11-13 months post-surgery). The primary focus in the paper is on men's responses to questions about their decisions to share information (or not) with others about their diagnosis and ongoing medical situation. Most men with prostate cancer avoided disclosure about their illness where possible, and placed great importance on sustaining a normal life. Factors related to limiting disclosure included men's low perceived need for support, fear of stigmatization, the need to minimize the threat of illness to aid coping, practical necessities in the workplace, and the desire to avoid burdening others. This study contributes to an understanding of disclosure issues related to prostate cancer, and raises issues about how best to be helpful to men, given their tendency to minimize the impact of illness, and the need for support.

Adaptation, Psychological↗
PubMed1996

The economic and psychosocial consequences of obesity.

Obesity is a multifaceted problem with wide-reaching medical, social and economic consequences. These are partly determined by the wealth and disease pattern of the population. In less-developed societies overweight may be advantageous and socially acceptable. In affluent societies obesity is a well-recognized health hazard and a socially stigmatized condition. For the obese person, excess weight denotes an increased risk of disabling chronic diseases, lowered quality of life and loss of earnings. For the society, obesity is a major economic burden. Treatment costs of diseases directly attributable to obesity are estimated to correspond to about 4-5% of the total health care expenditure. The indirect costs arising from loss of productivity due to obesity may be even higher.

Adaptation, Psychological↗
PubMed2004

The workers' compensation system: worker friend or foe?

BACKGROUND: The workers' compensation system was designed to help injured workers who have substantial medical expenses and perhaps have lost a great deal of income. This study determines both similarities and differences in how workers experience their interactions with the workers' compensation systems in Florida and Wisconsin. METHODS: Ethnographic open-ended interviews with 204 workers from Florida and 198 workers in Wisconsin were conducted. All the workers had back injuries in 1990 and were either paid workers' compensation temporary disability benefits for at least 4 weeks or received permanent disability benefits or compromise settlements. RESULTS: Some interactions with the workers' compensation system were positive. However, the majority of respondents in both states experienced their encounters with the workers' compensation system as cumbersome, frustrating, and demeaning. CONCLUSIONS: Mistrust, stigmatization, payment delays, and refusal of insurer personnel to pay benefits contribute to workers' negative experiences with the workers' compensation system. These insurer behaviors raise the costs to injured workers of workers' compensation benefits and thus may reduce the propensity of eligible workers to apply for benefits.

Accidents, Occupational↗
PubMed1993

Psychosocial aspects of osteogenesis imperfecta: an update.

Osteogenesis imperfecta (OI) is an inherited disorder in which affected individuals are stigmatized by virtue of physical differences from their peers. The extent to which these differences alter life style depend on the severity of the disorder, its natural history, the extent to which it affects social integration, the effect on physical appearance, and the presence of other affected family members. Some of these factors may adversely influence the ability of affected individuals to effectively adjust to their social and work environment and recognition of these factors may aid individuals and helpers in easing the path to a constructive life.

Adolescent↗
PubMed1993

Toward a social theory of psychiatric phenomena.

This essay relies on a positivistic/scientific perspective to define psychiatric phenomena. However, it draws a distinction between a biomedical versus a social science approach. The aim is to review some of the theoretical and empirical considerations that pertain to psychiatric phenomena that need to be addressed in order to develop a social theory about them. The object of the theory is to explain how psychiatric phenomena are labeled, interpreted, and handled across societies that differ in terms of social structure and culture. Some of the kinds of variables and questions that would allow for cross-cultural analyses are identified. In addition, two topics that a social theory could address--that of the medicalization and stigmatization of psychiatric phenomena--are introduced. These topics are elaborated by developing propositions that substantively illustrate the questions/hypotheses of a social theory of psychiatric phenomena. The essay illustrates that a social theory constitutes a complex enterprise that requires dealing with philosophical, methodological and empirical issues.

Attitude↗
PubMed2005

Accuracy of self-reported arrests among a forensic SPMI population.

Self-reports are prone to response error even in the most structured and standardized environment, but the highly stigmatizing nature of illegal behavior and the possible cognitive problems inherent to the SPMI population increase the likelihood of such error. Using administrative data as the gold standard, the validity of self-reported arrests was examined among 85 mentally ill substance-abusing individuals with justice involvement. The overall accuracy of self-reported arrests during a three-month recall period was 84.7%. Validity was higher among individuals who at the time of the follow-up interview were either in a jail diversion program or incarcerated. Individuals with a mood disorder appeared to be somewhat less accurate in their self-reports than subjects with schizophrenia, despite the implication of cognitive distortion accompanying this latter diagnostic category. Further research on issues such as the accuracy of self-reports over longer recall periods, or the accuracy of self-reported frequency of arrest, is necessary, given the reliance on self-report methodology in outcome studies.

Adult↗
PubMed2005

The impact of mental health evidence on support for capital punishment: are defendants labeled psychopathic considered more deserving of death?

Controversy surrounds the use of the Hare Psychopathy Checklist--Revised (Hare, 1991, 2003) in capital murder cases, where it has been introduced to support prosecution claims that a defendant represents a "continuing threat to society". Although widely presumed to have a prejudicial impact (e.g., American Psychological Association, 2004), little is known about how the lay public reacts to data derived from ostensibly stigmatizing assessment instruments such as the PCL-R. The present study examined the effect of psychopathy data on layperson attitudes by having 203 undergraduates review a capital murder case where the results of the defendant's psychological evaluation were experimentally manipulated. When expert testimony described the defendant as psychopathic, a much larger percentage of participants supported a death sentence (60%) than when testimony indicated that he was psychotic (30%) or not mentally disordered (38%). Interestingly, participant ratings of how psychopathic they perceived the defendant to be--regardless of the testimony condition to which they had been assigned--also predicted support for a death sentence. Given the limited probative value of the PCL-R in capital cases and the prejudicial nature of the effects noted in this study, we recommend that forensic examiners avoid using it in these trials.

Antisocial Personality Disorder↗
PubMed2005

Perceptions of illness in individuals with anorexia nervosa: a comparison with lay men and women.

OBJECTIVE: The current study examined and compared perceptions of illness in individuals with anorexia nervosa (AN) and lay men and women. METHOD: Participants with AN (n = 95) completed the Revised Illness Perception Questionnaire (IPQ-R). Lay participants (n = 80) completed a modified IPQ-R to elicit perceptions of AN. RESULTS: Participants with AN viewed their illness as chronic and highly distressing, with strong negative consequences. They had fairly negative perceptions of illness controllability and curability, which contrasted with the more optimistic beliefs held by lay participants. Both groups implicated emotional and psychological causes. DISCUSSION: The profile of illness perceptions expressed by the AN sample is associated with poor mental health and functioning and may inform the treatment approach. Lay perceptions of AN differed in the conceptualization of AN as a "slimming disease" amenable to change. This discrepancy may contribute to the stigmatization of AN.

Adult↗