Overlooked
Dr Cheryl Buhay Pathways Clinical Director takes look at diagnostic overshadowing.
Unconscious bias
Navigating the complex landscape of healthcare can be a challenge, and for many people, the path to a correct diagnosis is far from straightforward. Diagnostic overshadowing is a significant issue that I see regularly in my work. It's when a person's physical symptoms get incorrectly attributed to their existing mental health or substance use diagnosis. This bias, which is often unconscious, can lead to delayed or missed diagnoses of serious physical ailments, with potentially severe consequences.
Health over shadowed
As a clinical director at Pathways, I know firsthand that diagnostic overshadowing means that healthcare providers or kaimahi (staff) might attribute a person's experience to their mental health or substance use issues, rather than looking at what else their ailment could possibly be, including physical causes.
Specialist General Practitioner Dr. Louise Kuegler explains that diagnostic overshadowing in general practice often shows up when someone already has a mental health diagnosis, like anxiety or bipolar disorder, and then presents with new physical symptoms. For instance, a patient with a known generalized anxiety disorder might present with intermittent chest pressure and fatigue. She says, "If a doctor focuses on a past diagnosis of panic attacks, they risk missing something serious, like ischemic heart disease."
“Another group we often see are women in perimenopause, says Dr Kuegler. “Many have previously experienced anxiety or depression and are quickly diagnosed as ‘anxious’ when they present with sleep disturbance and anxiety. They are often prescribed SSRIs, when in fact the underlying issue is hormonal. Once they reach an experienced primary care physician who recognises perimenopause and initiates menopausal hormone therapy, their anxiety frequently resolves as soon as treatment begins.”
Why does it happen?
I believe a lot of it comes down to bias and stigma. There's a tendency to dismiss physical complaints, assuming a person with a mental health condition is "acting up again." Past medical history can create a dangerous bias, leading to assumptions instead of a fresh assessment. That judgement from before can cloud how we view and diagnose someone.
Dr. Kuegler also highlights the pressures on primary care, with long waits for specialist services and limited workforce capacity. "While holistic care is at the heart of general practice, the realities of time pressures, workforce shortages, and structural barriers often create tension between what we aspire to provide and what is practically possible," she notes. “Mental health issues are on the rise in general practice, with about one-third of GP consultations in New Zealand now including a mental health component. I believe this rise can be attributed to several factors, including the lingering impacts of the pandemic, economic pressures like housing stress, and the cost of living.”
Towards a holistic approach
Dr. Kuegler's key principle for GPs is to "treat new symptoms as new, avoiding premature closure based on past mental health labels." She advises healthcare professionals to always ask, "Could this be something else?" This approach includes taking a fresh history, performing a thorough examination, and arranging appropriate tests.
I also emphasise the importance of critical thinking and curiosity, and that our initial responses can have a significant impact. We must consider all possible scenarios, including new physical conditions that may develop. Organizations like Pathways and Equally Well are actively raising awareness.
Addressing diagnostic overshadowing requires a cultural shift towards unbiased assessment. It means actively challenging assumptions, listening intently to individuals, and prioritizing a comprehensive approach to health that respects the interconnectedness of mind and body. By doing so, we can ensure everyone receives the equitable and appropriate care they deserve.
