Depression and Diagnostic Overshadowing

Source: Serani

As someone who has lived with depression all my life, I’ve experienced a form of discrimination that makes it hard for me to get good medical care. Clinically, it’s called diagnostic overshadowing - and is defined as a process where health professionals wrongly presume that present physical symptoms are a consequence of their patient’s mental illness. As a result, the patient with mental illness gets inadequate diagnosis or treatment[i].

Casually speaking, I call it lazy medicine. As a healthcare professional myself, I can walk the diagnostic walk and talk the treatment talk - so, it can be easier for me to confront diagnostic overshadowing when it happens. I’ll generally start with, “What tests would you suggest if you weren’t dealing with a patient who had depression?” to address the mental illness bias coming from my doctor. Sometimes that helps to broaden the physician’s diagnostic outlook, minimizing the shadow of my mental illness in the treatment plan. When that works, I can feel good that my medical concerns are being addressed properly.

However, sometimes I can’t shake the diagnostic overshadowing going on. I tell the health professional that I’m frustrated by his or her lack of time or inclination to think beyond my depression diagnosis. Sometimes there’s finger wagging or I'll launch into a teachable moment soap-box lecture. Other times I don’t even bother to address the obvious bias. I just go elsewhere to find better care. And, sadly, it happens often. I’ve learned that sometimes a general physical issue can turn into a medical odyssey of sorts, where it takes months or years (yes, years) not days or weeks for diagnosis or treatment to finally occur.

Research indicates that children and adults with mental illness typically receive poorer health care than the general public[ii]. Studies also state that those who live with mental illness often report negative attitudes from their physicians, which prevents them from seeking further healthcare intervention[iii]. As a result, people with mental illness suffer higher rates of physical illness and undiagnosed disorders - and are more likely to die prematurely than members of the general population[iv].

Tips to Help with Diagnostic Overshadowing

When you find your medical symptoms marginalized or dismissed by your healthcare professional as a result of your mental health diagnosis, try the following:

• Find your voice. I know how it can hurt that your words are not being heard. Some of you may get angry. Others frustrated. A few of you may even feel helpless in that moment. Try to find your center and breathe for a moment or two. Then explain in a strong and reasonable voice that you feel your doctor isn’t really listening to you.
• Use the term. Using the phrase diagnostic overshadowing will alert your doctor that not only are you well-informed about things, but that you need him or her to check their bias at the door.
• Ask for more tests. If there is room in your doctor visit to be proactive, ask your physician, “How might you address my physical complaints if I didn’t have schizophrenia?” “What tests would your order if I wasn’t someone with panic disorder?” By doing this, you subtract the mental health presumptions from the medical equation.
• Call in the cavalry. There’s strength in numbers, so if you’re working with a healthcare professional who's fallen into diagnostic overshadowing, invite your psychologist, psychiatrist or other trusted health professional to talk with your physician. Sometimes other professionals can bring up stigma related issues more effectively than you going toe-to-toe with your doctor.
• Doctor shop. If you can’t clear the air with your physician or find that interventions haven’t made diagnostic overshadowing fade away, don’t feel insecure about doctor shopping. In fact, be confident about your choice to go elsewhere. Find a new healthcare professional by asking local mental health support groups for resources, or via word of mouth from trusted friends or family.
• Keep going. I have worked personally for many months, and in one situation over a year, out-running diagnostic overshadowing to get a medical issue rightly diagnosed. I have also witnessed patients of my own traverse the maze of diagnostic overshadowing clouding their own health status. It’s vital to keep moving forward if you have a medical issue. So don’t let the bias of doctors keep you from finding good healthcare. Keep going and make sure you get support from family and friends as you take on this important issue.

Citations

[i] Jones, S.; Howard, L. & Thornicroft G. (2008). Diagnostic overshadowing: Worse physical health care for people with mental illness. Acta Psychiatric Scandinavica, 118: 169-171.

[ii] Walker, E.; McGee, R.E. & Druss, B.G. (2015). Mortality in mental disorders and global disease burden implications: A systematic review and meta-analysis. JAMA Psychiatry, 72(4): 334-341.

[iii] Thornicroft, G. et. al. (2007). Discrimination in health care against people with mental illness. International Review of Psychiatry, 19(2): 113-122.

[iv] Jorm, A.F. & Reavley, N.J. (2013). Depression and stigma: From attitudes to discrimination. The Lancet, 381(9860): 10–11.