Table 1.
Research context, definitions, and themes
| Author(s) (Date) | Context | Diagnostic Overshadowing Definition | Theme(s) |
|---|---|---|---|
| Disability Rights Commission (2006) | Qualitative research; UK; focus groups made up of individuals with intellectual disability and/or mental illness | ‘Reports of physical ill health being viewed as part of the mental health problem or learning disability – and so not investigated or treated’ (Disability Rights Commission 2006, p. 6) | Individuals with MI feel mistrust of health services provided, feel labelled by health practitioners as ‘difficult’ and unable to remove the label |
| Clarke et al. (2007) | Qualitative research; Canada; focus groups made up of 27 emergency department clients with mental illness, 7 client family members, 5 community stakeholders | ‘Tendency to triage as ‘mental health’ based on history rather than on presentation’ (Clarke et al. 2007, p. 127) | Wait time; staff attitudes making patients with mental illness feel unimportant, shamed, guilted, stigmatized; diagnostic overshadowing; lack of treatment options; family needs |
| Thornicroft et al. (2007) | Qualitative research; UK; case studies of individuals with MI participating in community psychiatry; publication excerpted from book Shunned: Discrimination Against People with Mental Illness (Thornicroft 2006); published in internationally relevant, peer‐reviewed psychiatric journal | ‘Misattribution of physical illness signs and symptoms to concurrent mental illness, leading to underdiagnosis and mistreatment of the physical conditions’ (Thornicroft et al. 2007, p. 113) | Stigma, underestimating, underlying threat of treatment through coercion/unwanted treatment, feeling punished by healthcare staff |
| Jones et al. (2008) | Opinion piece / editorial; published in internationally relevant, peer‐reviewed psychiatric journal | ‘Process by which physical symptoms are misattributed to mental illness’ (Jones et al. 2008, p. 169) | Need more research into comorbidity to improve physical care for people with mental illness |
| Wood and Tracey (2009) | Qualitative research; US; case study of 220 doctoral students in clinical and counselling psychology | ‘Presence of one diagnosis interferes with the detection of other diagnoses’ (Wood & Tracey 2009, p. 218) | Practitioners reduce diagnostic overshadowing through training, feedback; should be vigilant, self‐critical |
| Nash (2013) | Opinion piece / best practices; UK; author presents views of mental illness charity activists and organizers on care recommendations and lessons learned for nursing audience | ‘Symptoms of physical illness are attributed to the service user's mental illness’ (Nash 2013, p. 22) | Stigma, underestimation, inequity, treatment delay |
| van Nieuwenhuizen et al. (2013) | Qualitative research; UK; thematic analysis of interviews of 25 emergency department clinicians | ‘Misattribution of physical symptoms to pre‐existing mental illness’ (van Nieuwenhuizen et al. 2013, p. 255), citing Jones et al. 2008 | Stigma; lack of knowledge; prejudice; fear of individuals with mental illness; time pressure; disagreement that diagnostic overshadowing occurs |
| Giddings (2013) | Opinion piece / editorial; published in official peer‐reviewed journal of Canadian Medial Association; provides examples of interactions with patients with MI in emergency department | ‘Overattribution of symptoms to any underlying or long‐term condition, resulting in missed diagnoses and improper management of conditions’ (Giddings 2013, p. 1555) | Diagnostic overshadowing likely more prevalent than clinicians believe; clinicians must be ‘attuned’ |
| Shefer et al. (2014) | Qualitative research; UK; interviews with 21 nurses, 18 doctors from 4 emergency departments | ‘Process by which a person with a mental illness receives inadequate or delayed treatment on account of the misattribution of their physical symptoms to their mental illness’ (Shefer et al. 2014, p. 2) | Stigma, time, problem communication |
| Holm et al. (2014) | Qualitative research; Norway; hermeneutic analysis of interviews with 15 older adults with depression in community health centers | ‘Misattribution of physical symptoms to a pre‐existing mental illness’ (Holm et al. 2014, p. 2), citing Nieuwenhuizen et al. (2013) | Living with stigma, not taken seriously, not knowing whether pain is physical or mental, like living in ‘war zone’ |
| Shefer et al. (2015) | Qualitative research; UK; interviews with 8 doctors, 7 nurses at 4 emergency departments | ‘Misattribution of physical symptoms to mental illness’ (Shefer et al. 2015, p. 346) | Need for liaison between emergency and psychiatry departments |
| Happell et al. (2016) | Qualitative research; Australia; focus groups of 31 consumers of mental health services | ‘Service users [sic] physical symptoms are attributed to their mental illness’ (Happell et al. 2016, p. 2934) | Stigma; healthcare providers dismiss physical illness as part of mental illness, fail to provide care; prejudice awareness |
| Joy et al. (2016) | Opinion piece; published in official peer‐reviewed journal of American Medical Association; mental health and ethics researchers offer recommendations on MI chart labelling in psychiatric crisis centers and emergency departments | ‘Psychiatric conditions overshadow their other conditions, potentially biasing the clinician's judgement about diagnosis and treatment such that the clinician may misattribute physical symptoms to mental health problems’ (Joy et al. 2016, p. 1539) | Stigma; implicit bias; labelling patient records harmful |
| Stoklosa et al. (2017) | Commentary; published in ethics‐focused peer‐reviewed journal of American Medical Association; responses to MI clinical vignette provided by US‐based psychiatrist, physician, and human trafficking survivor and activist | ‘A well‐described clinically and ethically problematic phenomenon in which clinicians ignore patients' general health concerns because of that patient's mental illness’ (Stoklosa et al. 2017, p. 29) | Implicit bias; stigma; trauma‐informed care |
| Geiss et al. (2018) | Quantitative research; US; retrospective chart review of 231 admissions from psychiatric unit of rural Level 1 Trauma Center | ‘Physical and/or behavioural symptoms are inappropriately accredited to mental illness’ (Geiss et al. 2018, p. 327) | Patients with delirium inappropriately placed in psychiatric unit; factors of age, arrhythmia, body temperature |
| Hext et al. (2018) | Clinical review/practice recommendations; published in peer‐reviewed British Journal of Nursing; presents guidance for UK‐based NHS Trust hospitals in working with patients with MI and physical illness | ‘Tendency of professionals to overlook the signs and symptoms of a secondary condition and, instead, attributing the behaviours to the primary condition, which may be a mental health problem, learning disability or other clinical condition’ (Hext et al. 2018, p. 480) | Challenging behaviours; de‐escalation; legal requirements |
| Cho (2019) | Opinion piece/practice recommendations; author presents exemplar vignettes of patients with MI as part of work with US National Institutes of Health Clinical Center | ‘Attribution of symptoms to an existing diagnosis rather than a potential comorbid condition’ (Cho 2019, p. 37) | Intersectional framework; ‘missed diagnoses and misdiagnoses’ |
| Chuttoo and Chuttoo (2019) | Qualitative research; UK; case study of patient with MI needing physical care; prepared for primary care nursing audience | ‘Symptoms being misattributed to the patient's mental health condition rather than underlying physical causes’ (Chuttoo & Chuttoo 2019, p. 78) | Stigma; nurses' role; importance of tranquil environment |
| Cromar‐Hayes and Seaton (2020) | Practice recommendations/review; UK‐focused paramedic recommendations on working with patients with MI needing emergency care | ‘A clinician dismisses a patient's physical complaints as part of their mental illness’ (Cromar‐Hayes & Seaton 2020, p. 23) | Stigma; making most of each patient encounter; paramedic culture change needed |
| Perrone McIntosh (2021) | Synthesis research; internationally relevant; scoping review of emergency department‐focused literature on emergency care for patients with MI | ‘Physical and/or behavioural symptoms are inaccurately correlated to mental illness’ (Perrone McIntosh 2021, p. 9) | Stigma; emergency department care constraints; perceived and experienced patient aggression; lack of knowledge, confidence on part of emergency nurses caring for patients with mental illness |
| Almeida et al. (2022) | Quantitative research; Portugal; cross‐sectional, questionnaire‐based study; 157 psychiatrists, 72 general practitioners | Not directly defined, but diagnostic overshadowing outcome explained as ‘associated with less availability and worse medical care quality’ (Almeida et al. 2022, p. 7) and citing (Jones et al. 2008) | Stigma, autonomy, coercion, diagnostic overshadowing, labelling, parental incompetence, permanence, pity, responsibility, segregation. Psychiatrists less likely to stigmatize than general practitioners. |
| Fontesse et al. (2021) | Quantitative research; conducted across Belgium, Canada, and France; survey of nurse perceptions of patients with MI; 336 nurse respondents | ‘Bias of misattributing physical symptoms to mental illness’ (Fontesse et al. 2021, p. 155) | Stigmatization, dehumanization, burnout |
| Molloy et al. (2021b) | Synthesis research; JBI protocol for qualitative systematic review of multi‐national research on misdiagnosis of somatic illness as MI; result is Molloy, Brand, and colleagues' (2021) publication | ‘A judgement bias where health care professionals mistakenly attribute clinical manifestations of physical illness (e.g. pain, tachycardia, hypertension) to manifestations associated with a pre‐existing mental illness’ (Molloy et al. 2021b, p. 1363) | Discrimination, inequity, stigma |
| Ho et al. (2021) | Synthesis research; integrative review following Whittemore and Knafl (2005) methodology; reviews 7 multi‐national studies, focused on audience of mental health nurses | ‘Physical health complaints being interpreted as symptoms of mental illness lead to a failure to diagnosis and treatment’ (Ho et al. 2021, p. 8) | Need for help for carers/caregivers, providers who specialize in providing physical care to individuals with mental illness; lack of care access and coordination; advocacy |
| Molloy et al. (2021a) | Synthesis research; qualitative systematic review of 6 multi‐national studies on misdiagnosis of somatic illness as MI; result of Molloy, Munro, and colleagues' (2021) protocol |
‘A complex and life‐threatening phenomenon that occurs when physical symptoms reported by mental health consumers are misattributed to mental illness by health professionals’. (Molloy et al. 2021a, p. 1) |
Stigma, misaligned care, professionals' lack of perspective of diagnostic picture and patients' lives |