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Analytical studies

Stigma: Physical Health Equality Research & Evaluation (SPHERE): An exploratory study


Every person has the right to proper and adequate healthcare. Often however, people with mental illness are stigmatised because of their condition when trying to access physical health care. This can be due to a phenomenon referred to as ‘diagnostic overshadowing’. ‘Diagnostic overshadowing’ can be defined as the process by which the physical needs of a patient are over-shadowed by their psychiatric diagnosis. People with mental illnesses have poorer physical health than people without mental illness. This has been shown with regards to obesity, cardiovascular and gastrointestinal disorders, diabetes, HIV and both chronic and acute pulmonary disease. 

Very little research however has gone into mental health patient satisfaction with the Emergency Department (ED) and thus even less research into diagnostic overshadowing with patients presenting with a physical problem in the emergency department who have co-morbid medical and psychiatric diagnoses. 


To determine the views and experiences of emergency department health care staff and patients presenting with a physical health problem who have a co-morbid mental illness regarding the provision of treatment and quality of care.


This is a qualitative study using one-to-one semi-structured interviews. The interviews were based on purposive sampling of the ED health care staff including ED nurses, nurse practitioners doctors (n = 25).


Diagnostic overshadowing was described as a significant issue. Contributing factors included: (1) problems of knowledge and information gathering; (2) clinicians' attitudes toward people with mental illness, substance misuse and frequent attenders; and (3) difficulties in working with mental health services in the context of a four hour target for discharge from the emergency department. Avoidance of patients with a psychiatric diagnosis was also described, due to fear of violence.

The physical health care of people with mental illness in emergency departments may be adversely affected by diagnostic overshadowing and avoidance by clinical staff, along with difficulties created by the illness, medication and the emergency department environment. Greater joint working between psychiatric and emergency department staff is suggested as one way to reduce diagnostic overshadowing. A paper on the study and its findings has now been published (van Nieuwenhuizen A et al 2012).

This work has led to further funding from the Maudsley Charity (PI Claire Henderson) to study the phenomenon of diagnostic overshadowing in a larger number of settings. The new study will also develop consensus guidelines for best practice in this area.


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