Emergency department staff views and experiences on diagnostic overshadowing related to people with mental illness

Nieuwenhuizen, Adrienne van; Henderson, Claire; Kassam, Aliya; Graham, Tanya; Murray, Joanna; Howard, Louise M.; Thornicroft, Graham

doi:10.1017/s2045796012000571

Cited by 94 publications

(110 citation statements)

References 21 publications

(22 reference statements)

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“…The concept of 'diagnostic overshadowing' originates from learning disabilities research, but can also be applied to mental health and dementia. [11][12][13] Diagnostic overshadowing occurs when multimorbid conditions mask the symptoms of dementia or conversely, there is the possibility that dementia could mask the existence of problematic multimorbid conditions. The combination and interaction of these factors can lead to adverse clinical outcomes, 14 and if admitted for inpatient hospital care, older people with multimorbidities including dementia have the highest readmission rates and highest rate of long-term care use after discharge.…”

Section: Introduction Backgroundmentioning

confidence: 99%

Home or hospital for people with dementia and one or more other multimorbidities: What is the potential to reduce avoidable emergency admissions? The HOMEWARD Project Protocol

et al. 2017

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IntroductionOlder people with multimorbidities frequently access 999 ambulance services. When multimorbidities include dementia, the risk of ambulance use, accident and emergency (A&E) attendance and hospital admission are all increased, even when a condition is treatable in the community. People with dementia tend to do poorly in the acute hospital setting and hospital admission can result in adverse outcomes. This study aims to provide an evidence-based understanding of how older people living with dementia and other multimorbidities are using emergency ambulance services. It will also provide evidence of how paramedics make decisions about taking this group of patients to hospital, and what resources would allow them to make more person-focused decisions to enable optimal patient care.Methods and analysisPhase 1: retrospective data analysis: quantitative analysis of ambulance service data will investigate: how often paramedics are called to older people with dementia; the amount of time paramedics spend on scene and the frequency with which these patients are transported to hospital. Phase 2: observational case studies: detailed case studies will be compiled using qualitative methods, including non-participant observation of paramedic decision-making, to understand why older people with multimorbidities including dementia are conveyed to A&E when they could be treated at home or in the community. Phase 3: needs analysis: nominal groups with paramedics will investigate and prioritise the resources that would allow emergency, urgent and out of hours care to be effectively delivered to these patients at home or in a community setting.Ethics and disseminationApproval for the study has been obtained from the Health Research Authority (HRA) with National Health Service (NHS) Research Ethics Committee approval for phase 2 (16/NW/0803). The dissemination strategy will include publishing findings in appropriate journals, at conferences and in newsletters. We will pay particular attention to dissemination to the public, dementia organisations and ambulance services.

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Section: Introduction Backgroundmentioning

confidence: 99%

Home or hospital for people with dementia and one or more other multimorbidities: What is the potential to reduce avoidable emergency admissions? The HOMEWARD Project Protocol

et al. 2017

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“…One service user mentioned an experience of diagnostic overshadowing [29] when his physical illness was dismissed as a symptom of his mental health problem. Others described how appropriate expressions of emotion had been confused with symptoms of mental illness.

“[Treatments or other things that have not been helpful in the past] In the past the police have thought I was intimidating because I was ‘high’ (manic) and a tall black guy.

…”

Section: Resultsmentioning

confidence: 99%

What service users with psychotic disorders want in a mental health crisis or relapse: thematic analysis of joint crisis plans

Farrelly

Brown

Rose

et al. 2014

Soc Psychiatry Psychiatr Epidemiol

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PurposeRecent legislation and guidance in England emphasises the importance of service user choice in care planning. However, it is not obvious how best to facilitate choices in care planning, and some clinicians are concerned that service users may make ‘unwise’ decisions. This study aimed to examine mental health service users’ preferences and priorities in the event of a future mental health crisis or relapse.MethodThematic analysis of 221 joint crisis plans (JCP) developed by service users and their clinical team as part of the CRIMSON randomised controlled trial. Participants had a diagnosis of a psychotic disorder, at least one psychiatric admission in the past 2 years, contact with a community mental health team, and complex care needs.ResultsTwo major categories of preferences were identified: first the manner in which crisis care would be delivered; and second, specific treatment interventions. Most service users requested full involvement in decisions about their care, clear and consistent treatment plans, access to familiar clinicians who knew them well, and to be treated with respect and compassion. Some service users requested hospitalisation, but the majority preferred alternatives. The most frequently preferred intervention was care by a home treatment team. Just under half made a treatment refusal, the majority being for specific medications, alternatives were offered.ConclusionsJoint crisis planning resulted in service users making choices that were clinically reasonable. The technique employed by JCPs appeared to empower service users by engaging them in a productive dialogue with their clinicians.

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“…Diagnostic overshadowing refers to a well-described clinically and ethically problematic phenomenon in which clinicians ignore patients' general health concerns because of that patient's mental illness [35][36][37][38]. At the core of diagnostic overshadowing is a clinical reasoning error; that is, some clinicians unconsciously tend to express negative bias when diagnosing patients who have co-occurring mental health and general health problems, such that legitimate general health problems are misattributed as originating from a patient's mental illness [36].…”

Section: Responsementioning

confidence: 99%

Human Trafficking, Mental Illness, and Addiction: Avoiding Diagnostic Overshadowing

Stoklosa

MacGibbon²,

Stoklosa

2017

AMA Journal of Ethics

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This article reviews an emergency department-based clinical vignette of a trafficked patient with co-occurring pregnancy-related, mental health, and substance use disorder issues. The authors, including a survivor of human trafficking, draw on their backgrounds in addiction care, human trafficking, emergency medicine, and psychiatry to review the literature on relevant general health and mental health consequences of trafficking and propose an approach to the clinical complexities this case presents. In their discussion, the authors explicate the deleterious role of implicit bias and diagnostic overshadowing in trafficked patients with cooccurring addiction and mental illness. Finally, the authors propose a trauma-informed, multidisciplinary response to potentially trafficked patients. CaseDr. Shah, an emergency department (ED) resident in New York City, entered the room of a young pregnant patient who was bleeding and visibly frightened. The patient, who only spoke Spanish, was accompanied by her brother, who translated. He explained that the patient suffered from schizophrenia and had been refusing her medications for the last couple of weeks. He added that she'd had a few episodes of aggressive behavior, directed at others and herself. While the patient's brother was talking, Dr. Shah noticed a few bruises and puncture marks with associated ecchymosis (subcutaneous bleeding similar to a bruise) on the patient's arm. The brother saw that Dr. Shah had noticed these marks and explained that the patient sells herself for drugs.Dr. Shah began to suspect that the patient's brother might not be trustworthy, so she requested a certified clinical interpreter. Through the interpreter, the patient conveyed that she was miscarrying and asserted that she does not have schizophrenia, although she admitted feeling depressed sometimes. The patient's tone became increasingly desperate and she explained, through the interpreter, that the man claiming to be her brother was holding her captive. She stated she was brought to the US as his fiancée,

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Emergency department staff views and experiences on diagnostic overshadowing related to people with mental illness

Cited by 94 publications

References 21 publications

Home or hospital for people with dementia and one or more other multimorbidities: What is the potential to reduce avoidable emergency admissions? The HOMEWARD Project Protocol

Home or hospital for people with dementia and one or more other multimorbidities: What is the potential to reduce avoidable emergency admissions? The HOMEWARD Project Protocol

What service users with psychotic disorders want in a mental health crisis or relapse: thematic analysis of joint crisis plans

Human Trafficking, Mental Illness, and Addiction: Avoiding Diagnostic Overshadowing

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