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  • Writer's pictureLachlan

Diagnostic Overshadowing

Updated: Dec 3, 2018

On average, people with mental health concerns don’t get the same level of medical care as people without mental health concerns. Why? A phenomenon called diagnostic overshadowing.

It’s a process by which health professionals incorrectly presume that physical symptoms are a consequence of their patient’s mental illness. As a result, people get inadequate diagnosis or treatment of their overall condition (Jones et al, 2008).

For example, a patient being treated for acute anxiety may have chest pain and shortness of breath, and a clinician is more likely to attribute these to their mental illness than to investigate them in their own right as potentially important signs of something else going on.

Over the long run, this kind of oversight leads to alarming statistics like this:

“Americans with depression, bipolar disorder or other serious mental illnesses die 15 to 30 years younger than those without mental illness -- a disparity larger than for race, ethnicity, geography or socioeconomic status” (Khullar, New York Times, 2018).

If we’re talking about social determinants of health, diagnostic overshadowing of mental health patients is a really big one.

My reaction to this is that the standard of care must be changed. It is understandable that treating mental health can take priority at times, because it feels very immediate to have a panic attack, or to feel suicidal. But clinicians cannot stop at treating only the symptoms of mental health. When one digs further into the patient’s whole physical and mental symptom picture, it is often the case that other conditions are discovered.

Below is a list of some of the underlying causes and contributors to depression alone (some more common than others). These conditions should be considered (within reason) and either ruled out or treated in anyone seeking help for their mood:

  • Nutritional deficiencies and blood sugar issues: food allergies, diabetes, hypoglycemia, anemia, vitamin deficiencies

  • Sleep issues: pain, sleep apnea, circadian rhythm disturbance

  • Hormonal imbalances: hyper- or hypothyroidism, sex hormone imbalances, PMS/PMDD, Cushing’s disease, Addison’s disease, high levels of PTH, pituitary dysfunction

  • Infections: Influenza, mononucleosis, syphilis (late stage), tuberculosis, viral hepatitis and pneumonia, SIBO, candida

  • Autoimmune conditions: celiac disease, multiple sclerosis, rheumatoid arthritis, lupus

  • Organ pathologies: heart problems, lung disease, liver disease

  • Structural issues: chronic pain, poor circulation, head injury, inflammation, dental issues, tumors

  • Functional: lack of sunshine, exercise, or nourishing relationships

  • Many pharmaceuticals and substances

Thankfully, clinicians are beginning to ring the alarm on diagnostic overshadowing and aim to raise the standard of care for people that struggle with mental health. I make it a large part of my work to investigate possible conditions that exist in parallel or in cause-and-effect cycles with the presenting mental health concern.

Mental health and physical health are not independent. The two cannot be separated from each other, nor should the presence of one overshadow the other and lead to poor overall care.

The most important thing if you are struggling with your mental health is to not give up seeking the right care for you. To get an idea of what this approach is like and if it is a path for you, consider booking a consult with me to hear more about my whole-person, patient-centred approach.


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

2. Saxena, S. (2018). Excess mortality among people with mental disorders: a public health priority. The Lancet Public Health, 3(6), e264-e265.

3. Khullar, D. (2018). The Largest Health Disparity We Don’t Talk About. The New York Times Online. Link

4. Shefer, G., Henderson, C., Howard, L. M., Murray, J., & Thornicroft, G. (2014). Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms–a qualitative study. PLoS One, 9(11), e111682.

5. Knaak, S., Mantler, E., & Szeto, A. (2017, March). Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. In Healthcare Management Forum (Vol. 30, No. 2, pp. 111-116). Sage CA: Los Angeles, CA: SAGE Publications.

6. Serani, D. (2015). Depression and Diagnostic Overshadowing. Psychology Today Online Blog. Link

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