Diagnostic Overshadowing Harms Patients With Psychiatric Diagnoses, Review Finds

Diagnostic overshadowing (DO) describes when doctors attribute symptoms or concerns to an existing condition. This is especially common for people with psychiatric diagnoses, where their medical complaints are commonly dismissed as psychological. A new article published in the Journal of Public Health finds that DO for people with psychiatric diagnoses is driven by stereotypes, stigma, and systemic issues such as high physician workloads and time pressure. This research, led by Olga Martinez-Navarro from the University of València in Spain, also finds that patients experience significant emotional and physical consequences of DO, including death.

Notably absent from this study is any consideration of psychiatric drug-induced harm. The current research ignores the reality that some portion of physical symptoms reported by people with psychiatric diagnoses is a result of psychotropic drug use, framing them instead as an overlooked physical illness. Any push towards more accurately diagnosing physical illnesses in people with a mental health diagnosis must consider drug-induced harms in this population.

Consequences of Diagnostic Overshadowing

Past research has found that people with a psychiatric diagnosis are twice as likely to be the victims of medical errors. The authors of that research believe this is at least in part due to DO. Research has linked DO to missed and delayed diagnosis of physical illnesses, poorer quality of healthcare for people with psychiatric diagnoses, increased risk of death, preventable physical health deterioration, delayed emergency treatment, and fragmented care pathways.

One lived experience expert wrote about being labeled “very mentally ill” by a psychiatrist after visiting the hospital for significant physical symptoms including extreme fatigue and weight loss. After being misdiagnosed as having factitious disorder, somatic symptom disorder, and psychosis, she was involuntarily detained in a psychiatric hospital where her physical symptoms were routinely dismissed as psychological. She writes:

After her release from the psychiatric unit, she was correctly diagnosed with mold toxicity and mast cell activation syndrome. With proof of a physical diagnosis, she asked that her psychiatric diagnoses be removed from her medical records and background checks. This request was refused, leaving her vulnerable to future DO.

Study Details

The goal of the current study was to investigate how patients and service users experience DO. This research also examined healthcare professionals’ perceptions of DO and practices that may lead to DO. The authors conducted a systematic overview of previous research on this topic. To be included in the current research, studies had to examine DO in adults who were mental health patients or service users, or healthcare professionals’ perceptions of DO. Included studies also had to be published in English or Spanish. Editorials, commentaries, conference abstracts, and case reports were excluded.

Qualitative, quantitative, and mixed-methods studies were included in the current research. Ten studies came from Europe, five from Australia and New Zealand, and three from North America. In total, the authors examined data from 17 studies including 1,736 participants.

The authors identified seven major recurring themes in the examined studies:

• Stereotypes specifically undermining physical symptom credibility

• Clinical practices of premature physical-to-mental attribution

• Physical consequences of DO

• Emotional consequences of poor care

• Professional challenges in providing adequate care

• Environmental facilitators of DO misattribution

• Factors that promote identification or prevention

Six of 17 articles discussed stereotypes that undermined the credibility of people with psychiatric diagnoses. Mental health service users and patients were commonly viewed by healthcare professionals as untrustworthy, prone to lying about there conditions, and incapable of managing their own health. This theme also involved the tendency of healthcare institutions to shrink the identities of people with mental health diagnoses down to a “psychiatric case.”

Eight included studies explored premature physical-to-mental attributions of mental health patients’ symptoms. This involved patients not receiving adequate medical assessments and doctors referring patients to psychiatrists prematurely. Doctors also displayed paternalistic attitudes that precluded shared decision-making.

Physical (discussed in 7 studies) and emotional (5) consequences of DO included errors and delays in diagnosis, disabilities and deaths as a result of missed or delayed diagnosis, feelings of hopelessness, distrust of healthcare systems, shame, anxiety, and hiding information from doctors on subsequent visits.

Nine studies discussed environmental and institutional problems leading to DO. Healthcare settings can involve distractions such as noise and crowds that may contribute to DO. Lack of hospital protocols, work overload, and limited time available to spend with patients could also contribute to DO. The authors discussed specific patient characteristics including race and diagnoses such as schizophrenia, substance abuse, bipolar disorder, and borderline personality disorder as environmental factors contributing to DO. Another way to frame patient characteristic involvement in DO is as racist and ableist biases on the part of healthcare providers and embedded in institutional practices.

One study explored professional challenges related to DO. This included patients omitting information and refusing to start new treatments, complex presentations of physical and psychological issues, and problems with communication.

Six studies discussed factors that could prevent DO. Factors such as interdisciplinary collaboration, increased physician training, and clinical experience could lead to fewer missed and delayed diagnoses. One included study found that having psychiatric nurses in emergency departments could reduce DO. This study additionally reported that the presence of psychiatric nurses improved patients’ experiences. Included studies also suggested that female doctors may mitigate DO due to displaying higher levels of empathy and conducting more comprehensive assessments.

This research had several limitations. There were few studies available that met the inclusion criteria. The authors used narrow search terms to identify studies for potential inclusion which may have resulted in missing relevant research. Included studies had small sample sizes and came from mostly high-income countries, limiting generalizability. Included studies used different measures, methods, and outcomes, making comparisons and system wide recommendations difficult. This research also examined physical symptoms in people with psychiatric diagnoses without considering psychotropic drug-induced harm.

The Realities of Drug Induced Harm in People with Psychiatric Diagnoses

The current study opens by declaring that “individuals with mental disorders experience higher morbidity and mortality than the general population, primarily due to co-occurring physical illnesses.” However, the authors seem to ignore the growing body of research that implicates psychotropic drugs like antidepressants, antipsychotics, and benzodiazapines in both the early deaths and physical illnesses of people with psychiatric diagnoses. Experts have said that psychiatric drugs are “killing more users than heroin [and] cocaine.” Peter Gøtzsche estimates that psychiatric drugs are the third leading cause of death in the US, behind heart disease and cancer.

Research has found that antidepressants, antipsychotics, and psychiatric stimulants primarily used to treat ADHD are linked to poor heart health. These drugs have been linked to increased rates of obesity with the accompanying health complications. Past research has linked antidepressants and antipsychotics to diabetes and high blood pressure. Psychiatric drugs have been associated with poor sleep quality, which has a number of negative effects on physical health. These drugs can also cause extreme physical symptoms when people attempt to stop using them, sometimes lasting for years.

The authors of the current research frame early death in people with mental health diagnoses as mostly a result of physical illness without any consideration of how psychiatric drugs contribute both to those deaths and to physical illness. This framing threatens to blame deaths and physical illnesses in this population on bad luck and patient characteristics, shifting the focus away from the realities of psychiatric drug-induced harm.

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Martinez-Navarro, O., & Martinez-Martinez, C. (2026). Diagnostic overshadowing in Mental Health: A mixed-methods systematic review of its impact on health inequities and system-level responses. Journal of Public Health. (Link)