Diagnostic overshadowing happens when mental health or substance use issues overshadows physical health problems and can prevent people from getting the health care they need.
This is not okay. We all need our health system to do better.
The Tupuānuku research
The Tupuānuku research, nourishing the physical health of tāngata whai ora, is a study funded by the Health Research Council for 2021–2023 led by University of Otago researchers Dr Ruth Cunningham, Dr Debbie Peterson and Dr Helen Lockett. The research investigated the enablers and barriers that affect the access and quality of physical health care for people with mental health and substance use issues in Aotearoa.
The research project had three integrated strands of work:
1. the investigation and analysis of routinely collected data,
2. exploring the stories of people with experience of mental health and substance use issues, and,
3. using these findings to bring change.
The study derives its title from Ngā Waka o Matariki, the Equally Well Māori health strategy. Tupuānuku, the star associated with the growth of all that springs from the soil for harvest, serves as the inspiration for this endeavor, which aims to nurture the physical well-being of tangata whai ora. This newfound insight is grounded in the wisdom inherent within Te Ao Māori.
Diagnostic overshadowing: a lived experience resource
In collaboration with StoryBox, the University of Otago developed this animated video about diagnostic overshadowing, and what you can do about it as someone using health services or supporting someone to use them.
The video is based on the findings of the research, and in particular, the stories that participants with lived experience shared in the research survey conducted in April 2022.
This survey has received ethical approval from Southern Health and Disability Ethics Committee and was designed by research staff at the University of Otago.
Please don’t hesitate to share this resource to anyone you believe would benefit from it, including your friends, whānau, general practitioner, pharmacist, and others. https://vimeo.com/933038301
Research findings to help bring change
The Tupuānuku research findings are starting to emerge through publications and will continue to be published throughout 2024. This work provides data from Aotearoa concerning individuals with mental health and substance use experiences as they seek access to healthcare services. The results of this research can be used for policy making, workforce development strategies, and resources for health practitioners and people with lived experience among others.
Below are the papers published from the Tupuānuku project so far:
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Cunningham, R., Imlach, F., Lockett, H., Lacey, C., Haitana, T., Every-Palmer, S., … & Peterson, D. (2023). Do patients with mental health and substance use conditions experience discrimination and diagnostic overshadowing in primary care in Aotearoa New Zealand? Results from a national online survey. Journal of Primary Health Care.
This study investigated experiences of people with mental health and substance use issues who sought help for a physical health condition in primary healthcare services, examining quality of care attributes. The majority of people reported positive experiences of primary care services however, experiences differed by diagnosis, number of diagnoses, and some demographic characteristics.
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Cunningham, R., Imlach, F., Haitana, T., Every-Palmer, S., Lacey, C., Lockett, H., & Peterson, D. It’s not in my head: A qualitative analysis of experiences of discrimination in people with mental health and substance use conditions seeking physical healthcare. Frontiers in Psychiatry, 14, 1285431.
The aims of this paper were to describe how people with mental health and addiction issues experienced discrimination in physical health services, and to explore the likely underlying beliefs of clinicians that lead to discrimination in physical healthcare.
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Cunningham R, Imlach F, Every-Palmer S, Haitana T, Peterson D. Dealing with Discrimination in Physical Health Care Services: Strategies of People with Mental Health and Substance Use Conditions. Journal of Patient Experience. 2023;10.
Following on from the previous two papers, this paper used the survey data to identify strategies used by people with mental health and addiction issues to avoid or minimise the impact of discrimination from physical health services. Strategies identified often meant people did not seek help or compromised the quality of their care.
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Cunningham R, Imlach F, Every-Palmer S, Haitana T, Peterson D, Clark T, Lockett H. Experiences of physical healthcare services in Māori and non-Māori with mental health and substance use conditions. 2024.
Further analysis of our survey of people with mental health and substance use conditions investigated service quality in four healthcare settings: general practice, emergency department, hospital and pharmacy. The quality domains were: treated with respect; listened to; treated unfairly due to mental health and substance use conditions; mental health and substance use condition diagnoses distracting clinicians from physical healthcare (diagnostic and treatment overshadowing).
We found that across the four health services, pharmacy was rated highest for all quality measures and emergency department lowest. Participants rated general practice services highly for being treated with respect and listened to but reported relatively high levels of overshadowing in general practice, emergency department and hospital services. Experiences of unfair treatment were more common in emergency department and hospital than general practice and pharmacy. Compared to Māori, non-Māori reported higher levels of being treated with respect and listened to in most services and were more likely to report ‘never’ experiencing unfair treatment and overshadowing for all health services.
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Cunningham R, Stanley J, Imlach F, Haitana T, Lockett H, Every-Palmer S, Clark M, Lacey C, Telfer K, Peterson D. 2024 Cancer diagnosis after ED presentations in people with MHSUC
In this paper we used routinely collected health service data to explore emergency presentations with four different cancers (lung, prostate, breast and colorectal). We found that the rates of emergency presentation were significantly higher in people with a history of mental health/addiction service use than people without for all four cancers, especially in people with a diagnosis of schizophrenia, bipolar disorder or psychotic disorders. Implementing pathways for earlier detection and diagnosis of cancers could reduce the rates of emergency presentation, with improved cancer survival outcomes. All health services, including cancer screening programmes, primary and secondary care, have a responsibility to ensure equitable access to healthcare for people with mental health and substance use conditions.
Upcoming publications to watch out for
We will be adding new publications to this page as they are published. These include papers on diabetes and cancer among people with mental health and substance use conditions in Aotearoa and further papers from the survey and follow up interviews looking at the experience of Māori with mental health and substance use conditions seeking physical health care.
Acknowledgements
- The Tupuānuku research was funded by the Health Research Council of New Zealand.
- The stories in this resource were provided to us by the participants in our 2022 survey – thank you all for sharing your experiences.
- The Tupuānuku research team are Ruth Cunningham, Debbie Peterson, Helen Lockett, Fiona Imlach, Kendra Telfer, James Stanley, Tracy Haitana, Mauterangimarie Clarke, Cameron Lacey, Susanna Every-Palmer, Abigail Freeland.
- We would also like to thank our advisory group who supported us through this mahi. Thank you for all your wisdom and encouragement. The Tupuānuku Advisory Group were Catherine Gerard, Tony O’Brien, Sarah Gray, Suzanne Pitama, Caro Swanson, Vanessa Caldwell, Ross Phillips, Suzana Baird, and Arran Culver.
- The diagnostic overshadowing resource was produced in partnership with our lived experience advisors Caro Swanson and Suzana Baird. Thank you both for all your ideas and enthusiasm, it was a real pleasure to work with you both. Thank you also to those who provided the voices for the stories included in the resource: Courtney Steele, Charlotte Paul, Debbie Peterson, Allen Henry.
For more information about the project and any feedback, please contact Associate Professor Ruth Cunningham in the Department of Public Health at the University of Otago Wellington: Ruth.Cunningham@otago.ac.nz
Other resources
Slides: What does good care look like and how can we get there?
Discover the heart of good care and how to reach it from the voices of the Tupuānuku research with our downloadable slides.These were born from real-life stories and serve as powerful tools to spark conversations, inspire action, and cultivate a culture of compassion. Let’s share these stories widely to create positive change in our communities.
SEE US campaign
Designed to overcome diagnostic overshadowing (when mental health and addictions health histories overshadow physical health needs) this campaign draws attention to it by giving a platform to the voice of lived experience and provides a multimedia toolkit for Equally Well partners.
