An ethnographic study of diagnosis of physical illness in people with mental health conditions in the emergency department

Why should we study physical health diagnosis for people with mental health conditions?

People with severe mental health conditions often have a shorter life expectancy. This is primarily due to treatable physical illnesses, which frequently go undiagnosed or are diagnosed too late. One explanation is ‘diagnostic overshadowing’, where a patient’s physical symptoms are wrongly attributed to their mental health condition.

However, this explanation focuses mainly on individual clinicians’ decision making, which can overlook a much bigger issue: diagnostic inequality can be the result of organisational processes.

For many patients, the emergency department (ED), often known as Accident and Emergency, plays a key role in diagnosis. Urgent and emergency care is under intense pressure, and this can have an impact on the diagnostic process.

This study draws on observations and interviews with patients, carers, and ED staff across three English hospitals to examine how physical health diagnosis is shaped in practice for patients with mental health conditions.

What we found: how mental health conditions affect physical health diagnosis

Patients with mental health conditions often face inequitable access to diagnosis for their physical health problems in the ED.

Key insights include:

• Physical symptoms may be taken less seriously when a patient also has a mental health condition, especially if symptoms overlap or are hard to explain.
• EDs are designed to address clear, urgent, physical problems. More complex sets of symptoms, which also involve mental health needs, could be harder to assess.
• Clinicians and patients actively try to mitigate the problems, by downplaying mental health history, emphasising red flag symptoms, or being extra cautious. This sometimes has unintended effects, from reduced attention to physical symptoms at one extreme to over-investigation at the other.
• ED’s operating conditions can also shape diagnostic inequality for people with mental health conditions. The NHS England urgent and emergency care plan 2025/26 examines ways of improving these operating conditions, but improvement efforts must consider groups whose needs are harder for ED staff to deal with appropriately.

How can we reduce inequities in diagnosing physical illness for people with mental health conditions?

Reducing diagnostic inequalities will require:

• Greater awareness of the overall environment and pressures within the ED and how these might affect the physical healthcare that people with mental health conditions receive.
• Rethinking how care is designed for this group, in ways that better support and acknowledge their difficulties in accessing and receiving appropriate care.
• Looking not only at individual patients, carers and clinicians, but also at the wider pressures, environments, and service design of EDs.