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Diagnostic inequalities relating to physical healthcare among people with mental health conditions  

Citation:

Diagnostic inequalities relating to physical healthcare among people with mental health conditions: a systematic review. Liberati, Elisa et al. eClinicalMedicine, Volume 80, 103026

Contributors
Dr Elisa Liberati, Research Associate
Dr Elisa Liberati
Dr Sarah Kelly
Natalie Richards
Natalie Richards
Annabelle Olsson
Annabelle Olsson
THIS Institute
SW
Stella Watkins
University of Cambridge
ES
Emily Smith
University of Cambridge
SC
Serena Cole
University of Cambridge

Why it matters 

There is plenty of evidence about the inequalities facing people with severe mental illnesses (SMI) and other mental health conditions, in terms of their physical health.  

People with SMI often have much shorter life expectancy, and this impacts on the individual, their families, friends, communities and society in significant ways. People with mental health conditions are between 1.4 and two times as likely to have cardiometabolic conditions – diseases like heart disease, stroke, and type 2 diabetes – than those without mental health conditions.  

There are many reasons for these inequalities, including factors like social and financial challenges, the effects of psychiatric medications on physical health, and poorer care for physical health issues. Inequalities in diagnosing physical health problems in people in this group are also likely, and these inequalities may produce additional challenges. If people aren’t diagnosed promptly, or if they are given the wrong diagnosis, then they won’t receive the right treatment for their physical health conditions. Until now, however, there hasn’t been a thorough review of the evidence. This systematic review aims to fill that gap. 

We worked with The McPin Foundation and people who have lived experience of SMI during the design of the study to ensure that we considered a wide range of patient, clinical, and academic perspectives, including the search terms we used and data synthesis. 

What we found  

We found a wide literature addressing this issue. Making sense of it was complicated by the differences in the ways studies were designed, the different ways authors described and measured problems in the diagnostic process, and the range of mental and physical health conditions covered by the studies.  

In particular, the way some studies were designed made it hard to tell whether some of the problems with diagnosis are the result of:  

  • problems in the healthcare system (systems that work less well for people with mental health conditions, or issues in clinicians’ diagnostic decision-making that affect people with mental health conditions more than others), or 
  • wider access problems (for example people not being sure about whether their symptoms are significant or being less likely to consult healthcare professionals with their symptoms in the first place.)  

Both issues are important but may need different approaches to reduce inequalities. 

Nevertheless, some issues were clear from the literature we reviewed: 

15 studies were set up in a way that allowed the authors to show that issues with diagnosis happened after patients entered the healthcare system – so were likely caused by issues within the healthcare system itself. All but one of these studies found that people with mental health conditions were more likely to experience issues in diagnosis – such as later or incorrect diagnosis – than those without mental health conditions. 

A further 23 studies used designs that could reflect problems before or after people entered the healthcare system – meaning that the problems could be caused by factors both inside and outside the system. Of these, 18 found evidence that people with mental health conditions were more likely to suffer from problems in the diagnostic process, four were inconclusive, and one found that people with mental health conditions were less likely to suffer from these problems. This study found that actively looking for physical health problems (like high blood pressure in people with schizophrenia) helped to improve the timeliness of their diagnoses. 

The literature covers a wide range of physical health conditions, especially cancer and cardiovascular diseases, and a range of mental health conditions including SMIs and other conditions such as anxiety and depression. We found diagnostic inequalities across the spectrum of mental health conditions, including severe mental illnesses and more mild or moderate conditions. 

Diagnostic inequalities are challenging to study, and having clearer definitions and more consistent ways to measure inequalities would improve research in this field. Our study adds to the evidence about diagnostic differences in physical health problems for people with mental health conditions, including errors that happen after patients seek care, which suggest issues within the healthcare system. More research is needed to understand these issues clearly so that effective solutions can be developed. 

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