Red X iconGreen tick iconYellow tick icon

A survey, carried out by University of Otago researchers, reveals a significant number of people living with mental health and substance use conditions in Aotearoa New Zealand report experiencing discrimination and clinician bias when seeking care for medical problems in our health system.

The results, published in the international medical journal Frontiers in Psychiatry, suggest “diagnostic overshadowing” – where a healthcare professional assumes a patient’s symptoms are due to their mental health rather than fully exploring physical causes – may be influencing decisions not to initiate medical investigations or treatment.

Ruth Cunningham 2023 image
Associate Professor Ruth Cunningham.

Lead author, University of Otago, Wellington Associate Professor Ruth Cunningham, says the survey results raise concerns about medical treatment bias towards people living with mental health and substance use conditions (MHSUC).

“The results of this survey provide another piece in the puzzle to understanding why those with experience of mental health and substance use conditions are dying at younger ages than other New Zealanders.

“They also show the need for urgent interventions to change how we support and manage the health of people living with mental health and substance use issues in Aotearoa to enable people to live long lives.”

Associate Professor Cunningham says with the health system transforming to enable a more person-centred care approach, these results provide an important opportunity to consider health inequities which are less talked-about.

“Clinicians have an important role in providing respectful care which considers a patient’s physical symptoms – not just their background of mental health and substance use – when making a diagnosis.”

The survey of 253 people with MHSUC who had accessed physical healthcare was carried out early last year by researchers at both the University of Otago, Wellington’s Department of Public Health, and colleagues from the University of Otago, Christchurch’s Māori Indigenous Health Institute (MIHI).

In its findings, 10 per cent of respondents reported experiencing discrimination due to their MHSUC always or most of the time – with significantly more prevalence in people with severe mental illness such as schizophrenia or bipolar disorder, those with four or more diagnoses, and LGBQA+ individuals.

In addition, 20 per cent reported experiencing diagnostic overshadowing always or most of the time – particularly Māori participants and people with severe mental illness.

“The survey results suggest diagnostic overshadowing is driven by stigma and discrimination, with respondents recounting how they were not believed when they reported their physical health symptoms, with an implicit or sometimes explicit assumption that they were making the symptoms up, exaggerating or even outright lying,” Associate Professor Cunningham says.

The study authors say notably, respondents presenting with pain reported a strong sense that their clinicians believed the pain to be imaginary or fabricated, not requiring treatment, and as a result, their physical symptoms were dismissed, leading to delays in investigations, diagnosis and treatment.

The authors suggest that a revised commitment to patient-centred care may now be needed, with an explicit focus on respect, partnership, listening to and developing a trusted relationship with the patient, to improve quality of care for people living with MHUSC.

Publication details

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
Ruth Cunningham, Fiona Imlach, Tracy Haitana, Susanna Every-Palmer, Cameron Lacey, Helen Lockett and Debbie Peterson
Frontiers in Psychiatry

For more information, contact:

Lorelei Mason
Communications Advisor
University of Otago, Christchurch
Mob +64 21 555 024

Associate Professor Dr Ruth Cunningham
Public Health Physician
Department of Public Health
University of Otago, Wellington

Back to top