Diagnostic overshadowing w Dr Cheryl Buhay
People living with mental illness or substance use challenges experience significant inequities in physical health outcomes, with physical illness often diagnosed later or overlooked altogether.
Diagnostic overshadowing occurs when symptoms are attributed to an existing mental health condition, substance use, disability or chronic health condition rather than being fully investigated. It remains a major issue in healthcare.
In Aotearoa New Zealand, this inequity is even more pronounced for Māori, where the impacts of stigma, racism, mistrust and fragmented care intersect. This episode explores why this happens, how it affects patients, and what clinicians can do differently.
Practical clinical pearls:
Individually: Build a habit of asking, “What else could this be?” Perform a focused physical examination and consider basic investigations, even when symptoms seem to fit with a known psychiatric diagnosis. This simple cognitive forcing strategy can interrupt premature closure and implicit bias.
At a system level: Implement integrated care models where physical and mental healthcare are delivered together, with shared records and coordinated plans. Integrated care can improve physical health outcomes for people with serious mental illness, reduce fragmentation and ensure physical symptoms receive appropriate attention, regardless of psychiatric comorbidity.
For Māori: Develop and fund culturally safe, Māori-led services that integrate physical and mental healthcare, address the social determinants of health, and build trust through culturally aligned care. This requires genuine partnership with Māori communities, action to address institutional racism, and adequate resourcing for Māori health services.
Resources:
Buhay C. Overlooked. The Horizon. Published September 16, 2025. Accessed May 18, 2026.
Lazris A, Roth A. Diagnostic overshadowing: when cognitive biases can harm patients. American Family Physician. 2023;108(3):292-294.
Iezzoni LI. Dangers of diagnostic overshadowing. New England Journal of Medicine. 2019;380(22):2092-2093. doi:10.1056/NEJMp1903078.
Shefer G, Henderson C, Howard LM, Murray J, Thornicroft G. Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms: a qualitative study. PLoS ONE. 2014;9(11). doi:10.1371/journal.pone.0111682.
Additional references:
Hallyburton A, Allison-Jones L. Mental health bias in physical care: An integrative review of the literature. Journal of Psychiatric and Mental Health Nursing. 2023.
Tosh G, Clifton AV, Xia J, White MM. Physical Health Care Monitoring for People With Serious Mental Illness. The Cochrane Database of Systematic Reviews. 2014.
Hall WJ, Chapman MV, Lee KM, et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. American Journal of Public Health. 2015.
Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A Decade of Studying Implicit Racial/Ethnic Bias in Healthcare Providers Using the Implicit Association Test. Social Science & Medicine. 2018.
Friedemann Smith C, Lunn H, Wong G, Nicholson BD. Optimising GPs' Communication of Advice to Facilitate Patients' Self-Care and Prompt Follow-Up When the Diagnosis Is Uncertain: A Realist Review of 'Safety-Netting' in Primary Care. BMJ Quality & Safety. 2022.
Goetz CJ, Mushquash CJ, Maranzan KA. An Integrative Review of Barriers and Facilitators Associated With Mental Health Help Seeking Among Indigenous Populations. Psychiatric Services. 2023.
Russell J, Boswell L, Ip A, et al. How Is Diagnostic Uncertainty Communicated and Managed in Real World Primary Care Settings? BMC Primary Care. 2024.
About Dr Cheryl Buhay:
Cheryl is an adult psychiatrist with Takanga A Fohe Pacific Mental Health and Addictions Service within Health New Zealand Te Whatu Ora Waitematā.
Previously, she was a Clinical Director within the non-government organisation sector, providing mental health and addiction support to communities across the country. She also spent several years as a Primary Care Liaison psychiatrist for Health New Zealand, working closely with general practitioners and their teams.
She is Chair of the NRPTP Vocational Training Committee for Psychiatry and an Honorary Senior Lecturer with the University of Auckland.
Listen here:
https://open.spotify.com/episode/0qrYj2lLuxrTEszZW3Hzro?si=_0do_xtQQe2c8Q7IjMta1g
