Hospitals Miss More Than a Quarter of Mental Illness Diagnoses

Severe mental illness diagnoses are missed by clinicians in more than one quarter of cases when people are hospitalised for other conditions, finds a new study led by UCL researchers.

People from ethnic minority groups are even more likely to have previously diagnosed mental illnesses go unnoticed by medical staff, according to the findings from hospitals in England, published in PLOS Medicine.

However, researchers found the situation is improving, as data from 2006 showed that severe mental illness diagnoses were missed in more than half of cases.

Corresponding author, Hassan Mansour (UCL Psychiatry), who led the study as part of his MSc, said: "When someone is admitted to hospital, it's important that the medical staff are aware of their other conditions, as these might affect what treatments are best for them, in order to provide holistic care.

"We found encouraging signs that clinicians are more frequently identifying severe mental illnesses in hospital patients than they were a decade ago, but there's a lot more that can be done, particularly to address disparities between ethnic groups, to ensure that everyone gets the best care available."

The large cohort study involved 13,786 adults who had diagnoses of severe mental illnesses, which included bipolar disorder and schizophrenia, from 2006 to 2017. They linked the data to 45,706 emergency hospital admissions for the same people over the same period, to see whether their previously-diagnosed mental illness was recorded when they were admitted to hospital for a physical health issue.

Across the whole study period, mental illnesses were recorded at hospitalisation 70% of the time, after a prior diagnosis. This figure rose from 48% in 2006 to 75% in 2017.

The researchers say the improvements over time may be due to NHS commitments towards whole person-centred care, financial incentives, improvements in coding practices, or expansions of liaison psychiatric services in hospitals.

Not all of the recordings included the specific diagnosis, as the figures include any recording of a psychiatric illness. Specific recording of schizophrenia occurred in only 56% of people with this condition and, for bipolar disorder, the specific condition was recorded in only 50%, meaning that conditions may be mis-diagnosed as another, possibly less severe, mental illness.

The researchers found that people from ethnic minority backgrounds were more likely to have missed diagnoses, particularly those from Black African or Caribbean backgrounds who were 38% more likely to have their diagnosis unrecorded compared to those from white ethnic backgrounds. The researchers say this may have been due to clinicians being less able to detect these conditions in people from other ethnic and cultural groups, or perhaps language barriers, or stigma felt by patients.

Hassan Mansour said: "The disparities we found between ethnic groups are concerning because previous studies have identified particularly poor health outcomes for people from minority ethnic groups with severe mental illnesses. Training in culturally-sensitive diagnosis may be needed to reduce inequalities in medical care."

Doctors also missed diagnoses more frequently for married people, which the researchers say could be due to stigma, if spouses providing information to hospital staff are reluctant to mention a mental illness diagnosis, or are unaware of it.

Co-author Dr Christoph Mueller (King's College London Institute of Psychiatry, Psychology and Neuroscience and South London and Maudsley NHS Foundation Trust) said: "Knowing that a patient has a severe mental illness can be important for their treatment, as they might benefit from additional support after being discharged, and they may also need to continue taking their psychiatric medications, or even make changes to these, while in hospital."

Senior author Dr Andrew Sommerlad (UCL Psychiatry and Camden and Islington NHS Foundation Trust) said: "If someone with a severe mental illness comes to hospital physically unwell, it might be an indicator that their mental health is getting worse. It could be a critical time to identify issues with mental and physical health, and an opportunity to access support for their mental illness."

The researchers are calling for better sharing of data between health services.

Dr Sommerlad said: "It's important to understand that physical and mental health are interlinked, and should not be seen as separate entities. Both can impact the other, so more needs to be done to bridge the gap and achieve truly integrated care that's accessible to everyone."

Reference: 

Mansour H, Mueller C, Davis KAS, et al. Severe mental illness diagnosis in English general hospitals 2006-2017: A registry linkage study. PLOS Medicine. 2020;17(9):e1003306. doi:10.1371/journal.pmed.1003306

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