A couple of years ago I did some work around inequalities in healthcare; the fact that people with mental health problems or learning disabilities tend to get significantly poorer access to and outcomes from health services. This was a reaction both to the many examples I’d come across through working with advocacy organisations and the BMA report that showed that diagnostic overshadowing (i.e. ascribing physical health complaints to issues relating to mental health or disability) contributes to a shortening of life expectancy of between 10 – 15 years.
Sometimes these issues are framed in terms of a shortfall in the person; that the person can’t speak up or articulate their problems well. Or that there is an intrinsic interlinking of mental health and physical health pathology. I’d like to offer an alternative narrative, but to do so I have to give some additional context.
There was a time when I was able to keep personal and professional stuff completely separate. Some of you will know that this kind of ended when I was open about my experiences with depression. In one post I talked of trying to view my depression as a state from which I was recovering rather than a one-off incident like a car crash. The comparison wasn’t arbitrary. I’d recently been in car accident and was sure that the road to recovery would be swift. Now, almost two years later, I am still dealing with spinal pain. Though I am a fan of irony it is little compensation for the pain and the impact that has on my life.
So what does this have to do with anything? Well, a little while ago after the physio had said I had a clear and consistent problem relating to a couple of my vertebrae I was sent for an MRI scan. When I phoned my GP surgery to find out the outcome, the doctor that I spoke to said that the results were unclear as the image not good enough for diagnosis. No problem there, such things happen. The next thing they said surprised me, though it really shouldn’t have. In short it was along these lines (paraphrased for brevity) :
GP: I see from your notes that there are references to depression. Are you sure that the pain isn’t just an expression of that?
Me: I’m pretty sure. I think it’s more to do with being in a stationary car that was hit from behind by a car going over 30 mph. The pain started about an hour after the incident. It hasn’t changed for 2 years. I’m pretty sure that’s the more likely cause.
GP: But you might not know how depression can affect the way you perceive pain. Are you sure it’s not about that?
Me: No, I’m pretty sure it was the car accident. I know a bit about depression, this isn’t part of it. By the way, how did you jump from “the image isn’t clear enough for diagnosis” to “are you sure it’s not in your head?”
There’s a wonderful idea in logic called Ockham’s (or Occam’s) razor. It basically means that if there are a competing ways of explaining something, you should choose the explanation that relies on the fewest assumptions. The GP assumed that it was more likely that I would experience back pain as an expression of depression. I assumed that it was more likely to be down to being rear ended by a car.
The GP assumed that an unclear MRI scan was down to my depression. (No, I don’t get it either). I assume it’s more likely to be down to having to lie on my back for a scan on an injury that is exacerbated by any pressure being put on my back. I would say that I’d leave it to you decide which was the more likely explanation, but we’d both know I was lying.
I was able to talk this through with the GP, we got to a reasonable endpoint. But I absolutely felt as if a health problem with a definably physical cause (it even had a registration plate for goodness sake) was being put down to my past mental health. It takes a pretty big assumption to overshadow a car.
So I’m offering this up as an example. Whether we call it diagnostic overshadowing or the credibility gap, the problem can’t be located solely in the person who is disadvantaged in healthcare. It’s not just about being able to speak up; I can do that. It’s not about a lack of articulacy; I hope I’ve shown I can manage to string a few words together. It’s not even about mysterious causes. Cars have not been mysterious since the early 1900s. The problem is caused by the fact that, regardless of how much it strains Ockham’s razor, too many people think that mental health problems somehow preclude physical ill health.