Severe mental illness diagnosis in English general hospitals 2006-2017: A registry linkage study

Autoři: Hassan Mansour aff001;  Christoph Mueller aff002;  Katrina A. S. Davis aff002;  Alexandra Burton aff001;  Hitesh Shetty aff003;  Matthew Hotopf aff002;  David Osborn aff001;  Robert Stewart aff002;  Andrew Sommerlad aff001
Působiště autorů: Division of Psychiatry, University College London, United Kingdom aff001;  King’s College London, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom aff002;  South London and Maudsley NHS Foundation Trust, London, United Kingdom aff003;  Camden and Islington NHS Foundation Trust, London, United Kingdom aff004
Vyšlo v časopise: Severe mental illness diagnosis in English general hospitals 2006-2017: A registry linkage study. PLoS Med 17(9): e32767. doi:10.1371/journal.pmed.1003306
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003306



The higher mortality rates in people with severe mental illness (SMI) may be partly due to inadequate integration of physical and mental healthcare. Accurate recording of SMI during hospital admissions has the potential to facilitate integrated care including tailoring of treatment to account for comorbidities. We therefore aimed to investigate the sensitivity of SMI recording within general hospitals, changes in diagnostic accuracy over time, and factors associated with accurate recording.

Methods and findings

We undertook a cohort study of 13,786 adults with SMI diagnosed during 2006–2017, using data from a large secondary mental healthcare database as reference standard, linked to English national records for 45,706 emergency hospital admissions. We examined general hospital record sensitivity across patients’ subsequent hospital records, for each subsequent emergency admission, and at different levels of diagnostic precision. We analyzed time trends during the study period and used logistic regression to examine sociodemographic and clinical factors associated with psychiatric recording accuracy, with multiple imputation for missing data.

Sensitivity for recording of SMI as any mental health diagnosis was 76.7% (95% CI 76.0–77.4). Category-level sensitivity (e.g., proportion of individuals with schizophrenia spectrum disorders (F20-29) who received any F20-29 diagnosis in hospital records) was 56.4% (95% CI 55.4–57.4) for schizophrenia spectrum disorder and 49.7% (95% CI 48.1–51.3) for bipolar affective disorder. Sensitivity for SMI recording in emergency admissions increased from 47.8% (95% CI 43.1–52.5) in 2006 to 75.4% (95% CI 68.3–81.4) in 2017 (ptrend < 0.001). Minority ethnicity, being married, and having better mental and physical health were associated with less accurate diagnostic recording. The main limitation of our study is the potential for misclassification of diagnosis in the reference-standard mental healthcare data.


Our findings suggest that there have been improvements in recording of SMI diagnoses, but concerning under-recording, especially in minority ethnic groups, persists. Training in culturally sensitive diagnosis, expansion of liaison psychiatry input in general hospitals, and improved data sharing between physical and mental health services may be required to reduce inequalities in diagnostic practice.

Klíčová slova:

Bipolar disorder – Critical care and emergency medicine – Diagnostic medicine – Electronic medical records – Ethnic epidemiology – Hospitals – Mental health and psychiatry – Schizophrenia


1. Simeone JC, Ward AJ, Rotella P, Collins J, Windisch R. An evaluation of variation in published estimates of schizophrenia prevalence from 1990─ 2013: a systematic literature review. BMC Psychiatry. 2015;15(1):193.

2. Merikangas KR, Jin R, He J-P, Kessler RC, Lee S, Sampson NA, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Archives of General Psychiatry. 2011;68(3):241–51.

3. Correll CU, Solmi M, Veronese N, Bortolato B, Rosson S, Santonastaso P, et al. Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large‐scale meta‐analysis of 3,211,768 patients and 113,383,368 controls. World Psychiatry. 2017;16(2):163–80.

4. Jayatilleke N, Hayes RD, Chang C-K, Stewart R. Acute general hospital admissions in people with serious mental illness. Psychological medicine. 2018;48(16):2676–83.

5. Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Archives of General Psychiatry. 2007;64(10):1123–31.

6. Hayes JF, Marston L, Walters K, King MB, Osborn DP. Mortality gap for people with bipolar disorder and schizophrenia: UK-based cohort study 2000–2014. The British Journal of Psychiatry. 2017;211(3):175–81.

7. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2012;380(9859):2163–96.

8. Firth J, Siddiqi N, Koyanagi A, Siskind D, Rosenbaum S, Galletly C, et al. The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. The Lancet Psychiatry. 2019;6(8):675–712.

9. Phelan M, Stradins L, Morrison S. Physical health of people with severe mental illness: can be improved if primary care and mental health professionals pay attention to it. British Medical Journal Publishing Group; 2001.

10. Nazareth I, King M, Haines A, Rangel L, Myers S. Accuracy of diagnosis of psychosis on general practice computer system. British Medical Journal. 1993;307(6895):32–4.

11. Sellar C, Goldacre M, Hawton K. Reliability of routine hospital data on poisoning as measures of deliberate self poisoning in adolescents. Journal of Epidemiology & Community Health. 1990;44(4):313–5.

12. Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical recognition and recording of alcohol disorders by clinicians in primary and secondary care: meta-analysis. The British Journal of Psychiatry. 2012;201(2):93–100.

13. Davis KA, Sudlow CL, Hotopf M. Can mental health diagnoses in administrative data be used for research? A systematic review of the accuracy of routinely collected diagnoses. BMC Psychiatry. 2016;16(1):263.

14. Casey JA, Schwartz BS, Stewart WF, Adler NE. Using electronic health records for population health research: a review of methods and applications. Annual review of public health. 2016;37:61–81.

15. Stewart R, Soremekun M, Perera G, Broadbent M, Callard F, Denis M, et al. The South London and Maudsley NHS foundation trust biomedical research centre (SLAM BRC) case register: development and descriptive data. BMC Psychiatry. 2009;9(1):51.

16. Cunningham H. GATE, a general architecture for text engineering. Computers and the Humanities. 2002;36:223–54.

17. Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Journal of Clinical Epidemiology. 2008;61(4):344–9.

18. Organization WH. ICD-10: international statistical classification of diseases and related health problems: tenth revision. 2004.

19. Surtees P, Kendell R. The hierarchy model of psychiatric symptomatology: an investigation based on present state examination ratings. The British Journal of Psychiatry. 1979;135(5):438–43.

20. Davis KAS, Bashford O, Jewell A, Shetty H, Stewart RJ, Sudlow CL, et al. Using data linkage to electronic patient records to assess the validity of selected mental health diagnoses in English Hospital Episode Statistics (HES). PLoS ONE. 2018;13(3).

21. Benabarre A, Vieta E, Colom F, Martinez-Aran A, Reinares M, Gasto C. Bipolar disorder, schizoaffective disorder and schizophrenia: epidemiologic, clinical and prognostic differences. European Psychiatry. 2001;16(3):167–72.

22. Digital N. Hospital Episode Statistics (HES) 2019 [cited 2019 Aug 24]. Available from:

23. Smith T, Noble M, Noble S, Wright G, McLennan D, Plunkett E. The English indices of deprivation 2015. London: Department for Communities and Local Government. 2015.

24. Pirkis JE, Burgess PM, Kirk PK, Dodson S, Coombs TJ, Williamson MK. A review of the psychometric properties of the Health of the Nation Outcome Scales (HoNOS) family of measures. Health and Quality of Life Outcomes. 2005;3(1):76.

25. Mueller C, Molokhia M, Perera G, Veronese N, Stubbs B, Shetty H, et al. Polypharmacy in people with dementia: associations with adverse health outcomes. Experimental Gerontology. 2018;106:240–5.

26. Digital N. HES Data Dictionary: Admitted Patient Care 2018 [cited 2010 May 16]. Available from:

27. Fleiss JL, Levin B, Paik MC. Statistical methods for rates and proportions. John Wiley & Sons; Hoboken, New Jersey 2013.

28. Armitage P. Tests for linear trends in proportions and frequencies. Biometrics. 1955;11(3):375–86.

29. Rubin DB. Multiple imputation for nonresponse in surveys. Hoboken (NJ): John Wiley & Sons; 2004.

30. von Hippel PT. How many imputations do you need? A two-stage calculation using a quadratic rule. Sociological Methods & Research. 2018;49(3). doi: 10.1177/0049124117747303

31. Perkins A, Ridler J, Browes D, Peryer G, Notley C, Hackmann C. Experiencing mental health diagnosis: a systematic review of service user, clinician, and carer perspectives across clinical settings. The Lancet Psychiatry. 2018;5(9):747–64.

32. Macdonald A, Adamis D, Craig T, Murray R. Continuity of care and clinical outcomes in the community for people with severe mental illness. The British Journal of Psychiatry. 2019;214(5):273–8.

33. Hardoon S, Hayes JF, Blackburn R, Petersen I, Walters K, Nazareth I, et al. Recording of severe mental illness in United Kingdom primary care, 2000–2010. PLoS ONE. 2013;8(12).

34. Maruthappu M, Sood HS, Keogh B. The NHS five year forward view: implications for clinicians. BMJ. 2014;349:g6518.

35. Marshall L, Charlesworth A, Hurst J. The NHS payment system: evolving policy and emerging evidence. London: The Nuffield Trust; 2014.

36. Sharpe M. Psychological medicine and the future of psychiatry. The British Journal of Psychiatry. 2014;204(2):91–2.

37. Nelson A. Unequal treatment: confronting racial and ethnic disparities in health care. Journal of the National Medical Association. 2002;94(8):666.

38. De Hert M, Cohen D, Bobes J, Cetkovich-Bakmas M, Leucht S, Ndetei DM, et al. Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level. World Psychiatry. 2011;10(2):138–51.

39. Carliner H, Collins PY, Cabassa LJ, McNallen A, Joestl SS, Lewis-Fernández R. Prevalence of cardiovascular risk factors among racial and ethnic minorities with schizophrenia spectrum and bipolar disorders: a critical literature review. Comprehensive psychiatry. 2014;55(2):233–47.

40. Fontanella CA, Guada J, Phillips G, Ranbom L, Fortney JC. Individual and contextual-level factors associated with continuity of care for adults with schizophrenia. Administration and Policy in Mental Health and Mental Health Services Research. 2014;41(5):572–87.

41. Barnett P, Mackay E, Matthews H, Gate R, Greenwood H, Ariyo K, et al. Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data. The Lancet Psychiatry. 2019;6(4):305–17.

42. Eack SM, Newhill CE. Racial disparities in mental health outcomes after psychiatric hospital discharge among individuals with severe mental illness. Social Work Research. 2012;36(1):41–52.

43. Sommerlad A, Perera G, Singh-Manoux A, Lewis G, Stewart R, Livingston G. Accuracy of general hospital dementia diagnoses in England: sensitivity, specificity, and predictors of diagnostic accuracy 2008–2016. Alzheimer's & Dementia. 2018;14(7):933–43.

44. Wilkins CH, Wilkins KL, Meisel M, Depke M, Williams J, Edwards DF. Dementia undiagnosed in poor older adults with functional impairment. Journal of the American Geriatrics Society. 2007;55(11):1771–6.

45. Allsopp K, Read J, Corcoran R, Kinderman P. Heterogeneity in psychiatric diagnostic classification. Psychiatry Research. 2019;279:15–22.

46. Huda AS. The Medical Model in Mental Health: An Explanation and Evaluation. Oxford University Press,Oxford, United Kingdom 2019.

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PLOS Medicine

2020 Číslo 9

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