Stroke recognition, diagnostic evaluation, and acute management in patients with severe mental illness: a scoping review of clinical care pathways

## Project Description ### Background and Rationale Stroke is a time-sensitive medical emergency in which early recognition, prompt diagnostic evaluation, and timely initiation of acute treatment are essential. Adults with severe mental illness (SMI), including schizophrenia spectrum disorders, bipolar disorder, and severe major depressive disorder, experience substantial cardiovascular and cerebrovascular health burdens. However, they may also encounter barriers throughout the acute stroke care pathway, potentially contributing to delays in diagnosis, differences in treatment delivery, and inequities in clinical outcomes. One particularly relevant concern is diagnostic overshadowing, in which new physical or neurological symptoms are attributed to an existing psychiatric diagnosis rather than investigated as potential manifestations of an acute medical condition. Symptoms such as agitation, altered behavior, or communication difficulties may complicate clinical assessment, while stigma, clinician bias, and systemic barriers may further affect access to timely and appropriate care. Although primary studies and cohort-level evidence have described stroke risk, clinical outcomes, and disparities in treatment among people with psychiatric disorders, the available evidence remains fragmented. A comprehensive mapping of the evidence across stroke recognition, diagnostic evaluation, and acute management is needed to clarify what is known, identify gaps in the literature, and inform future research and improvements in clinical practice. ### Purpose and Research Question The purpose of this scoping review is to systematically map the available evidence on the recognition, diagnostic evaluation, and acute management of stroke among adults with severe mental illness in acute clinical care settings. The primary research question is: *What is known about the recognition, diagnostic evaluation, and acute management of stroke among adults with severe mental illness in acute clinical care settings?* The review will also address the following questions: 1. What diagnostic delays in stroke have been reported among patients with severe mental illness? 2. Do stroke diagnostic pathways differ between patients with severe mental illness and the general population? 3. Are there disparities or specific considerations in the delivery of acute stroke treatments to patients with severe mental illness? 4. What clinical, systemic, and professional barriers to stroke recognition and management have been described in this population? ### Objectives The primary objective is to map the available evidence on stroke recognition, diagnostic evaluation, and acute management in adults with severe mental illness receiving care in acute clinical settings. The secondary objectives are to identify reported diagnostic delays; describe differences in stroke care pathways between patients with and without severe mental illness; characterize disparities in the receipt of acute stroke therapies; and identify clinical, systemic, and professional barriers that may affect recognition and management. ### Eligibility Criteria The review will include studies involving adults aged 18 years or older with an established primary diagnosis of severe mental illness. Eligible diagnoses include schizophrenia spectrum disorders, bipolar disorder, major depressive disorder with psychotic features, severe major depressive disorder, and other specified or unspecified psychotic disorders. Eligible studies must address acute stroke recognition, diagnostic evaluation, or management in acute clinical settings, including emergency departments, stroke units, and acute inpatient care. The review will consider quantitative, qualitative, and mixed-methods evidence, as well as descriptive studies, case series, and case reports, where they meet the eligibility criteria. Studies focused exclusively on individuals younger than 18 years, non-severe mental disorders, psychiatric diagnoses secondary to another medical or neurological condition, outpatient-only populations, chronic stroke management, rehabilitation, or long-term follow-up without relevant acute-care data will be excluded. Studies addressing post-stroke psychiatric sequelae without a pre-existing severe mental illness will also be excluded. Editorials, commentaries, letters without primary data, and evidence syntheses will not be included as primary sources, although reference lists may be examined to identify potentially eligible studies. ### Methods The review will follow a structured scoping review approach. The literature search will combine controlled vocabulary and free-text terms related to stroke, severe mental illness, diagnostic evaluation, acute treatment, and barriers to care. Sources searched include PubMed/MEDLINE, Embase, Scopus, Web of Science, LILACS, SciELO, and grey literature sources. The planned search of PsycINFO will be documented according to its actual completion status. Search results will be imported into Rayyan for reference management, deduplication, and screening. Records will undergo title-and-abstract screening followed by full-text assessment against the prespecified eligibility criteria. Screening decisions will be made independently by reviewers, with disagreements resolved through the review team's established consensus and adjudication process. Data from included sources will be charted using a structured extraction instrument. Relevant information will include study characteristics, population and psychiatric diagnoses, stroke type, clinical setting, recognition and diagnostic processes, diagnostic delays, neuroimaging, acute treatments, treatment timing, barriers to care, and reported clinical outcomes, where available. After the final set of included sources has been established, reference lists of included studies will be examined to identify additional potentially eligible studies. Any additional records identified through citation searching will be assessed using the same eligibility criteria. The findings will be synthesized descriptively and narratively, with evidence organized around the three principal domains of stroke recognition, diagnostic evaluation, and acute management. The review will characterize the breadth and nature of available evidence and identify areas where evidence is limited, inconsistent, or absent. ### Expected Outcomes and Significance This review is expected to provide a structured overview of the available evidence concerning acute stroke care in adults with severe mental illness. It will characterize reported diagnostic delays, differences in clinical pathways, patterns in the use and timing of acute stroke therapies, and barriers that may contribute to inequitable care. The review will also identify gaps in the existing literature, including areas in which evidence is insufficient to determine whether observed differences are attributable to psychiatric diagnoses, clinical characteristics, healthcare processes, or broader structural factors. By distinguishing established findings from unanswered questions, the review will help define priorities for future observational research and the development of targeted interventions. Ultimately, the findings are intended to support future research, inform clinical practice improvement, and provide a foundation for more equitable, timely, and evidence-informed acute stroke care for adults with severe mental illness.