What factors may have been encouraging young people in the UK to medicalise normal feelings and emotions in recent years?

Is there an epidemic of mental health problems among young people in the UK today – or are we seeing a medicalisation of a normal negative feelings and emotions? We have identified five distinct factors which may help explain what is happening:

• Expanding definitions of mental disorders
• The unreliability of diagnostic tools
• An increasing culture of overmedicalisation
• The lack of youth-specific mental care facilities
• Societal changes

These factors are explored below.

Expanding definitions of mental disorders

The Diagnostic and Statistical Manual of Mental Disorders (DSM), sometimes known as the ‘Psychiatry’s Bible’ is the standard reference text for diagnosing mental disorders. The fifth edition of DSM (DSM-5), published in 2013, tended to expand definitions of mental illness in general, and diagnostic criteria in particular. (1) While each edition of the DSM undergoes changes – deletions, additions, and revisions – critics raised the concern that the more inclusive definition of mental disorders in DSM-5 could lead to overdiagnosis and diagnostic inflation. Indeed, several reviews suggest that the expansions of the DSM with each new edition have consistently resulted in a growth of diagnoses as well as more inclusive disorder criteria.

Although these changes may appear minimal at first, “slight variations in diagnostic criteria can have significant effects on prevalence” (2), as evidenced by broadened criteria for PTSD, ADHD, Autism Spectrum Disorder, Generalized Anxiety Disorder, and Major Depression. Compared with earlier editions, for instance, critical voices argued that the criteria for major depressive disorders were so loose that ordinary sadness could be mistaken for clinical depression.

Research since the publication of DSM-5 suggests the impact on diagnosis may sometimes have been less than anticipated. This may be the case, for example, if busy doctors sometimes operate on auto-pilot e.g. diagnosing in the way they always have rather than reading the small print in the latest DSM. However, the research did find evidence of diagnostic inflation for some disorders, including one of the most common, Generalized Anxiety Disorder.(3)

Thus, we can see here that the problem of over diagnosing children and young people may be part of “a general trend to diagnose all human behaviour” (4), resulting from loosened definitions of mental ill health and disorders. According to a PLOS Medicine editorial, normal life experiences are deemed illnesses, and are considered in need of medical treatment when they may not need it, or when there are nonmedical options. This, the editorial continues, is evident “especially among children.” (5)

Such a widening of definitions and diagnostic criteria and the lowering of treatment thresholds, it has been suggested, are rooted in the shift towards a culture of medicalisation.(6) Children, in such a culture, “have become socialised into interpreting their experience through the language of mental health deficits” and are often “encouraged to communicate their problems through a psychological vocabulary like ‘stress’, ‘trauma’ or ‘depression’ to describe their feelings.” (7)

The limitations of diagnostic tools

Diagnosing mental health disorders is intrinsically difficult. Unlike certain physical and somatic disorders, it is currently not possible to detect mental ill-health/disorders by physiological, neuronal, or genetic correlates.(8) There is no mental health equivalent for most of the methods used to diagnose physical illness, such as physical examination, sending samples to laboratories for testing or medical imaging (e.g. X-ray, CT or MRI scans). Instead, there is significant reliance on interpreting self-reporting by patients. The situation is even more challenging when it comes to diagnosing children and young people. In comparison to adults, a “multi-informant” approach is utilised when determining the presence of mental disorders in children. This means that in addition to the child’s description of their mental health, parents and other relevant caregivers will provide descriptions of the child’s behaviour. (9) Yet, the diagnostic process is prone to errors and can be influenced or undermined by several factors, including the diagnostic criteria, the structure of the health care system, as well as the “characteristics of the diagnostician.” (10)

Diagnosticians largely depend on the subjective descriptions by the informant, and the informant may be influenced by what is dubbed the “halo effect”; namely a cognitive bias whereby some factors that are deemed important influence the overall judgment of the situation. According to some studies, parents may be vulnerable to such biases.(11) Additionally, it may be the case that children simply express mental disorders differently compared to adults (12), clearly acknowledged in the DSM-5 which states that children may express major depression through mood swings rather than sadness.

We also have to take into account the context of both the diagnostician and the specific health system. Studies have shown, for example, that the diagnosis of mental disorders in the US and UK “differed according to their nationality”, which seems to further indicate the subjective components inherent to such decision-making. An additional, and final, factor to consider is that some diagnosticians may assign a diagnosis prematurely due to parental pressure; for example, when a diagnosis is required for the young person to access treatment. (13)

How a culture of medicalisation may miss the mark

As mentioned earlier, the trend towards unnecessary and unwarranted medical treatment of mental ill health in children and young people is largely reflective of a culture of medicalisation in the UK. (14) A 2016 paper by Gray, White, and Russell in the Journal of the Royal Society of Medicine describes how UK health services, and the National Health Service in particular, foster medicalisation, with an extensive issuing of treatments, “increasingly for people without symptoms at all.” (15) As a consequence of this, we may underestimate the deeply socio-economic aspect to many mental disorders. There is a clear link between mental health and poverty, and many low-income groups exhibit higher rates of mental disorders compared to medium and high-income groups. This problem, according to Boardman, Dogra, and Hindley, (16) is especially noticeable among children “with a threefold difference in prevalence of any mental disorder between rich and poor households.”

If it is the case that mental health disorders are linked to socioeconomic status, then we ought to engage such issues of inequality through policies, “not by prescribing pills.” (17) A culture of medicalisation prohibits us from engaging proactively with the underlying causes of mental health problems in younger people.

The socio-economic dimension to mental health diagnosis also suggests a paradox when it comes to the widely reported student mental health crisis in universities. Despite widening participation initiatives, university students (particularly in Russell Group universities) are still largely from middle class families. So, they should be less likely to experience a mental disorder. Yet every year brings more news of a growing mental health crisis in universities, suggesting an increase in mental health problems among their predominantly middle-class students. This apparent paradox can perhaps be explained if we distinguish between diagnosed mental health conditions/disorders (more prevalent among low-income groups) and self-reported mental distress, which may suggest a medicalisation of normal feelings and emotions (prevalent among higher income groups?).

The importance of youth-friendly mental health services

Rather than prematurely medicalising mental health problems, and perhaps simply normal stages of life, policies need to focus on prevention, early interventions, and the promotion of resilience. In an international study of youth mental health services in Australia, Ireland, and the UK, (18) the authors argue for the importance of reorienting existing mental health services to provide youth-specific care. The study, based on recent attempts at reshaping mental health services, highlights several key features and principles that are important for delivering care that can meet the needs of young people suffering from mental ill-health. It needs to allow for sufficient youth participation at all levels of care; shared decision-making based on optimism and stepwise care; and the “elimination of discontinuities at peak periods of need for care”. The study’s conclusion is that mental healthcare for younger people ought to be mainly preventative and focus on “promoting resilience and symptom reduction” so as to avoid medicalising mental problems and negative emotions prematurely.

For example, the study refers to the provision of youth-friendly centres, which young people could consult for both physical and mental health problems, through the Headspace initiative in Australia. It notes, ‘The provision of a youth-friendly environment is vital as this is rarely available in standard primary care or the specialist mental health systems, and provides a soft entry point that is more appealing and effective in attracting distressed or struggling young people into the service without labelling or prematurely medicalising the problem’ – with the availability of physical health services also providing a stigma-free access point to the scheme for young people.

Societal changes

We have seen so far that a combination of four factors (the tendency to expand definitions of mental disorder; the risk of error in mental health diagnosis due to the limited diagnostic tools available; the trend towards medicalisation in the NHS more generally; and a lack of youth-friendly mental health services) mean more young people are now likely to receive the diagnosis that they have a mental health condition than in previous generations.

However, we have also seen, in the example of university students from generally higher socio-economic backgrounds fuelling the reported student mental health crisis, that this isn’t necessarily just an issue of changing clinical diagnosis. We appear to have moved to a situation where normal negative feelings and emotions are routinely considered to be a mental health problem by young people themselves. For example, the NHS describes feeling anxious as normal, including when preparing for an exam or job interview. Even under DSM-5 it is only when the anxiety becomes abnormal (occurring more often than not for at last six months, challenging to control, accompanied by a physical or cognitive symptom and disproportionate to any actual risk) that it is diagnosable as Generalized Anxiety Disorder. However, in pilot research conducted by Health Action Campaign in partnership with three universities, 90% of a sample of first year students perceived anxiety to be a mental health problem. (19) This is in line with national surveys conducted by the National Union of Students (NUS) in 2013 and 2015, which presented anxiety as a mental health problem. (20)  

We may therefore need to consider possible social or cultural factors which have encouraged the medicalisation of normal feelings and emotions. For instance, has media (and social media) coverage of mental health changed over the years? 

Several points can be suggested (21):

-        The increased public perception that being well means only having positive feelings taking over the social discourse on mental health. When the measure of health is simply feeling good, negative emotions become a marker of being unwell.

-        The distorted reality of social media leads many young people to hide imperfections, which is making it more difficult to address negative feelings proactively. (22)

-        Confusion regarding the term ‘mental health’ – for previous generations this was a plus (positive mental health) but many young people now interpret this as a minus i.e. having a mental health problem.

-        The use of terms denoting illness, such as depression, to mean all negative emotions. Now, words like sadness, disappointment, disgruntlement, demoralisation and unhappiness are all lumped together as depression.

-        Living with and on devices like smartphones may be making us lonelier, as this limits face to face contact and the capacity of a text message doesn’t allow for the expression of complex ideas.

More research would be needed here to confirm this hypothesis – but the points appear plausible.

It may also be worth considering if medicalising normal feelings and emotions provides any social benefits for young people, which might help explain its increase? For example:

• Does it give their negative feelings and emotions more status and importance to describe them using medical terminology?
• Is this part of a tradition of young people (and possible people more generally) dramatizing what has happened to them to make it seem less ordinary and mundane?
• Does it provide competitive advantage with peers e.g. anecdotal evidence of girls in particular competing to claim to be the most stressed?
• Does it help game the system (e.g. anecdotal evidence of some students, their parents or schools using this to get more time to complete course work or exams, as allegedly has been the case with dyslexia and special needs previously)? (23.24)
• This is a largely under-researched area and one where reliable data may sometimes be difficult to access. For example, how many students would voluntarily admit to any of the points above, some of which may be subconscious anyway. However, it may be an area worth researching further.

Conclusions

• Expanding definitions of mental disorders, the unreliability of diagnostic tools and an increasing culture of overmedicalisation may all be leading more young people to be diagnosed as having a mental health condition.
• A shortage of youth-friendly mental health services increases the risk of labelling or prematurely medicalising young people’s problems.
• Societal and cultural changes, reflected in linguistic changes (e.g. ‘mental health’ moving from being seen as positive mental health by previous generations to now meaning a mental health problem for some young people) may be leading more young people to interpret normal negative feelings and emotions as mental health problems.
• Describing normal negative feelings and emotions as mental health problems may have benefits for some young people, although this is a largely untested hypothesis.

Mikael Leidenhag and Michael Baber, August 2022.