For the past few years, I’ve been running well-being workshops in schools and universities, both as someone who has experienced mental health problems myself and in my role as an ambassador for the charities SANE and Rethink Mental Illness. And something has started to bother me.
At the end of my sessions, adolescents come up to me, fluent in the language of mental health, and tell me they have a mental health condition – be that generalised anxiety disorder, or depression, or one of any number of personality disorders. But when I ask more about their diagnosis, it transpires that the only expert they have consulted is Dr Google.
This trend for self-diagnosis is running in parallel with an expansion in the number of possible mental health conditions, described by the psychologist Lucy Foulkes as “prevalence inflation”. Manuals such as the American Diagnostic and Statistical Manual of Mental Disorder (DSM), or the International Classification of Diseases, help psychiatrists to make their diagnoses. The first edition of the DSM, published in 1952, was 100 pages long. It now runs close to 1,000. Critics say we have started to find pathologies in normal human experiences. Or, to put it another way, to medicalise what Freud called “ordinary human unhappiness”.
To take some examples. Someone who would once have just been considered shy might today – according to the DSM – be diagnosed with “avoidant personality disorder”. The manual also reveals a second trend in this area: the lowering of the threshold for what it takes to be diagnosed with a given disorder for many mental health problems. In earlier editions, for instance, you might have needed to show symptoms for six months. Now the duration for some has been reduced to three.
This is not to dismiss the suffering of those involved. The teenagers who come up to me at the end of my workshops are clearly distressed. Many of them are dealing with hugely challenging lives. But I do wonder if receiving a mental health diagnosis is the best answer to their problems.
It’s a dilemma that has also concerned Jo Watson, a psychotherapist who remembers the moment in 2016 when three young people had been referred to her as a counsellor at the inner-city school where she was working. Two had been diagnosed with bipolar disorder, and told there was something fundamentally wrong with their brains. The third had been given a diagnosis of borderline personality disorder, or as it has been more recently being renamed, “emotionally unstable personality disorder”.
“Having listened to these young people, it was clear to me that they had all faced incredibly challenging situations that no one should ever have to endure. What they needed was a safe space to process their experiences and someone they could trust to guide them through it,” she writes in Drop the Disorder and Do Something! (2024), a book of essays she has edited on the current culture of mental healthcare.
Overdiagnosis matters because of the huge numbers of people involved. The numbers are large enough to make one worry about their potential to overwhelm the NHS. A total of 8.6 million people were prescribed antidepressants in England in 2022-23, with the number having almost doubled since 2011, according to NHS figures. Meanwhile, in 2022-23 nearly 450,000 children and young people under 18 were prescribed antidepressants and over four million under-25s.
Could it be time to adjust the dominant model of diagnosis and treatment in the NHS, which is focused on medication and human biology, and work towards a more holistic, person-centred approach instead? And what would this approach mean for the future of NHS mental healthcare?
Broadly speaking, it would entail a greater emphasis on understanding what has gone wrong in people’s lives and supporting people dealing with trauma and emotional distress, without just seeking to medicate it (if medication is required, making medication only one aspect of a wider recovery plan). This is an approach embraced by Sam Everington, who runs a large NHS practice in east London. His view is to address what “matters to people, rather than what is the matter with them”. His clinic combines education, social and housing as well as medical services.
Everington is also a believer in “social prescribing”: finding answers to psychological distress beyond medication, be that joining a choir, a local gardening scheme, or turning to art or poetry therapy (an enthusiasm of mine).
We clearly need a balance. There is still a role for a medical approach, as I know myself, having suffered severe depression and been treated in hospital for it. But ideally, medication should be prescribed as a last resort, at the lowest possible doses, for the shortest period of time.
Where possible, we should avoid putting people in diagnostic boxes, defining them as patients suffering from a fixed pathology which they can’t recover from – as happened to the teenagers I met. Instead, we must see each patient as a whole person, with their own individual needs.
Rachel Kelly’s new book “The Gift of Teenagers: Life Lessons They’ve Taught Me, and a Few I’ve Taught Them” will be published by Hachette in 2025
[See also: Sara Sharif died alone. We need to strengthen our communities]
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