Sami Timimi is a child and adolescent psychiatrist, psychotherapist and author of the new book Searching for Normal: A New Approach to Understanding Mental Health, Distress, and Neurodiversity.
I was talking to my youngest daughter on a cold evening in April, 2022. Still shrouded in the shadows of COVID lockdowns with social distancing signs on London pavements, we sat in a restaurant littered with hand sanitizers accumulating crystalline congealed blobs on the tray below their now mostly empty dispensing levers. Enforced alienation in an already hyper-individualistic culture was contributing to rising referral rates at the child and adolescent mental health service where I worked as a consultant psychiatrist.
Zoe, who was 24 at the time, was in one of those nihilistic moods. Her generally happy-go-lucky predisposition was now often punctuated by pessimism. She was struggling to find a stable job, feel a sense of purpose, and imagine a better life awaited her. She explained that many of her friends and friends of friends felt the same way. An invisible blanket of humdrum gloom and despondency had replaced the ardour and energy of youth. They were getting diagnosed with ADHD, trauma, depression, anxiety, PTSD, autism, and often several such diagnoses. Their conversations were interpolated by references to gender identity, neurodiversity, emotional regulation and “having” mental health. When she explained the circumstances of these peers, which included bereavements, enforced isolation during lockdowns, financial insecurity, struggling to find an affordable place to live, and so on, I realized she was describing an accelerating – and to me, worrying – sociocultural process.
My other daughter, Michelle, had been telling me about chats taking place with other parents at the school gates and nursery car park that my three gorgeous grandchildren attend. “He’s probably on the spectrum,” “She’s masking all day and then has meltdowns at home,” “Have you considered whether these are traits of ADHD?” Parents, teachers, support workers, and child-care assistants talking the language of psychiatric symptoms and diagnoses as they tried to make sense of three- to 10-year-old children’s behaviours.
As a child and adolescent psychiatrist, I was also noticing a shift toward more young people and/or their parents, teachers, friends and other professionals imagining they had a mental disorder that needed diagnosing. The mother of a 14-year-old patient told me with confidence her son needed medication to address “some sort of chemical imbalance.” A 16-year-old girl was “pretty sure” she was bipolar (“I’ve looked this up”) and told me that her friends, all apparently medicated, expressed shock when they learned my patient had not been prescribed anything. The mother of another young woman was certain she had autism, ADHD, depression and anxiety. “But I think that’s not all that’s wrong with her,” she told me, “There’s something more. Something deeper. Maybe she has some sort of personality disorder.”
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Even my colleagues weren’t immune. “I think he may have some neurodiversity, perhaps even autism” was becoming a common utterance I heard from therapists, social workers and psychologists.
A patient information leaflet on “antidepressants” produced by a British national mental health service and passed anonymously to me, included the following advice: “It can sometimes take weeks, months or even years, to get the right medicine at the right dose for you. Think of it as a bit like dating. Some make you feel sick or sleepy; some are great to start with but wear off; others may not be much to start with but after a while grow on you. Then you might have found the one that makes you feel good long-term. So don’t lose hope if the first one doesn’t work.”
An emboldened and bloated Mental Health Industrial Complex (MHIC) has grown its tentacles beyond the hospital and the clinic, worming its way into the minds of the masses. Is this a sign of a society embracing psychological liberation? Or is it something more sinister – the monetization of distress and difference whilst psychologizing and distracting from the social drivers of psychic pain.
Rising rates, declining outcomes
Multiple studies have highlighted the increasing prevalence of anxiety, depression and other mental health conditions in Canada, particularly in its youth. Between 2012 and 2022 the prevalence of mood and anxiety disorders increased substantially, particularly among women and those between the ages of 15 and 24.
For example, the one-year prevalence of generalized anxiety disorder among young women tripled from 3.8 per cent in 2012 to 11.9 per cent in 2022. Meanwhile, a 2019 survey that asked Canadian youth aged 12 to 17 years to rate their mental health, found that 12 per cent rated their mental health as “fair” or “poor.” That proportion had more than doubled to 26 per cent in 2023, when the respondents were now aged 16 to 21 years. Among the 88 per cent of youth who rated their mental health as “good,” “very good” or “excellent” in 2019, 21 per cent reported experiencing a decline to “fair” or “poor” by 2023.
Some studies suggest these increases may have an element of social contagion. According to Canadian research published in 2023, kids – especially teenage girls – are presenting with self-described Tourette’s, eating disorders, autism, Dissociative Identity Disorder (DID) and other mental disorders in exponentially increasing numbers. The authors conclude that identifying with and glamourizing certain “disorders” has become a way for some teenagers to express negative emotions in a way that, rather than stigmatizing them, makes them feel part of a community or unique and special.
With this type of concept spread what sometimes happens is young people (particularly girls) watch videos (such as those on TikTok) by content creators who self-identify as having these various “illnesses” (like ADHD). Videos show and describe how the symptoms manifest during everyday activities and how it is an important part of the creator’s identity. Then, these youngsters present with the outward symptoms, just as described by the content creator, thus producing sudden outbreaks of a particular condition, or increases of those considered more common (such as ADHD).
The “Treatment Prevalence Paradox”
While more is being spent on treatment of individuals, the general population prevalence of many mental health conditions is rising. Hence, on the one hand treatment access has improved and become more available, but on the other hand the omnipresence of mental health conditions has not decreased, but instead has increased across all age groups, and particularly in young people. This is known as the Treatment Prevalence Paradox (TPP).
There has been a cascade of recently written books by psychiatrists, sociologists, psychologists and historians coming to the same conclusion: Our beliefs and practices around mental health have failed to improve either our scientific knowledge or clinical outcomes.
Despite increasing consumption of therapy and psychiatric medication, mental health in Western countries (which have the most globally developed mental-health services) is getting worse by multiple metrics. Suicide rates have risen, more people are worried and/or depressed, the mortality gap between those being treated for severe mental conditions and the rest of the population is wide and increasing, and there are rising rates of people receiving disability benefits for mental-health difficulties.
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International studies show this decline in mental health across all age and gender groups, with English-speaking countries having the lowest levels of mental well-being, and those between the ages of 18 and 24 having the worst mental health of all. The trends keep going in the wrong direction. Wherever you look across the Western world you will find stories about mental-health epidemics and data that shows more people being diagnosed, more services being created, and more psychiatric treatments being consumed.
These worsening outcomes are not true for cancer, not true for heart disease, not true for diabetes, or almost any other area of medicine. Something is going badly wrong.
The growth of mental health diagnoses has not occurred because of any new scientific discoveries. No one has discovered mythical “chemical imbalances,” characteristic brain differences, or robust genetic associations with any psychiatric condition (the two exceptions being with the dementias and intellectual disability).
Brain scan images showing Alzheimer’s dementia, top in dark blue, compared to another scan with early developing spots, in light blue, that researchers said were likely showing the early stages of Alzheimer’s disease. The results of the research were published in the new England Journal of Medicine in 1996.The Associated Press
This is why what are called “tests” in psychiatry do not tell you anything about the brains or bodies of those diagnosed. They are largely questionnaires supplemented by impressionable observations.
In response to these alarming trends, some are calling for more resources to enable better detection and more (early) interventions. But this may further worsen outcomes if the fundamental concepts that build our beliefs and practices rest on inappropriate foundations. For a start, it assumes we know what we mean by “mental health” and therefore what a mental illness or disorder is. You’d be forgiven for thinking that there are specific targeted treatments out there and that people get better with interventions delivered by professionals with special expertise. You’d likely think that our problem with mental health is stigma and lack of services; that the issue is woeful underfunding and long waiting lists, and that more needs to be done to educate the population.
But these are not the real problems. In fact, the above assumptions are likely a major cause of growing mental-health problems, rather than its solution.
You see there is a truth that we (in the mental-health business) hope no one will notice – we literally don’t know what we are talking about when it comes to mental health. We are unable to escape something that all the definitions of mental health or illness have in common. They are all subjective. They are constructed by a belief, an opinion, an idea. They are not phenomena that lend themselves to sitting in the world of objective facts in the same way that a broken bone does. This means they can be expanded in a myriad of ways to capture a kaleidoscope of distress, alienation and dissatisfaction.
The World Health Organization defines mental health as “a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community.” What does “realize their abilities” mean? Is it in the sense of being aware of them, or in the sense of putting them into effect? What are the normal “stresses of life” and what does it mean to “cope” with them? What does it mean to “work well,” and how does a person know that they are contributing to a community? Which community? How do you define a contribution anyway? There must be many people who, for lack of education, money, or opportunity, are in practice unable to do so. Are these unfortunates by definition mentally ill? I could go on.
The consequences for us adopting this non-scientific, simplistic framework have been catastrophic for our collective mental health and for our understanding of distress. It means definitions can expand horizontally (by taking in new behaviours or lesser extreme versions) or vertically (by incorporating new populations).
ADHD starts its clinical life as hyperkinetic disorder, rare and thought of as “developmental” – meaning most children were expected to grow out of it. It is then thought of as affecting more children, including lesser disruptive behaviours and incorporating attention difficulties rather than just the “hyperactive” element. Next, it becomes seen as potentially lifelong, but still a mainly male “disorder.” Introducing the concept of “masking” then means that you don’t have to display the behaviours, but rather “feel” you have them, thus enabling a whole new cohort (mainly women) to be brought into the ADHD diagnostic realm.
None of these evolving diagnostic mutations were the result of new biological discoveries.
Psychiatric diagnoses are consumer brands, not medical diseases
Diagnosis is a system of classification based on categorizing a proximal cause. We can take a car to a garage to run diagnostic tests. Computer technicians will run diagnostics looking for software faults or computer viruses causing a program to malfunction.
In medicine, diagnosis is the process of determining which disease explains, i.e., has caused, a person’s symptoms and/or signs. Making an accurate diagnosis is a technical skill that enables effective matching of treatment to address specific disease processes occurring in the body. Health care involves a lot more than this, as it is a human social activity, meaning that patients have a relationship with health care providers as well as an awareness that physical suffering also impacts a person’s psychosocial world. But a diagnostic system enables progress on the technical aspects of care.
Dr. Seth Gale points out evidence of Alzheimer’s disease on PET scans at the Center for Alzheimer Research and Treatment at Brigham And Women’s Hospital in Boston in 2023.BRIAN SNYDER/Reuters
The availability of empirical measures enables advances in scientific knowledge and clinical outcomes as we classify a case using measurements that map into the world of objective facts, such as measuring a person’s blood sugar levels to ascertain whether they may have diabetes.
But in mental health we are reliant on subjectivity. Psychiatric diagnoses therefore cannot point toward any causal agent (apart from a few such as those related to forms of dementia).
Consider the following example: If I were to ask the question “What is depression?” it’s not possible for me to answer that question by reference to a particular known abnormality. I cannot say that depression is a disease that occurs due to having abnormally low levels of serotonin in the brain, because no one has found this despite extensive research and so there are no medical tests done to confirm or refute this.
Selective serotonin re-uptake inhibitors (SSRIs) are a class of widely prescribed drugs, including fluoxetine, branded by Eli Lilly as Prozac.MATT DETRICH/The Associated Press
Instead, to answer the question I will have to provide a description such as, “Depression is the presence of persistent low mood and negative thinking.” Saying that feeling low is caused by depression is a bit like saying the pain in my head is caused by a headache. If we try to use a classification that can only describe, in order to explain, we end up with a circular thinking trap.
Technically speaking, therefore, there is no such thing as a psychiatric diagnosis, yet we act as if we know what we’re talking about and as if we have explanations for certain states of mind and associated behaviours. So why has this unscientific idea spread so widely?
The mental-illness health epidemic is growing alongside a crisis of economy and political legitimacy in Western societies. The distress and insecurity produced becomes another source of profiteering in the marketized economy where personhood is socially produced through individualized consumption. This individualization has helped create a profitable MHIC where psychiatric diagnoses function more like commercial brands.
At the same time, this enables distraction from social causes of distress such as poverty, inadequate housing, social injustice, discrimination, exclusion, and chronic financial insecurity; alongside militarism, and appalling levels of violence inflicted by governments on global citizens they control (or try to control). Cancel culture from right and left, impotence of politicians to take us out of seemingly endless cycles of austerity, and loss of trust in mainstream media, leaves a crisis of legitimacy alongside material deprivations in a landscape of growing inequality. The postwar dream of looking forward to a better life than your parents has faded. Job insecurity, high rents, homelessness, crumbling infrastructure, crippling debts, food banks, extortionate bills alongside mental health epidemics are the zeitgeists of our age.
Like identity politics, MHIC shifts the focus away from the political arena of the runaway elite class of the super-rich oligarchs, to competing minority rights and the space between the ears.
Is there anything we can we do to help each other and our children?
I am continually impressed by the extraordinary ability of even the most severely afflicted of the young patients I see to recover functionality and meaning in their lives. The world may be in crisis, but I remain optimistic. Humans are remarkably resilient.
Here are a few thoughts:
I’m all too aware that there will be thousands of parents reading this who may have been told by teachers that their child has ADHD or is on the autistic spectrum, or has “anxiety” and therefore needs an assessment. I can understand why a parent may wish to pursue that given that we have publicized the existence of such conditions and encouraged early diagnosis. My advice – don’t agree to such a referral. Fight it every step of the way. Love your kids, be patient, and most of you will find a way through.
We should be able to talk about how we feel without jumping into panic mode and imagining that what we’re describing could be the onset of some mental disorder. I try to help the young people I see understand that being able to tolerate, live through and find meaning in low mood or anxiety (for example) is a sign of resilience, not a marker of disorder.
Don’t try too hard. We live in a society whose politics and economics promotes a compare and compete hyper-individualist model of human nature. This puts pressure on us and our children to perform. We then see our children or ourselves as primarily vulnerable and get drawn into noticing all sorts of ways their mental and behavioural health could go “wrong.” As we are launched into a seemingly never-ending search for the right diagnosis and treatment, we start collecting labels and accompanying interventions. Each step in this journey has the potential to make it harder to accept your child (or yourself) just the way they are with all their uniqueness and the mysterious wonderful variety of ways they might thrive in this maddening world. Be patient and categorize psychological problems in the sphere of the ordinary and/or understandable.
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Don’t fear emotions. When we put emotions in the class of problems that can only be solved with special expertise such as a specific therapy or worse psychiatric medication, we risk losing agency and alienating ourselves from parts of ourselves that are to be experienced rather than feared. Emotions are part of dynamic and multifaceted systems and like any dynamic system (such as the weather) the one constant is change. Our duty as parents (and to each other as adults) is not to prevent our children from experiencing distress (which is impossible), but to be there and take the time and have the patience to be with them and support them when they do.
See nurturing relationships as a greater priority than controlling behaviour. When we are distressed by the behaviour of our children (or other adults in our life) we often hope we can get through to them so that they change in a way that would stop their frustrating/irritating/worrying behaviour. Unfortunately, this can accidentally damage the relationship, leading to further problems and more tension in that relationship. The only bit in a relational dynamic that you can reliably influence is your own contribution. Think about those aspects of your relationship that you want to nurture. It can be incredibly powerful if, even in the worst of times, you can keep in mind, notice, and comment on, those bits of behaviour, however fleeting, small, or temporary that remind you of what you love, what brings you joy, and what you value in your child (or other adult). It’s a bit like retraining your internal radar away from picking up all the cues for the things that distress you and reprogramming it to notice the things that you like.
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Beware of concept creep. As what I call the Mental Health Industrial Complex has burrowed its way into day-to-day language and “common sense,” concepts have been popularized that encourage us to view behaviours and experiences in pathological ways. We no longer become sad or miserable, we get depressed. We now talk about emotional regulation and dysregulation, having “meltdowns,” and “masking.” Strip away this language. You and your children’s experiences nearly always sit in the realm of the ordinary and/or understandable.
There are profound consequences for each of us and our society as a whole of us literally not knowing what we’re talking about when it comes to mental health and/or neurodiversity. Arming yourself with some knowledge to help you avoid the prolific spread of scientism (faith masquerading as science) could save you or your child becoming another number in the growing crowds of those who are deemed to have lifelong and incapacitating mental disorder/illness. These conditions were never meant to be a life sentence.