Between a quarter and a fifth of young people in the UK now suffer a mental disorder by psychiatrists’ criteria, and over a half of young people say they have or have in the past suffered a mental disorder. One in six adults in America is prescribed psychiatric medication. These statistics represent a huge and relatively recent shift in how our society thinks about problems of thinking, feeling and being; it’s clear that, in Western society, by the terms with which we currently define it, our mental health is getting worse. I work as a general practitioner in the UK, and around 90% of clinical encounters to manage mental ill-health take place not in hospitals or with specialist psychiatrists, but with doctors in the community like myself. Between a third and a half of my consultations touch on mental illness.
Many factors have influenced this shift, and because so much discussion of it takes place online, opinion about causes has become polarised. One view is that the rise is due to a welcome and long-overdue recognition of just how widespread mental and emotional difficulties are in our culture, and that historic underfunding of mental health services has hugely contributed to our worsening health. Another is that as a society and in the therapeutic professions we are labelling normal feelings as pathological. Yet another view holds that the competitive, relentless pressures of our increasingly digital culture combined with a sluggish economy are making us ill. If you look for it, you can find elements of truth in all of these perspectives. In my clinical work, I don’t get to choose a ‘side’ in these discussions; the perspectives and preoccupations my patients bring to the consulting room are the ones I have to work with. My responsibility with each remains the same: first, do no harm, then attempt to ease suffering.
I often have to reassure my patients that the categories in the DSM and the ICD are not drawn from neuroscience; they arise from culture and society – the life of the mind is inextricably cultural. The metaphor of ‘wiring’ in the brain has gone too far – our minds are a whirlpool, roiling and fluid, and nothing like a circuitboard. Archaeologists tell us that the human brain hasn’t changed much in size or shape in over 300,000 years, yet attitudes and approaches to the life of the mind shift relentlessly across time and geography – which is a reason for hope, because it means they can always change for the better. Our states of mind are experienced in context, and respond to flows of care and trauma, trust and distrust, love and disgust. The West’s overmedicalised discourse too often neglects the truth obvious to everyone with training in psychology: that mental health problems are dimensional, rather than categorical – which is to say that almost every issue is an exaggeration or a warping of a tendency that in a more measured dose, or a different context, could contribute to human wellbeing rather than detract from it.
The first ethical principle of medicine is ‘Do No Harm’, but there’s gathering evidence that some mental health diagnoses can sometimes do a great deal of harm – that they can become self-fulfilling spells that curse as often as they cure. The thresholds to be offered a diagnosis are much lower today than they were thirty years ago, and the range of feelings and behaviours that can be accorded a label are wider too. Mental health awareness campaigns have helped to destigmatise mental ill-health, but worrying evidence is also emerging that such campaigns sometimes worsen mental health outcomes. As the statistics for mental illness continue to move in the wrong direction, we in the therapeutic professions have to pause and take stock.
We can’t blame all of the shift on the economy, or politicians, or social media, or Big Pharma, or Covid – we should ask how much we ourselves in the therapeutic professions are to blame. The statistics suggest that our mental health has become fragile, but our minds are not brittle or rigid, they are dynamic, resilient and adaptive – I’d say they’re better described as unfragile. Their capacity for change and growth is part of their very nature.
Other cultures do things differently, and haven’t seen such huge increases in mental ill-health in recent years. A kinder and more humble approach to psychiatry would be open to asking why that might be, and why our culture seems to be getting this so wrong. It’s time to recharge the public conversation around mental health and illness with a little more humility and curiosity. We need courage to discuss these issues openly, and the belief that as a society and as a therapeutic culture, we can do better.