It has board games, club nights until “silly o’clock” and bouncy castles. But Open Door, a social enterprise for youngsters on the Wirral peninsula, has still not achieved peak fun. Its founder, Lee Pennington, plans soon to move the charity to the “Joy Building”, an ex-council property that will be adapted so that visitors can whizz between floors on slides. Not that long ago, the charity would have called itself a youth club. Now it uses a different argot. “We’re rebranding mental health,” says Mr Pennington. “We’re trying to engage the disengaged, normalise the conversation and ultimately have a good time doing it.”
Mr Pennington is not alone in trying to get more Britons to open up about their mental health. Visitors to Open Door have included the Prince and Princess of Wales, who have spearheaded mental-health awareness campaigns in recent years. Such efforts have been very successful in destigmatising mental-health problems. In a survey in 2019 more than three-quarters of Britons said that mental illness is an illness like any other, the highest of all 29 countries polled. Awareness has only increased since the covid-19 pandemic.
That is in many ways welcome. Britain may be the home of the stiff upper lip but there is nothing wrong with it wobbling. Conditions such as anxiety and depression, to say nothing of more severe forms of psychosis, can and do blight lives; early interventions can stop problems spiralling out of control. But some now fret that things have gone too far. “We’re starting to wonder whether it’s time to scale down our mental-health awareness,” says Simon Wessely, a professor of psychiatry at King’s College London. Lucy Foulkes, a psychologist at the University of Oxford, is blunter. “The campaigns are alienating the very people they are meant to help,” she says.
The case to re-examine the way that mental health is talked about and treated in Britain rests on two arguments. First, that demand for mental-health services has been artificially inflated. Second, that this increased demand is inadvertently harming people who most need help.
On the first argument it is beyond dispute that demand for mental-health services has gone up in recent decades. The last big study of adults by the National Health Service (nhs), in 2014, found that one in five women and one in eight men had anxiety or depression (a follow-up survey was stymied by covid-19). In the decade to 2021 rates of antidepressant use grew more in Britain than in any other European country; only the Portuguese and Icelanders take more antidepressants.
There are reasons to think that mental suffering could be increasing, particularly among the young. “It’s not easy to be a young person at the moment,” says Dr Jon Goldin, a consultant child-and-adolescent psychiatrist at the Soke clinic in London. For Dr Goldin, the factors which contribute to a mental-health problem are typically predisposing (ie, genetic), precipitating (ie, the pandemic) and perpetuating (ie, financial hardship). Factors that protect mental health include supportive relationships and a sense of meaning; British teenagers are more likely to say these are absent than peers in other rich countries.
The pandemic will have triggered some illnesses. Covid infections have had a direct impact on the brains, and mental health, of some. Eating disorders, usually associated with anxiety, have exploded among young women. An nhs survey in 2023 found that a fifth of 8- to 16-year-olds and a quarter of 17- to 19-year-olds in England had a probable mental disorder, up from 12% and 10% in 2017.
But these arresting statistics are also a reason to question what exactly is going on with the nation’s mental health. They typically come from self-reported surveys, which produce less reliable results than clinical interviews; in 2023 they were based on the “Strengths and Difficulties Questionnaire” (sdq), a short online survey. Youngsters (or their parents) were invited to respond to 25 statements such as “I usually share with others (food, games, pens, etc)“ and “ Other people my age generally like me”. They were categorised as having a probable mental-health condition if their scores exceeded a threshold.
A survey cannot exercise the judgment of clinicians or determine if an “abnormal” result reflects a mental disorder or a normal response to an abnormal event. During the pandemic a girl who preferred to “play alone” and was “easily scared” would have been adhering to official guidelines and cultural expectations. On the sdq these statements would push her closer to a threshold for a mental disorder.
The official definitions of mental disorders have also broadened. The fifth and latest edition of the Diagnostic and Statistical Manual of Mental Disorders (dsm), a widely recognised resource for psychiatrists worldwide, was released in 2013. It lowered the thresholds for some of its 298 listed disorders, meaning that fewer symptoms are required for a diagnosis. For attention-deficit hyperactivity disorder (adhd), for example, dsm-5 reduced the number of symptoms from six to five. Impairments once had to be “clinically significant”; now they need to “reduce the quality of social, academic or occupational functioning”.
Shifting diagnoses are not unique to psychiatry. But without objective biomarkers, the boundaries demarcating mental illness look arbitrary. This is particularly so when cultural definitions of mental-health disorders are changing. A study published in 2019, measuring the effect of a mental-health awareness campaign in England, showed that public understanding of what constitutes a mental illness has widened to include normal responses—like stress and grief—to life experiences.
When the mental-health net expands in this way, more and more people are likely to get scooped up in it. In one survey in 2022 some 57% of British students reported having a mental-health issue. According to a recent government study, 76% of parents with school-aged children sought help or advice for their child’s mental-health concern from 2021 to 2022. “You’re going to lose any sense of what mental illness is if you start to apply it to 30%, 50% of the population,” says Adrian Massey, author of a book called “Sick-Note Britain”.
Clinicians see these changes in their own practices. “We’re getting more and more expert parents and families coming in [who] know what they need to access,” says Dr Ramya Mohan, a consultant psychiatrist who works in the private sector as well as the nhs. Mersey Care, an nhs trust, is carrying out 400% more adhd assessments for adults than it was four years ago; Dr Noir Thomas, its chief medical officer, notes that the increased awareness has resulted in more people presenting with “subthreshold diagnoses”.
In a recent co-authored paper, Dr Foulkes suggests that while awareness may indeed help some people to recognise previously unreported symptoms, it may also lead to some people self-diagnosing, or pushing for diagnoses, thereby relabelling milder forms of distress as mental-health problems. Increased prevalence in turn drives more awareness, creating a perpetual upwards cycle.
Relabelling can be easy. Your correspondent took an online self-assessment for adhd offered by Oxford cbt, a private mental-health clinic, in which the highest possible score is 48. She answered first as she normally would (19/48) and then took the test again in order to deliberately score zero. In both cases the tool concluded that she “may be experiencing low-level signs of adhd or another difficulty”.
The medicalisation of milder problems is not necessarily helpful for individuals. A student with low-level anxiety who is exempted from a class presentation, for example, might end up exacerbating the symptoms through avoidance.
Mental-health treatments are not always productive. A study from the University of Cambridge found that volunteers were happier when they learned to suppress negative thoughts, not bring them up as they might in psychotherapy. Another study, of mindfulness courses in 84 British schools, found no evidence that they helped pupils’ mental health more than normal teaching. “There is a need for much better, more rigorous science about what works for whom and when,” says Miranda Wolpert, director of mental health at Wellcome, a charitable foundation.
Part 1/2
I do think mental health awareness has taken an interesting turn. Rates of mental illness have definitely gone up alongside typical causes of mental health issues like poverty, social media usage and loneliness. That said, I do think fewer people have chronic depression/anxiety than reported; I think a lot of people feel depressed/anxious more often because of how life generally is for most people. I do not want to downplay how those people feel, their feelings and wellbeing are very important, however I think we would find rates of mental wellbeing improve significantly is society was just fairer and more people felt like they had fulfilling lives. Medication and therapy are important for some people, however I think significantly more people would just benefit from a society that was more emotional open than British society generally is. The era of ‘stiff upper lip’ should have died when COVID hit and we all realised how hard being cut off from others really could be.
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It has board games, club nights until “silly o’clock” and bouncy castles. But Open Door, a social enterprise for youngsters on the Wirral peninsula, has still not achieved peak fun. Its founder, Lee Pennington, plans soon to move the charity to the “Joy Building”, an ex-council property that will be adapted so that visitors can whizz between floors on slides. Not that long ago, the charity would have called itself a youth club. Now it uses a different argot. “We’re rebranding mental health,” says Mr Pennington. “We’re trying to engage the disengaged, normalise the conversation and ultimately have a good time doing it.”
Mr Pennington is not alone in trying to get more Britons to open up about their mental health. Visitors to Open Door have included the Prince and Princess of Wales, who have spearheaded mental-health awareness campaigns in recent years. Such efforts have been very successful in destigmatising mental-health problems. In a survey in 2019 more than three-quarters of Britons said that mental illness is an illness like any other, the highest of all 29 countries polled. Awareness has only increased since the covid-19 pandemic.
That is in many ways welcome. Britain may be the home of the stiff upper lip but there is nothing wrong with it wobbling. Conditions such as anxiety and depression, to say nothing of more severe forms of psychosis, can and do blight lives; early interventions can stop problems spiralling out of control. But some now fret that things have gone too far. “We’re starting to wonder whether it’s time to scale down our mental-health awareness,” says Simon Wessely, a professor of psychiatry at King’s College London. Lucy Foulkes, a psychologist at the University of Oxford, is blunter. “The campaigns are alienating the very people they are meant to help,” she says.
The case to re-examine the way that mental health is talked about and treated in Britain rests on two arguments. First, that demand for mental-health services has been artificially inflated. Second, that this increased demand is inadvertently harming people who most need help.
On the first argument it is beyond dispute that demand for mental-health services has gone up in recent decades. The last big study of adults by the National Health Service (nhs), in 2014, found that one in five women and one in eight men had anxiety or depression (a follow-up survey was stymied by covid-19). In the decade to 2021 rates of antidepressant use grew more in Britain than in any other European country; only the Portuguese and Icelanders take more antidepressants.
There are reasons to think that mental suffering could be increasing, particularly among the young. “It’s not easy to be a young person at the moment,” says Dr Jon Goldin, a consultant child-and-adolescent psychiatrist at the Soke clinic in London. For Dr Goldin, the factors which contribute to a mental-health problem are typically predisposing (ie, genetic), precipitating (ie, the pandemic) and perpetuating (ie, financial hardship). Factors that protect mental health include supportive relationships and a sense of meaning; British teenagers are more likely to say these are absent than peers in other rich countries.
The pandemic will have triggered some illnesses. Covid infections have had a direct impact on the brains, and mental health, of some. Eating disorders, usually associated with anxiety, have exploded among young women. An nhs survey in 2023 found that a fifth of 8- to 16-year-olds and a quarter of 17- to 19-year-olds in England had a probable mental disorder, up from 12% and 10% in 2017.
But these arresting statistics are also a reason to question what exactly is going on with the nation’s mental health. They typically come from self-reported surveys, which produce less reliable results than clinical interviews; in 2023 they were based on the “Strengths and Difficulties Questionnaire” (sdq), a short online survey. Youngsters (or their parents) were invited to respond to 25 statements such as “I usually share with others (food, games, pens, etc)“ and “ Other people my age generally like me”. They were categorised as having a probable mental-health condition if their scores exceeded a threshold.
A survey cannot exercise the judgment of clinicians or determine if an “abnormal” result reflects a mental disorder or a normal response to an abnormal event. During the pandemic a girl who preferred to “play alone” and was “easily scared” would have been adhering to official guidelines and cultural expectations. On the sdq these statements would push her closer to a threshold for a mental disorder.
The official definitions of mental disorders have also broadened. The fifth and latest edition of the Diagnostic and Statistical Manual of Mental Disorders (dsm), a widely recognised resource for psychiatrists worldwide, was released in 2013. It lowered the thresholds for some of its 298 listed disorders, meaning that fewer symptoms are required for a diagnosis. For attention-deficit hyperactivity disorder (adhd), for example, dsm-5 reduced the number of symptoms from six to five. Impairments once had to be “clinically significant”; now they need to “reduce the quality of social, academic or occupational functioning”.
Shifting diagnoses are not unique to psychiatry. But without objective biomarkers, the boundaries demarcating mental illness look arbitrary. This is particularly so when cultural definitions of mental-health disorders are changing. A study published in 2019, measuring the effect of a mental-health awareness campaign in England, showed that public understanding of what constitutes a mental illness has widened to include normal responses—like stress and grief—to life experiences.
When the mental-health net expands in this way, more and more people are likely to get scooped up in it. In one survey in 2022 some 57% of British students reported having a mental-health issue. According to a recent government study, 76% of parents with school-aged children sought help or advice for their child’s mental-health concern from 2021 to 2022. “You’re going to lose any sense of what mental illness is if you start to apply it to 30%, 50% of the population,” says Adrian Massey, author of a book called “Sick-Note Britain”.
Clinicians see these changes in their own practices. “We’re getting more and more expert parents and families coming in [who] know what they need to access,” says Dr Ramya Mohan, a consultant psychiatrist who works in the private sector as well as the nhs. Mersey Care, an nhs trust, is carrying out 400% more adhd assessments for adults than it was four years ago; Dr Noir Thomas, its chief medical officer, notes that the increased awareness has resulted in more people presenting with “subthreshold diagnoses”.
In a recent co-authored paper, Dr Foulkes suggests that while awareness may indeed help some people to recognise previously unreported symptoms, it may also lead to some people self-diagnosing, or pushing for diagnoses, thereby relabelling milder forms of distress as mental-health problems. Increased prevalence in turn drives more awareness, creating a perpetual upwards cycle.
Relabelling can be easy. Your correspondent took an online self-assessment for adhd offered by Oxford cbt, a private mental-health clinic, in which the highest possible score is 48. She answered first as she normally would (19/48) and then took the test again in order to deliberately score zero. In both cases the tool concluded that she “may be experiencing low-level signs of adhd or another difficulty”.
The medicalisation of milder problems is not necessarily helpful for individuals. A student with low-level anxiety who is exempted from a class presentation, for example, might end up exacerbating the symptoms through avoidance.
Mental-health treatments are not always productive. A study from the University of Cambridge found that volunteers were happier when they learned to suppress negative thoughts, not bring them up as they might in psychotherapy. Another study, of mindfulness courses in 84 British schools, found no evidence that they helped pupils’ mental health more than normal teaching. “There is a need for much better, more rigorous science about what works for whom and when,” says Miranda Wolpert, director of mental health at Wellcome, a charitable foundation.
Part 1/2
I do think mental health awareness has taken an interesting turn. Rates of mental illness have definitely gone up alongside typical causes of mental health issues like poverty, social media usage and loneliness. That said, I do think fewer people have chronic depression/anxiety than reported; I think a lot of people feel depressed/anxious more often because of how life generally is for most people. I do not want to downplay how those people feel, their feelings and wellbeing are very important, however I think we would find rates of mental wellbeing improve significantly is society was just fairer and more people felt like they had fulfilling lives. Medication and therapy are important for some people, however I think significantly more people would just benefit from a society that was more emotional open than British society generally is. The era of ‘stiff upper lip’ should have died when COVID hit and we all realised how hard being cut off from others really could be.