- Mental disorders can have fuzzy boundaries with normality, enabling rising rates of diagnosis and self-diagnosis, especially in youth.
- While self-reported mental health problems have increased, actual rates of mental disorders, especially serious ones, appear to be stable.
- Many factors may contribute to self-labeling, including increased awareness, reduced stigma, the internet, peer influence and social contagion.
Sixteen-year-old Zoe listened expectantly as I began to provide feedback to her and her parents about my diagnostic impressions, following two hours of psychiatric interviewing. When I told them that I didn’t think her anxiety or depression were of clinical proportions and that I didn’t think she needed psychiatric treatment, she appeared crestfallen. When I said that I hoped she would take this as good news, she seemed angry. She shut down and disengaged from the rest of the session—a marked change from her prior eagerness and enthusiasm to participate in the interview process.
Twenty-five years ago, when I first started practicing as a psychiatrist, this kind of feedback would typically have been met with relief. Moreover, my young patients would quite often have been reluctant and embarrassed participants in the first place, often “dragged” to my office by their concerned parents. But Zoe’s reaction is fairly common these days. In fact, consultations with patients like Zoe are frequently initiated and requested by the teenaged patients themselves.
Is mental health worsening?
All this coincides with media reports of a mental health epidemic in young people, and greatly escalating self-reported mental health problems in youth and young adults, a trend that seems to have begun a decade or two ago.
Is the actual rate of mental disorders rising? Is life more stressful now than in the past, thus triggering more mental disorders?1 Is it that people are now more willing to seek help due to reduced stigma? Maybe we’re now recognising and diagnosing these disorders more readily and effectively? All these questions have been asked by researchers. The data generally point to a combination of a number of factors, but there does not appear to be much rise in the actual rate of mental disorders—particularly major mental illnesses, the rates of which appear to have remained fairly stable.2, 3
How do we define mental disorder?
There is a long history of debate about how to define a mental disorder. We still do not have a satisfactory definition. This is not really surprising, given the complexity of the subject. In fact, even in general medicine the concept of disorder is not sharply definable.
The DSM-54 defines a mental disorder as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as a death of a loved one, is not a mental disorder.”5
Contrary to critics of yesteryear who argued that mental illnesses were a myth, there is no doubt whatsoever among credible professionals today that serious mental illnesses are all too real, and are a very major cause of substantial disability. The difficulty is with the vast swath of mental health problems at the boundary of normal and abnormal—psychological distress that may be a normal but intense reaction to stress. To be clear, such distress may be far from trivial, and maintaining good mental health should be a priority in all of our lives. But we needn’t equate intense distress or severe stress with suffering from a mental disorder, and with needing a medical diagnosis or treatment.
A big part of the problem, and the reason why the diagnostic criteria lend themselves to over-diagnosis, is the attempt to divide mental and behavioral phenomena into distinct categories, as if they existed in separate “boxes.” In reality, they are almost always dimensional in nature, i.e. they exist on a continuum with normality. It should therefore be more a question of the degree to which your mental health may be impaired rather than a yes-or-no question of having a disorder or not. The various categories also overlap with each other, so we should not be surprised that it is usual for people to acquire more than one diagnosis. DSM-5 acknowledges the problem of attempting to divide dimensional phenomena into categorical disorders.6, 7
Most psychiatric disorders are probably better conceptualized as representing the tail ends on each side of a bell curve for a given human trait or tendency, with most of the general population in the mentally healthy average range—the central bulge of the curve.8 The cut-off for diagnosis is usually defined by “clinically significant distress or impairment in social, occupational (or academic), or other important areas of functioning.”9
The publication of the DSM-5 in 2013 met with considerable criticism. Most notably from Allen Francis, chair of the APA task force overseeing the previous edition (DSM-IV, published in 1994), who expressed concern about “diagnostic inflation” due to loosening of some of the diagnostic criteria and addition of new poorly tested diagnostic categories.
Among other things, Frances was critical of the psychiatric diagnostic system for having over time “opened the door to loose diagnosis by defining conditions that were no more than slightly more severe versions of such everyday problems as mild depression, generalized anxiety, social anxiety, simple phobias, sexual dysfunctions, and sleep disorders.” He warned of the risk of “market-driven diagnostic fads” fueled by pharmaceutical companies, pointing to greatly increased rates of diagnosis of ADHD,10 bipolar disorder spectrum, and autism spectrum, as examples of this.11
Why might people want to be diagnosed with a mental disorder?
There appears to have been a cultural and generational shift away from feelings of stigma around a mental disorder diagnosis to not only an openness to acquiring such diagnoses, but in some—especially young people, a desire and almost a pressure to acquire such. There may be many possible reasons contributing to this trend. Obvious ones include the emphasis on mental health education in schools, celebrities going public about their mental health problems, the internet, social media, peer influence and social contagion.
The younger generation have bought into the language of mental health and the advice to talk openly about it. Overall this is welcome progress, but today’s youth seem almost to have replaced the use of the word "stress" with "anxiety disorder" or "mental health issue," too quick to self-label with a variety of psychiatric diagnoses.
One teenage girl, who in my opinion did not meet criteria for a definite disorder of any kind, articulated her reasons for seeking a psychiatric consultation honestly and clearly: “I would like a diagnosis so I know that something is going on and I’m not ‘faking it,’ so I have a valid reason to feel awful sometimes and not have people get on my case about it.”12
Unrealistic expectations of psychiatry 13
There is an unrealistic assumption that psychiatry is the answer to problems of the human condition. This is part of a larger cultural expectation that all problems are fixable or solvable, and a tendency to over-simplify highly complex problems.
Harboring unrealistically optimistic expectations of psychiatric and psychological treatment can lead to tremendous disappointment and frustration when treatment fails to meet those expectations, resulting in worsening despair. To be sure, my profession is guilty of having oversold its role, and of having medicalized common human problems. But the problem is equally our society’s unrealistically high expectations of modern medicine and therapy.
Psychiatrists do what we can to help everyone who comes to us for “treatment,” generally attempting psychotherapy or counseling for mild to moderate problems, and medication for moderate to severe problems.14 Nonspecific problems, and traits that are simply part of who the person is, don't lend themselves well to specific treatments or therapies. On the other hand, severe disorders such as crippling anxiety that legitimately justify the term mental “illness” and which desperately require more specific treatments can unfortunately be difficult to treat, and for more than a small percentage of sufferers are quite intractable.
Sometimes all we psychiatrists can offer is well-honed empathy, and some insight and perspective. To say this is frustrating would be a great understatement. There are times when we feel as helpless as our patients in the face of the overwhelming complexities and challenges inherent to being human. The reality is that there are no easy answers and solutions to many of life's problems.
Unpredictable positive outcomes
On a more hopeful note, there can be unexpected outcomes for some seemingly intractable psychological and psychiatric problems. Sometimes, after a long line of disappointments, the next treatment simply works—even dramatically. And not infrequently, a positive turn of events occurs that has nothing to do with treatment. Some people who were not initially helped by psychiatric treatment or psychotherapy improve on their own, or learn to adapt to their depressive or anxious tendencies or other problems. People are remarkably adaptable and resourceful, to their own surprise (however, not everyone is resilient, of no fault of their fault own). I have known many people who, over time, amazed everyone by turning their lives around in positive ways, whether by determination, maturation, or circumstance.
Life circumstances and human nature are famously unpredictable, for better and for worse. It’s my privilege to be there with my patients when wonderful improvement happens. But I try to remember to be humble and realistic by not assuming that the treatment or therapy I am providing is the cause of the happy turn of events I am witnessing.
1. I work in a large regional hospital in Toronto, and am writing this article a year and a half into the ongoing COVID-19 pandemic. In our youth psychiatry clinic we’ve certainly seen many mental health problems where the academic and social disruptions of the repeated societal lockdowns and other stresses of the pandemic were triggering or contributing factors. On the other hand, most of my existing patients have managed just fine during the pandemic. But the increase in self-reported mental health problems discussed in this article is a longer-term trend predating the pandemic by a number of years, and it's hard to argue that life is truly more stressful overall now in modern Western societies than it was in previous generations.
2. Serious mental illness generally refers to illnesses such as schizophrenia and bipolar disorder. Even for anxiety disorders, the rates of strictly defined disorders do not seem to have changed much—what has increased is symptoms rather than the full-blown disorder. E.g. see John, A., A. L. Marchant, J. I. McGregor, J. O., et al. "Recent trends in the incidence of anxiety and prescription of anxiolytics and hypnotics in children and young people: An e-cohort study." J Affect Disord 183 (Sep 1 2015): 134-41. And Bandelow B, Michaelis S. Epidemiology of anxiety disorders in the 21st century. Dialogues Clin Neurosci. 2015;17(3):327–335. And this infographic. But some studies have found an increase in the prevalence of diagnoses, e.g. Lipson, S. K., E. G. Lattie, and D. Eisenberg. "Increased Rates of Mental Health Service Utilization by U.S. College Students: 10-Year Population-Level Trends (2007-2017)." Psychiatr Serv 70, no. 1 (Jan 1 2019): 60-63. The authors of that paper relate the increased service utilization and diagnoses in part to decreased stigma. Another paper also reporting an increase is: Weinberger AH, Gbedemah M, Martinez AM, Nash D, Galea S, Goodwin RD. Trends in depression prevalence in the USA from 2005 to 2015: widening disparities in vulnerable groups. Psychol Med. 2018;48(8):1308-1315.
The prevalence data overall are mixed, complex and difficult to interpret, plagued by the question of whether increased rates represent a real increase or just an increase in diagnoses. See also:
Mental illness: is there really a global epidemic? (The Guardian)
The State Of Mental Health In America (MHA – Mental Health America)
Most U.S. Teens See Anxiety and Depression as a Major Problem Among Their Peers (Pew Research Center)
Canadian Community Health Survey (Statistics Canada)
3. However, suicide rates, which counterintuitively do not always imply major mental illness, have been rising since the 2000s among young people in the U.S. and possibly elsewhere, after having previously fallen since the early 1990s from still-higher levels. While not all suicides are due to mental illness per se, we can all agree that whatever is causing these young people to take their lives is a very serious societal concern. See QuickStats: Suicide Rates for Teens Aged 15–19 Years, by Sex — United States, 1975–2015. MMWR Morb Mortal Wkly Rep 2017;66:816. DOI: http://dx.doi.org/10.15585/mmwr.mm6630a6. The uptick in the suicide rate among youth in the United States in 2007-2015 has been especially among girls. The youth suicide rate had previously declined to its lowest point in 2007 before starting to rise again (the rate for boys remained lower in 2015 compared with its peak in the mid-1990s, as the decline in suicides for boys since the mid-1990s had been steeper than girls). More recent data suggest that youth suicide rates are continuing to rise, but it is not uniform by sex—rates in young males may actually be declining but are outpaced by large increases in young women.
The reasons for the disproportionate increase of suicides in females are unclear, but informed speculation points possibly to social contagion, and changing gender expectations and cultural norms. See also: State suicide rates among adolescents and young adults aged 10–24 : United States, 2000–2018. https://www.cdc.gov/nchs/data/nvsr/nvsr69/NVSR-69-11-508.pdf. And: Zulyniak S, Wiens K, Bulloch AGM, et al. Increasing Rates of Youth and Adolescent Suicide in Canadian Women [published online ahead of print, 2021 May 17]. Can J Psychiatry. 2021;7067437211017875. doi:10.1177/07067437211017875.
It should also be noted that non-suicidal self-harm has definitely increased very greatly in the last couple of decades among girls, with social contagion effects almost certainly being a major contributing factor. Self-cutting used to be considered by psychiatrists to be a fairly reliable sign of personality disorder, whereas today it is simply a common coping strategy among emotionally upset girls. Boys do it too, but the rate is far higher among girls.
[Click 'more' to view footnotes 4-14, below.]
4. American Psychiatric Association DSM-5 Task Force, Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 5th ed. (Washington, DC: American Psychiatric Association, 2013), p.20.
5. The definition goes on to say that “Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.”
6. DSM-5, p. 12.
7. The other well-known problem with how psychiatric diagnoses are made is of course that they rely almost entirely on self-reported symptoms and behavioral observations of clinicians, both of which involve subjective judgement. To this day there are still practically no objective tests, especially biological ones, by which a diagnosis can be made. It’s not that mental disorders are not based in the biology of the brain. They most certainly are—there is an abundance of evidence for that (and the “mind” is simply what the brain does). Psychiatric disorders differ from standard neurological disorders not in their underlying neural substrate, but in their complexity. There are a great many intriguing neuroscientific research findings of brain differences in mentally ill people compared with mentally healthy people, but none of those findings can yet be applied to the practical clinical setting to make a diagnosis in an individual patient.
8. It is probably the case for most human traits that both ends of the curve are disadvantageous. Too much or too little of a given trait, such as anxiety, tends to be maladaptive. Psychiatric disorders can thus be understood (with certain exceptions) as amplifications or extreme forms of general human states and traits. Certain factors, many of them genetic, predispose some people to mental illness. Environmental factors such as stress can trigger episodes of symptoms impairing functioning in predisposed individuals. Many psychiatric disorders wax and wane over time, sometimes being severe enough to constitute a disorder and at other times staying within the “normal” range.
9. Exactly how much distress or dysfunction qualifies as clinically significant is a matter of judgement on the part of the clinician. Most disorders also stipulate a minimum number of symptoms and a minimum duration/persistence. The threshold for diagnosis may also vary by context or environment. Thus, there is an unavoidable element of subjectivity for both patient and clinician when defining a disorder.
10. In my article on ADHD, I have suggested additional, more complex reasons for the increase in ADHD diagnoses. The ADHD question also illustrates many interesting points in general about how we might understand mental health problems on a continuum with normality, and why so many people genuinely struggle and are at a disadvantage due to having characteristics that are toward one end of the spectrum of human diversity for common and important traits.
11. Frances A. The new crisis of confidence in psychiatric diagnosis. Ann Intern Med. 2013;159(3):221-222. doi:10.7326/0003-4819-159-3-201308060-00655. See also: A. Frances, Saving Normal: An Insider’s Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life (New York: William Morrow, 2013)
12. Psychological motives, such as the need for validation, are major reasons for people seeking psychiatric diagnosis. But more concrete motives, such as obtaining academic accommodations from schools, are also fairly frequent incentives for young people seeking such diagnoses. To be sure, many accommodations are fully justified and necessary. But there is a problem when large proportions of students enrolled in post-secondary institutions are receiving accommodations for common difficulties like relatively mild/moderate anxiety and mild/moderate focusing difficulties. It becomes unfair to those who are not receiving these accommodations, who are put at a relative disadvantage.
The psychological need for validation and identity can be so strong that one of the more surprising trends noticeable in the last several years has been the increasing number of young people seeking a diagnosis of Borderline Personality Disorder. BPD used to be a very undesirable and stigmatizing label, signifying someone who is “high maintenance” in the extreme, due to their extremely difficult, unstable, self-destructive, and often manipulative personality traits.
13. Parts of this article are adapted from: Ralph Lewis, Finding Purpose in a Godless World: Why We Care Even If The Universe Doesn’t (Amherst, NY: Prometheus Books, 2018).
14. Part of the point of this article is that mild to moderate problems don’t necessarily warrant a diagnosis of a mental disorder. For these problems, and for more general psychosocial problems, the psychotherapeutic roles of psychiatrists and clinical psychologists overlap—and to some degree also overlap with the roles of social workers and other mental health professionals.