Source: The Conversation – UK – By Joanna Moncrieff, Professor of Critical and Social Psychiatry, UCL
Speaking on BBC One’s Sunday With Laura Kuenssberg, Wes Streeting, the UK health secretary, expressed concerns that some mental health conditions were overdiagnosed. The Conversation asked two experts to comment on Streeting’s claim. Is the health secretary right?
Mental distress is under-diagnosed – but over-medicalised
Susan McPherson, Professor in Psychology and Sociology, University of Essex
A year ago, the UK’s then prime minister, the Conservative Rishi Sunak, announced “sick note culture” had gone too far. His work and pensions secretary claimed “mental health culture”, Mel Stride, had gone too far.
These statements merged concern about affordability of disability benefits with ideas about overdiagnosis of mental illness. This appeared to be in response to a report from the Resolution Foundation, a thinktank.
The report said that people in their 20s were more likely to be out of work than people in their 40s. The report attributed this to an increase in young people reporting mental distress (from 24% in 2000 to 34% in 2024).
This was used by some journalists to support the idea of young people as work-shy snowflakes feigning mental illness, which angered many including disability activists, mental health campaigners and members of the opposition Labour party.
A year on, the UK now has a Labour government. Wes Streeting, the secretary of state for health and social care, is facing criticism for appearing to echo conservative tropes. In an interview about government plans to reduce benefits for disabled people, he agreed that overdiagnosis accounts for an increase in people on benefits due to mental illness. This appears to mirror those media stereotypes about work-shy millennials.
If that is what Streeting meant, then the evidence is not on his side. Ten years ago, a UK national survey of psychiatric symptoms found that a third of people whose psychological symptoms were severe enough to merit a diagnosis, did not have a diagnosis.
More recent research using the UK Longitudinal Household Study grouped people according to whether they do or do not have a psychiatric diagnosis and whether they do or do not have psychological symptoms severe enough to merit a diagnosis. The study found 12 times as many people in the “undiagnosed distress” category (with severe symptoms but no diagnosis) than the overdiagnosed category.
The study also identified significant inequalities. People living with a disability had nearly three times the risk of undiagnosed distress compared with people without a disability.
Women had 1.5 times the risk of undiagnosed distress compared with men. Lesbian, gay or bisexual people were 1.4 times more likely to have undiagnosed distress compared with heterosexual people. People aged 16-24 had the highest risk compared with all other age groups.
This all suggests inequalities in undiagnosed distress are a much bigger problem than overdiagnosis in the UK. Given that many forms of support in the UK depend on having a diagnosis, undiagnosed distress probably means people are not getting the support they need.
However, Streeting also said that too many people “just aren’t getting the support they need. So if you can get that support to people much earlier, then you can help people to either stay in work or get back to work.”
Given this nod towards prevention and the importance of non-medical support, it is conceivable that Streeting’s sentiment may have been about “over-medicalisation” of mental distress rather than overdiagnosis. The difference is important.
The term “diagnosis” reflects a medical model of mental illness. Many would agree that the medical idea of “diagnose and treat” does not serve people with mental distress well. This is because there is a lot of evidence suggesting the underlying causes of mental distress are social, economic, environmental or a result of past trauma.
If Streeting had said “over-medicalised”, he would have been in tune with a growing global concern about over-medicalisation and over-use of medication to treat mental distress, a position advocated by the UN and the World Health Organization.
Despite UK guidelines recommending psychological treatments as first line interventions for depression, antidepressant prescribing has risen 46% over the last seven years with over 85 million prescriptions in 2022-23. This alongside an increase in long-term use of psychiatric medication with no reduction in mental distress at the population level. If Streeting had said “over-medicalised”, the evidence would have been on his side.
A mental health diagnosis is just a label – and usually an unhelpful one
Joanna Moncrieff, Professor of Critical and Social Psychiatry, UCL
There has been a dramatic escalation in the number of people seeking treatment for mental health problems in recent years. In the year from April 2023 to 2024, 3.8 million people were in contact with mental health services in England alone, which is 40% higher than before the COVID pandemic. The figures include 1 million children. One in five 16-year-old girls is in contact with services.
The statistics reveal a tendency to over-medicalise a variety of human problems that was supercharged by the pandemic and is likely to result in harmful effects on physical and mental health.
What many people don’t realise about a mental health diagnosis is that it is nothing like the diagnosis of a physical condition. It doesn’t name an underlying biological state or process that can explain the symptoms someone is experiencing, as it does when someone gets a diagnosis of cancer or rheumatoid arthritis, for example.
A mental health diagnosis doesn’t explain anything. It is simply a label that can be applied to a certain set of problems. The process by which this label is conferred is not scientific or objective and is influenced by commercial, professional and political interests.
In most situations, giving people with mental health problems a diagnostic label is unhelpful. It convinces people they have a biological defect, it leads to ineffective and often harmful medical treatment, and most of the time, it misses the actual problems.
Because getting a diagnosis implies you have a medical condition, it misleads people into thinking that they have an underlying biological abnormality, such as a chemical imbalance, even though there is no good evidence that mental disorders are caused by underlying brain or bodily dysfunctions. Research has shown this makes people pessimistic about their chances of recovery and less likely to improve.
Being diagnosed often leads to being prescribed a psychiatric drug, such as an antidepressant. About 8.7 million people in England now take an antidepressant, half of them on a long-term basis.
Prescriptions for other drugs, such as stimulants (prescribed for a diagnosis of ADHD), are also rising fast, even leading to medication shortages. Yet the evidence that any of these drugs improve people’s wellbeing or ability to function is minimal. Moreover, like all substances that alter our normal biological make-up, particularly those that interfere with brain function, they cause side-effects and health risks.
Antidepressants can cause severe and prolonged withdrawal symptoms, sexual dysfunction (which may persist) and emotional numbing or apathy, among other unwanted effects. Stimulants can cause cardiovascular problems and neurological conditions. The widespread, unwarranted prescribing of these drugs will adversely affect the health of the population.
Giving people a diagnosis can also obscure the nature of the person’s underlying problems and prevent these from being addressed.
Mental health problems are often meaningful reactions to stressful circumstances, such as financial, housing and relationship problems and experiences of abuse, trauma, loneliness and lack of meaning. Reducing over-medicalisation doesn’t necessarily mean fewer services. What we need is different services that provide appropriate support for people’s actual problems, not treatment for medical labels.
We also need ways to excuse people from responsibilities when necessary, without making them feel like they have to take on a “sick” role that implies they are forever ill and helpless.
Much of today’s employment is poorly paid, insecure, boring, exploitative and pressurising. It shouldn’t surprise us that some people find it hard to endure. We need to improve working conditions for everyone, but we also need to support people who find these conditions especially challenging, without having to label them as sick.
Joanna Moncrieff is or has been a co-investigator on grants funded by the UK’s National Institute of Health Research and the Australian government Medical Research Future Fund for studies exploring methods of antidepressant discontinuation. She is co-chair person of the Critical Psychiatry Network, an informal and unfunded group of psychiatrists
Susan McPherson receives funding from NIHR Applied Research Collaboration East of England. She is affiliated with the Labour Party.
– ref. Are mental health conditions overdiagnosed in the UK? Two experts go head to head – https://theconversation.com/are-mental-health-conditions-overdiagnosed-in-the-uk-two-experts-go-head-to-head-252535
