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For better or worse: Is increased awareness leading to over-diagnosis?

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Joel Rayer | Unsplash

Opinion by Hannah Marriage

Increased conversation around mental health issues is great, but let's be sure it's not getting in the way of legitimate mental health concerns.

Over the past few years, more people have been coming forward to talk about mental health, including many celebrities. Throughout the Covid-19 pandemic, there was also a lot of promotion around mental wellbeing and the need to look after our minds as well as our bodies. However, has all this conversation actually made any difference?

As a mental health nurse, I understand more than most the stigma surrounding mental health. There is also evidence to suggest that those individuals with severe and enduring mental health conditions, such as bipolar or schizophrenia, are likely to have poorer life outcomes. Their quality of life is considered much lower due to low income, poor diet, inability to secure permanent employment and so on.

However, the term ‘mental health’ has become solely focused on those who have depression and anxiety rather than the much broader term found in clinical definitions. In fact, we hardly hear about how those with schizophrenia or bipolar disorder cope on difficult days, or how the general public can provide more inclusive environments for them.

This ignorance on the other, more serious mental health conditions shows how the general population still do not actually understand what it is to have a mental health problem. Instead, we focus on a couple, and mostly, those aren’t understood properly.

A blurred line between mental health issues and normal emotions

Having depression or anxiety is so talked about now, that there is little acknowledgement for normal levels of sadness and nervousness/fear and what that is, and almost no scope for resilience. So many young people are now using ‘anxiety’ and ‘depression’, almost like a fashion statement: it is seen as a ‘get out clause’. For example, having to sit multiple exams when doing GSCEs increases anxiety, and many students are requesting additional support now for their mental health to get through such a ‘difficult’ time. Except, every year students are faced with the same increase in stress and go through these exact emotions. Every parent can relate to their child’s worries, yet in their day, they wouldn’t have asked for additional support.

What we fail to acknowledge with the youth of today is that stress and anxiety are normal emotions, not synonymous to clinical diagnosis. Parents would have the resilience skills to realise these feelings are ‘normal’ under the current circumstance of exams and know that it will pass once the exams are over. So why are we allowing our younger generations to be blinded by the idea that they have anxiety and require medication? When actually a few lessons in resilience could not only improve their exam outcomes but also provide them with a very valuable life lesson? Feelings of pressure and stress due to increased workload is expected, and young people need to learn how to manage this rather than label it with clinical diagnoses. Depression has also been coined by many in a similar vein. The moment someone becomes sad, it is labelled as ‘depression’.

The point is that being sad is a very ‘normal’ emotion, and the fact that it is something we all need to experience is almost forgotten. Everyone seems to think that a pill will solve all their problems, and this has been evidenced in the steep rise in antidepressants being dished out.


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Exacerbating a failed system

Where the system is failing is the talking therapy that is required alongside an antidepressant, without which could see the patient returning to the same depressive state if they come off the medication as no life changes have been made. Antidepressants work by changing the chemical balance in the brain and allow people to function without feeling so low in mood. However, it is only through complete lifestyle changes that a person can truly feel better, and the medication alone should not be the answer. Clinical guidelines produced by the National Institute of Clinical Excellence (NICE) therefore recommend talking therapy before an antidepressant.

Unfortunately, the waiting lists for such therapies have grown so extensively that people just aren’t receiving the help they need at a fast enough rate. There are also many individuals who seek out clinical therapy for what is just a normal period of low mood due to life circumstances, and where a different type of therapy might help. Once again, resilience is missing, and young people are aligning low mood with a clinical diagnosis.

Distinguishing between a time for concern, and the time for resilience

It is worth noting that there are many people who do have a clinical diagnosis of both depression and anxiety, where the period of ‘normal’ is exceeded and a genuine problem noted. These individuals require additional support from mental health specialists at varying levels and medication to help. However, the true experiences of these individuals is just as lost as the other serious mental health conditions. Everyone around mental health patients thinks they understand these conditions, due to their own experiences based on normal emotions, which is completely different.

However, if we were to teach the following generation what normal emotions look like, tension and anxiety would be considered, well, normal. And promoting resilience gives younger people the skills to control their emotions. We can stop this downward cycle, decrease waiting lists for therapy and lower the use of antidepressants. Boosting our children’s self-assurance and belief in their skills is vital – it would be wonderful to help young people successfully navigate through their natural emotions by acknowledging them for what they are.

What does 'mental health' truly mean?

Whilst I do think the increased conversations we are having about mental health through celebrity stories is a positive one – and there has been a reduction in stigma regarding ‘talking about mental health’ – I firmly believe there is still a long way to go in understanding what is truly meant by mental health. We need to be educating people around normal emotions and resilience; helping improve coping strategies for life, and how to correctly address emotions rather than label with clinical diagnosis.

​Clinical definitions according to the International Classification of Diseases (ICD-11): Anxiety: Related to behavioural disturbances, with symptoms severe enough to result in significant distress or impairment in functioning.

  • The presentation is characterised by physiological symptoms of excessive arousal, apprehension, and avoidance behaviour

  • The symptoms result in significant distress or significant impairment in personal, family, social, education, occupational or other important areas of functioning

  • The symptoms are not better accounted for by another mental, behavioural or neurodevelopmental disorder

  • The symptoms or behaviours are not developmentally appropriate or culturally sanctioned

  • The symptoms or behaviours are not the manifestation of another medical condition

  • The symptoms are not because of a substance or medication on the central nervous system, including withdrawal

Depression: A mood disorder which must contain at least five of the following characteristics, occurring nearly every day, for at least 2 weeks:

  • Depressed mood (self-reported or observed) and/or irritability

  • Lack in pleasure in activities, especially those that would usually bring enjoyment

  • Reduced ability to concentrate on tasks, or marked indecisiveness

  • Beliefs of low self-worth or excessive/inappropriate guilt

  • Hopeless about the future

  • Recurrent thoughts about death, suicidal ideation, or evidence of attempted suicide

  • Significantly disrupted sleep – increased waking in the night or excessive sleep

  • Significant change in appetites or significant weight change (gain or loss)

  • Psychomotor agitation or retardation

  • Reduced energy, fatigue, or marked tiredness following expenditure of only a minimum of effort

Symptoms should not be linked to the following:

  • Bereavement

  • The manifestation of another medical condition (i.e. brain tumour)

  • The effects of substances/medication on the central nervous system

  • Impairment of personal, family, social, educational, occupational, or other areas of functioning


Further reading:

  • Ritsner. M, Lisker. A and Grinshpoon. A (2014) Predicting 10-year quality-of-life outcomes of patients with schizophrenia and schizoaffective disorders. In Psychiatry and Clinical Neurosciences 68, p308-317

  • Rackman. A (2022) Nearly half a million more adults on antidepressants in England BBC News website


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