For years now, policymakers have sought an explanation for the mental health crisis among young people. Suicide attempts and psychiatric hospitalizations were rising even before the pandemic. Then the rates of anxiety and depression doubled worldwide.
Why is this happening? The social psychologist Jonathan Haidt points to smartphones, and the algorithms that draw kids away from healthy play and into dangerous, addictive thought loops. No, his critics say. The real problem is a grim social landscape of school shootings, poverty and global warming. Or academic pressure. Or insufficient health care.
A group of researchers in Britain now propose another, at least partial, explanation: We talk about mental disorders so much. I cover this notion in a story The Times published today.
This hypothesis is called “prevalence inflation.” It holds that our society has become so saturated with discussion of mental health that young people may interpret mild, transient suffering as symptoms of a medical disorder.
This is a problem, they say, because identifying with a psychiatric diagnosis may not be helpful. Students who self-label as anxious or depressed are more likely than similar students who don’t self-label to view themselves as powerless over the disorder, recent studies have shown. They may respond by avoiding stressful situations like parties or public speaking, which could make their problems worse.
One of the psychologists behind the prevalence inflation theory, Lucy Foulkes of the University of Oxford, traces her skepticism back to 2018, when she began teaching undergraduates. They were “bombarded” with messages warning that they might be in crisis, she said. “It seemed like the more we were trying to raise awareness about it, it wasn’t getting better, and in fact, it only seemed to be getting worse.”
She grew critical of curricula that teach children to recognize and manage their emotions, sometimes referred to as social emotional learning. Schools have introduced an array of programs, teaching children the basics of techniques like mindfulness and cognitive behavioral therapy, which have proved beneficial in adults.
Several recent studies have found lackluster or negative effects for students who received trainings, especially those who started out with more severe symptoms. That evidence has done little to dampen their popularity, Foulkes said.
An urgent need
Many experts in the field of adolescent mental health defend awareness campaigns and school-based trainings. “Especially with teens, we need more universal interventions, not less,” said Zachary Blumkin, a child psychologist at Columbia University Irving Medical Center.
The main reason, they say, is that traditional, one-on-one therapy and psychiatric care is not easily available. Teenagers in crisis can wait months to see a clinician. They often land in emergency rooms as a last resort.
For that reason, the field has gravitated toward preventive models. These teach all students — not just the troubled ones — to manage distressing emotions. A 2023 meta-analysis of 252 such programs concluded that, generally, children benefit from them. There is also promise in a more tailored approach, one that lets schools focus on kids with the most acute needs.
Some experts also disagree that over-diagnosis is a problem.
Andrew Gerber, a child psychiatrist, says we should think of mental illness as a spectrum: Disorders like anxiety or depression occur in a bell curve distribution, so they’re more like hypertension than appendicitis. And like hypertension, he said, they’re worth treating early in their progression, with medication and therapy. “Anyone who tries to define a sharp line between ‘real’ illness and what is not real, no matter where they put the line, is doomed to get it wrong and do damage in the process,” said Gerber, the president and medical director at Silver Hill Hospital in New Canaan, Conn.
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| Lucy Foulkes Sandra Mickiewicz for The New York Times |
Foulkes disagrees. Even when we have good treatments, we’re bad at identifying whose disorder is likely to deteriorate, she said. And some children struggle because something is wrong at home, like domestic abuse or poverty or bullying. Mindfulness trainings are unlikely to help these kids.
“A lot of the time, what’s causing the problem is not something that’s going to improve with medication or therapy,” she said. “You’re running the risk of just telling people they have a problem without helping alleviate it.”
A generation is growing up fluent in the language of mental health, something that will benefit teens who badly need treatment. But others may apply medical diagnoses to the painful, normal adversity of growing up.
The “prevalence inflation” hypothesis asks us to keep an eye on those excesses. People hurt after breakups and struggle to adjust to new schools; negative feelings aren’t always a sign of mental illness. They can even teach us resilience.