Over the past decade, there have been extensive mental health awareness efforts in the western world to improve public understanding about mental health problems. High profile charity campaigns, interventions within schools, universities and workplaces, and numerous personal disclosures from celebrities and public figures have helped to reduce stigma, improve mental health literacy and encourage people to seek help. Despite this, reported rates of mental health problems, including anxiety, depression, eating disorders and self-harm, have increased.

In a recently published paper, our Researcher of the Month, Dr Lucy Foulkes and co-author, Dr Jack Andrews propose that awareness efforts have led to more accurate reporting of symptoms, which is beneficial, but that they have also led some individuals to report milder forms of distress as mental health problems. In Dr Foulkes’s words, these are “problems of living that were not previously considered mental health problems, and still should not be”. The authors hypothesise that because labelling distress as a mental health problem can affect self-concept and behaviour, this then becomes self-fulfilling and leads some people to experience an increase in symptoms. They further argue that this increase in symptoms drives further awareness efforts and the two processes continue to intensify, influencing each other cyclically. They call this the prevalence inflation hypothesis.

Summary

“If people are repeatedly told that mental health problems are common and that they might experience them – and this is especially true for young people who frequently receive mental health information in schools – then it makes sense that they might start to interpret any negative thoughts and feelings through this lens.”

There is some evidence that the rise in the reporting of mental health symptoms follows an existing trend which started several decades ago. The increase in mental health problems has been attributed variously to social media, austerity, income inequality, academic pressure and the Covid-19 pandemic, among other causes. In this paper, Dr Foulkes and Dr Andrews hypothesise about the impact of mental health awareness initiatives as one additional contributory factor.

Improved recognition of mental health problems is hugely beneficial and might lead to more help-seeking and treatment, help reduce rates of deaths from suicide and provide more accurate prevalence rates of mental health problems. Reducing stigma and improving mental health literacy through mental health awareness-raising efforts has given some people the ability to better recognise and report mental health problems that have previously gone under the radar. It is possible that individuals are now seeking help for mental health problems that have always existed, but weren’t recognised or disclosed.

However, Dr Foulkes suggests that caution is needed about the delivery and content of these awareness efforts. Some campaigns emphasise the bravery of disclosing mental health problems. This is an important way to reduce shame and stigma (both barriers to help-seeking), but can also ascribe social value to describing difficulties as mental health problems, perhaps making it more desirable to some people. Mental health problems are now also sometimes glamourised or romanticised on social media.

Other campaigns encourage individuals to notice, label, and seek help for negative psychological experiences, and promote the use of psychiatric terminology. This may lead some people to overinterpret and overpathologise common, mild, transient and normal psychological experiences as mental health problems that require labelling and treating. Research shows that individuals often don’t rely exclusively on a clinician for a diagnosis, but combine clinical opinion with other sources of information, including social media, the internet and newspaper articles, labelling themselves with specific diagnoses. Conflating or confusing psychiatric disorders with the stresses and challenges of normal life is now commonplace. One consequence of our awareness of the vocabulary of mental health without a corresponding depth of understanding, is that terminology can be misused. For example, someone might say that they ‘suffer from anxiety’, when feeling anxious about certain tasks is perfectly normal.

The paper suggests that interpreting and labelling psychological experiences as mental health problems can, in some cases, lead to changes in self-concept and behaviour that bring these symptoms into existence in a self-fulfilling prophecy. This theory is backed up by evidence from several studies which have found that mental health interventions teaching teens and adults about the symptoms of mental health problems, or generalised, preventative psychoeducation interventions teaching cognitive behavioural therapy principles or mindfulness have in some cases led to an increase in internalising or depressive symptoms or people feeling ‘low’ when they didn’t before.

Dr Foulkes further suggests that the relationship between the rise in mental health symptoms and awareness programmes could continually escalate. As prevalence rates increase, awareness efforts increase in response and the pattern continues cyclically, intensifying each time. She calls for this hypothesis to be tested empirically in future studies.

Implications

Implications for parents

Consider how mental health terminology is used within family life. Think carefully about the language you use when describing everyday psychological experiences. If your teen says, “I’m so depressed”, but they are just having an off day or experiencing everyday ups and downs, take the opportunity to explore what they really mean. It’s important to teach our children that some experience of negative emotions and stress is a normal, if unpleasant, part of life. Our goal should not be to eliminate stress and difficulty entirely, but to equip ourselves with helpful coping strategies to manage it. Model coping strategies that work for you and explore strategies that might work for your child. They need to learn that constant happiness is unattainable and experiencing a rainbow of emotions is normal. We need to figure out how to talk about lower, manageable levels of anxiety (about an upcoming presentation at school, for example), without immediately reaching for diagnostic labels.

It’s important to know how to be a good listener and to promote and model active listening as a valued skill. Encouraging people to talk about their problems (as mental health awareness campaigns often do) is only effective if the person they tell knows how to listen. Listen actively, with your whole body. Look at your child, nod and use facial gestures that demonstrate empathy. Ideally, our body language should convey no judgment. If they seem more comfortable talking to you without eye contact (side by side in the car, for example), then stick to this. Try not to interrupt too much, but if there is an appropriate pause, you might sometimes step in and check that you have grasped what they mean. You can do this by repeating what they have said, summarising it and checking you have understood correctly. “Is that accurate?” “Would you say that is a good summary of what you have been telling me?” “Does everything that I have said make sense?” The Samaritans has some excellent tips on active listening.

If your child is exhibiting genuine signs of depression (low mood, irritability and/or not getting pleasure from usually pleasurable activities for at least two weeks), anxiety that is impacting on their day to day life or other worrying symptoms, such as self-harm or disordered eating, it is vital to seek clinical advice.

Implications for schools

Dr Foulkes notes that, “If empirical evidence emerges that mental health awareness efforts can indeed lead to overinterpretation, then there is an urgent need for evidenced-based guidance for how to continue such efforts in various settings (e.g. schools, social media campaigns) while minimising the risk of harm.”

In the meantime, she suggests that we need to move beyond raising awareness that mental health problems exist and towards explaining their complexity, exploring the fact that mental health problems lie on a spectrum, where different issues require different levels and types of support. Some approaches are invaluable for some people, but unhelpful or even actively dangerous for others. Many factors contribute to mental health problems and they often emerge as a response to the context in which someone lives and challenging experiences that they have gone through. Practical initiatives which tackle difficulties (such as bullying or loneliness, for example), rather than simply raising awareness, might help to alleviate or improve distress.

Any Tooled Up subscriber interested in this subject can listen to our interview with Dr Lucy Foulkes and read the accompanying notes.