Has Britain talked its way into

Sharing concerns about depression might not be too healthy, says Sam Ashworth-Hayes – and could have huge spending implications

The stiff upper lip is not what it used to be. In 1920, the average Briton’s stoicism was so famed that, when Alexander Vasilyevich Kolchak – admiral, polar explorer and, since 1918, supreme ruler of Russia – was captured by revolutionaries, the official account of his execution approvingly noted that he died “like an Englishman”.

Britain has changed a lot since then. We now rank among Europe’s most adept at talking about our feelings and mental health. NHS officials have spent the last decade discussing the need for “parity of esteem” between mental and physical health; celebrities and politicians alike urge us to speak out rather than bottle things up.

In many ways, this effort has been a huge success. “People are realising they don’t need to suffer in silence,” says Vicki Nash, associate director of social change at the charity Mind, “and that they can seek help.”

The question is whether it’s making us healthier. All of this talking about Britain’s mental health doesn’t seem to have improved it; mental health services are overwhelmed, with a backlog of 1.2 million people waiting for treatment. The number of patients receiving antidepressants has risen by nearly 2 million since 2015, while the share of adults reporting “common mental disorders” has marched steadily upwards, from 15 per cent in 1993 to 19 per cent in 2014, followed by a record number of mental health referrals last year, up 22 per cent on 2019.

Earlier this month, it was reported that, partly as a result of this ongoing increase in mental health problems, the Department for Work and Pensions predicts that two million more people will be claiming disability benefits by 2030 – bringing the total to one in every nine people in the country, with a corresponding rise in the bill.

It’s hard to shake the impression that while Britain is a more emotionally literate country than it used to be, it may also be a sicker one.

The normalisation of mental health problems

The campaign to normalise discussing mental health was a truly worthy one, with roots deep into the last century. Originally seen as something almost taboo, with patients treated in institutions out of the public eye, mental health slowly shifted into a topic of national policy discussion. Mounting criticism of institutional care led in the 1980s to a policy of “care in the community”, and a shift in the emphasis of funding.

A new treatment model did not mean an end to the sense of stigma, however, and over the last decade campaign groups and parliamentarians have worked tirelessly to push the issue up the political agenda, securing additional funding, and launching campaigns to get Brits talking to each other about their feelings.

The “Heads Together” campaign backed by the Prince and Princess of Wales, alongside the Duke of Sussex, is an excellent example. Launched in 2016, the trio filmed the two princes discussing how they had bottled up their emotions about the death of Princess Diana, launched a 24/7 mental health texting service, urged celebrities to speak openly to “shatter the stigma” of discussing the topic, and even had the FA Cup final renamed after the initiative.

Britons are now admirably aware of the complexities of mental health conditions, topping a list of 29 countries when it comes to understanding mental illness as an illness like any other, and being the second least likely to view it as disqualifying for public office. The question is whether this has been an entirely positive thing. There are, after all, trade-offs everywhere in life.

Sir Simon Wessely is regius professor of psychiatry at King’s College London and a member of the NHS England board. As he puts it, “the rate of defined disorders has not changed for 50 or 60 years. The rates of schizophrenia, bipolar, you name it – they’re the same. Autism rose because we changed the definition. The rates of everything else have remained stable, with one exception. For the first time, we’ve seen a significant rise in anxiety and depression in young women aged

16-24 across OECD countries.”

What’s more, in surveys of workplaces and straw polls of students, when people are asked if they have a mental health issue, “every time, two thirds put their hands up. Any time any occupation gets a survey, you find high rates of people with mental health problems, sometimes remarkably high rates”. So where has this rise come from?

Unintended consequences

Dr Lucy Foulkes is a research fellow in the department of experimental psychology at the University of Oxford,

and the author of What Mental Illness Really Is… (And What It Isn’t). Her research suggests that talking about mental health can backfire in unexpected ways.

The joint rise in conversations about mental health and mental health conditions may not purely be a matter of people better understanding their own health, and seeking the support they were always entitled to.

Britain’s policy of deinstitutionalisation was driven by concerns that institutional treatment was damaging; the cure was, if not worse than the disease, harmful in its own way. It is now increasingly clear that talking about mental health too may not be an unalloyed good. As the population becomes more aware of the symptoms of mental health conditions, we may be beginning to see people interpret their experiences and emotions through this lens.

In turn, they may begin to behave in ways that exacerbate their real, underlying symptoms. Someone with low levels of anxiety, for instance, may decide to avoid things that trigger their anxiety, and in turn become increasingly sensitive to them.

“If you tell people that disorders are really prevalent, they’re more likely to interpret their own symptoms in that way,” says Dr Foulkes. “When people self-identify as having depression, that predicts worse coping with their mental health, over and above what you’d predict from their level of symptoms. It could ultimately be self-fulfilling.”

Phrased in this way, talking about mental health sounds like the opposite of effective therapy. As Dr Foulkes puts it, when it comes to cognitive behavioural therapy, a key element is “doing things that you don’t want to do”, because “once you’ve done it, it makes you feel better. For anxiety, it’s about testing yourself, doing things that make you anxious. Because that’s how you learn things aren’t as bad as you thought they’d be.” In other words, precisely the reverse of what those catastrophising their own symptoms appear to be doing.

The result is that this can lead to a worsening of mental health, increasing the rates of illness – and intensifying efforts on the part of well-meaning people to spread awareness in a vicious circle of what’s known as “prevalence inflation”.

A different, but potentially related process plays out online. A paper published earlier this year in the journal Comprehensive Psychiatry examined social media as a potential “spread vector” for tic-like behaviours and identity disorders in young people that differed significantly from classical psychiatric symptoms. The conclusions drawn by the authors were startling: it appeared that some young people were seeking attention or acceptance within an online community by assuming an identity associated with a mental disorder, rather than genuinely experiencing symptoms.

For anyone who’s been a teenager on the internet – or at least spent time with younger relatives – this will all sound dreadfully familiar. The desire to stand out, garner attention or find a group of like-minded people is extremely powerful in teenagers and children, and it’s difficult to avoid the conclusion that giving young people the language of mental health to talk about their feelings and emotions may have contributed.

Sir Iain Duncan Smith, a former secretary of state for work and pensions, believes that this is a warning sign. “We’re building up a massive problem with the young,” he says. Social media, and smartphones, are proving “incredibly damaging”, and at least one policy priority should be “finding ways to tell parents to get their kids off social media.”

Worse than the disease

Both this trend and the different phenomenon of prevalence inflation take as their root people adopting new language to talk about emotions and feelings.

In Sir Simon’s view, “the phrase ‘mental health’ is the new thing on the block. It’s not that in other times people never talked about their emotions; you only need to read classical poetry to know that they did. They just didn’t use the language we

‘We risk medicalising disorders that are not really the business of GPs’

Sir Simon Wessely