Are mental health conditions really being overdiagnosed?

Alastair Santhouse’s recently published book No More Normal provides a window on to an experienced clinician’s thinking on mental health and exposes the fissures that exist within global debate about the subject.

The author suggests that as awareness of mental health has expanded, so has the propensity to overdiagnose, rather than accepting that what someone may be experiencing is the regular human condition. Over the course of almost 300 pages, he might well be saying that as the cadence of conversation around mental health has increased, we have reached a point where we are, in fact, talking too much.

“I have worried too long about the problem of diagnostic creep, whereby the category of normal is consistently eroded,” he writes. “What counts as a diagnosis and what counts as normal mental health are becoming more flexible. Increasingly, the concept of evidence is not decided by evidence but by social trends and appeals to emotion.

“We are now medicalising people who in previous generations would have been considered normal.”

Santhouse said in a recent Telegraph interview to promote the book that many of his patients suspect they have a mental illness but become upset when he tells them what they are experiencing fits within the range of normal.

In the book, the author cites a 2023 editorial in the Economist, provocatively titled “How to stop overmedicalising mental health”, which is clearly an influential reference point in his narrative, that concluded we should “avoid the mass medicalisation of mild forms of distress. All suffering should be taken seriously, but a diagnosis is not always in someone’s best interests”. Compassion carries us only so far forward, we need to be more thoughtful, too, it said.

Returning to No More Normal, society has, Santhouse writes, “become increasingly one of self-care, which can tip into self-obsession. This is a recipe for trouble”.

He takes aim at depression by asking at what point does a normal level of sadness move over into a formal diagnosis, and he writes that where the two meet is hard to accurately delineate. And then, in his words, there is the “strange” and “muddled” history of trauma and PTSD, about which he says there is still no real consensus on what psychological trauma means. Adult ADHD was a diagnosis that “barely existed” a generation ago, he writes.

By now, his thesis will be clear to you: a propensity to want to define elements of our experience has led to a decline in the threshold of what is regarded as normal and to the emergence of a culture of overdiagnosis.

The more challenging aspect of that argument is that if we truly lean into the idea that this is the era of overdiagnosis, then we risk turning discussions about mental health into a form of generational war.

For decades, the misconceptions about mental health were discriminatory and derogatory. Poor mental health has often been seen as an incurable deficiency, a weakness or even a danger to society. Compare this to how society views a physical illness and the chances for success and recovery through rehabilitation. If we accept the overdiagnosing argument, we risk devaluing mental health discussions by saying what you thought was one thing is something far less consequential all together. In most parts of our lives, a significant part of a rise in diagnosis can be attributed to awareness and education rather than contagion.

Santhouse acknowledges that the shame around mental health (it is worth noting that the literal meaning for stigma, so often used to discuss the mental health landscape, is “a mark of disgrace”) has been in steady decline, but he caveats it by making the point that “progress in society changes the landscape of disease. Tell me what your diseases are and I will tell you what decade you are living in”.

So where does that leave us? First, read the book. It’s challenging and engaging – depending on your point of view, you will either strongly agree or completely disagree with his argument, which he supports by using anecdotes and evidence – but his words make it impossible to shake the feeling, for this writer at least, that this is a weaponisation of mental health after decades of hard-fought disarmament.

“Life can be hard and the hard parts are unavoidable. But life’s problems are a challenge to be overcome. They are not necessarily a sign of illness or disease,” he concludes.

Some of this news organisation’s work is in mental health. We run an in-country fellowship programme for journalists, in partnership with the Carter Centre in the US, who want training and mentorship and to be able to learn how to produce fair reporting on mental health. Much of the message we carry to those interested in working on mental health stories is to recognise how language shapes the conversation and the media’s responsibility in that endeavour, as well as to understand the importance of lived experiences, nuance, recovery, telling the whole story and recognising your own biases. We champion empathy but we also demand accuracy.

As the editorial on overmedicalising that I cited earlier concluded, we all need to be compassionate and more thoughtful in our complicated and complex world. To do so, we may need to reinterpret what “normal” really means.