My psychological research rarely makes good comedy material, but in a standup show in London recently, those two worlds collided. One of the jokes was about how everyone is getting diagnosed with ADHD these days – about the social media videos that encourage viewers to identify common human experiences, like daydreaming or talking a lot, as evidence of the condition. The audience laughed because everyone got it – they’ve all witnessed how common it seems to have become in the last few years. When something becomes this prevalent in society, and this mystifying, it’s no surprise it ends up as a punchline.
Part of my work as an academic involves trying to solve the puzzle of why so many more people, especially young people, are reporting symptoms of mental illness compared to even five or 10 years ago. (ADHD is a form of neurodivergence, rather than a mental illness, but both have seen an increase, so they are related questions.) Whenever I talk about this – to colleagues, school staff, parents – it doesn’t take long until someone brings up that judgment-laden, hot-button word: overdiagnosis.
Overdiagnosis, in its original use, is primarily a critique of medical professionals. In the current public debate about mental illness, though, the focus tends to be on people overdiagnosing themselves. The concern is that individuals are labelling their own mild or transient life problems with the language of disorder.
Is this happening? Yes. There is evidence of “concept creep” – terminology once reserved for mental illness is now being used to cover more mild phenomena. On social media, people are using the language of mental illness more casually and often inaccurately. Clinicians tell us that more patients are now arriving at appointments with existing self-diagnoses. Given the shifting language around mental health and complexity of diagnosis, at least some of these will be false positives. The existing research allows us to conclude that there is some degree of overdiagnosis happening, and that this is indeed one piece of the puzzle of increasing rates of mental illness.
But puzzles have many pieces, and to decide that overdiagnosis is the only cause constitutes a dangerous oversimplification. For starters, some of the increase we are seeing might ironically be the result of a more accurate and compassionate public understanding of mental illness. Stigma has certainly not disappeared, but over the past 15 years, considerable effort has been spent on mental health awareness campaigns, and during this time there has been a measurable decrease in stigma and an increase in willingness to seek help.
We should not be remotely surprised that public health initiatives have had this effect: that was the whole point. But if fewer people are suffering in silence and are instead able to recognise and admit that they are struggling, this will make it look like the numbers are increasing more than they truly are.
Then there is the important possibility that things really might be getting worse, especially for young people. Mental illness is often triggered or exacerbated by stressful lives, and there’s plenty of evidence that life over the last 15 years has been hard. There has been a rise in financial insecurity, major geopolitical and environmental events, and the lingering impact of Covid. Services that might once have been protective against mental health problems, like youth community provision, have been stripped of funding. Smartphones and social media have also become a big part of most people’s lives. That alone cannot explain the change we are seeing and should not be used as a scapegoat, but it is likely part of the picture.
It is difficult to know fully the relative contribution of each of these factors – overdiagnosis, improved awareness, legitimately increased risk. To confidently answer this question, we would need research that not only showed each factor increasing in parallel with the rate of mental illness but demonstrated a causal relationship too. But that would require well-designed longitudinal or experimental studies where different factors can be controlled or changed, which is often practically or ethically impossible.
Our task then, is to hold all these possibilities in mind. Too often, people observe rising rates of mental illness and debate it as a binary: either “real” or “made up”, with overdiagnosis to blame for the latter. But this is the wrong way to understand the problem. Overdiagnosis could be happening in some individuals or subgroups alongside a genuine rise in others. Underdiagnosis could simultaneously be a problem too, for example, in groups where stigma remains high and access to services is limited. We need to acknowledge that several things might be happening at once.
Crucially, the possibility of overdiagnosis should not be used to dismiss anyone reporting psychological distress or other symptoms of mental illness. There is a longstanding problem of people not being taken seriously when they report such symptoms, particularly among the young. It is easy and convenient to call them snowflakes, to decide that the mental health conversation is mere evidence of their fragility. But to do so misrepresents the problem – in fact, it’s actively unhelpful. Being dismissed when you’re in crisis not only increases distress, it means that, fearful of not being believed, you are likely to use escalating terms to convey your symptoms – compounding an already complicated shift in the use of language around mental health.
When I sat in the audience at that gig, I thought about the people who really do have ADHD, some of them likely sitting around me. ADHD is a condition that can be profoundly disruptive and disabling, even with decent support. Comedians should be free to make jokes about cultural phenomena – that’s the whole point. Anyone should be allowed to question whether, at a population level, overdiagnosis might be contributing to increasing rates of ADHD or mental illness.
But when it comes to individuals, we must be careful. Many people aren’t getting the help they need. It’s impossible to understand the depth of someone’s difficulties by judging them from the outside. If a person tells you they are struggling, you should believe them.
Dr Lucy Foulkes is a psychologist at the University of Oxford
Further reading
The Age of Diagnosis by Suzanne O’Sullivan (Hodder, £10.99)
Bad Influence: How the Internet Hijacked Our Health by Deborah Cohen (Oneworld, £10.99)
Normally Weird and Weirdly Normal: My Adventures in Neurodiversity by Robin Ince (Pan, £10.99)
The Guardian
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