Mental health awareness has become one of Canada’s most visible public health projects, but population-level mental health keeps declining.supplied
Lester Liao is a developmental pediatrician at McGill University.
Elia Abi-Jaoude is a child psychiatrist at the University of Toronto.
Michael Inzlicht is a professor of psychology at the University of Toronto.
A 10-year-old girl watches YouTube with a friend during their after-school program. An ad pops up. A two-minute quiz can tell her if she has ADHD. She takes it, of course. And just like that, she comes home to talk to her child psychiatrist dad about how she has ADHD.
This story is not unique. Mental health awareness has become one of Canada’s most visible public health projects. The messaging is everywhere: Bell Let’s Talk, school wellness e-mails, workplace campaigns, social media initiatives.
Yet despite these efforts, population-level mental health keeps declining. Medication use is increasing. How can this be?
While increased awareness of mental-health issues means we are surely detecting some of what was previously overlooked, drawing attention to the very problems we are trying to reduce may also magnify them.
Encountering certain ideas can influence how we see ourselves and can change our behaviour. In fact, just telling people about ADHD can make them think that they have it, even when they have reported no significant symptoms beforehand. Schoolwide interventions for anxiety and depression can exacerbate symptoms in the short term. And copycat suicide is real.
Awareness efforts do more than highlight. They frame ordinary experiences as medical problems. While destigmatization is the goal, medicalization becomes the norm. Anxiety over a test becomes not a passing experience but a symptom of a larger disorder. Sadness becomes depression. Social discomforts are reconceived as “autistic traits.”
The trouble with increasing diagnoses is that medications for what’s identified as a medical problem become a logical next step. We reach for pharmaceutical solutions when social or behavioural approaches might serve us better – despite the fact that medicines can carry real side effects.
Nausea from chemotherapy may be an acceptable trade-off. But appetite and growth suppression from psychostimulants in a child with borderline attention difficulties is more concerning. Perhaps we ought to ask more questions about our screen-riddled, sedentary culture. Or we might consider why the youngest in a class are more likely to be diagnosed with ADHD.
Diagnoses can also be their own form of harmful intervention. An ADHD diagnosis can erode self-efficacy, convincing a person they lack the ability to take initiative. It is not unusual to hear patients refer to “my” depression or “my” anxiety as if it is a distinct entity that controls them.
People seeking identity are especially susceptible to what the late philosopher Ian Hacking called looping effects. We create diagnostic categories, and then people learn to identify with them, changing their self-concepts to fit the label.
Belonging matters. Yet communities organized around diagnoses differ from those built around shared interests or values. These are groups defined by troubles. To remain a member, one must remain troubled. Even antidepressant drugs are depicted on social media as lifestyle accessories.
An important distinction must be made to not crowd out the vulnerable. Many people are genuinely suffering from conditions like major depression or profound autism. One cannot be suggested into having profound autism. It is a disorder, not a cultural identity. And one does not disempower somebody with major depression by identifying the noonday demon. These conditions do not diminish the value of such people. The diagnoses name the trouble and seek to help precisely because all people are of value.
When attention and resources are directed to broader populations, those with the most debilitating illnesses are the true victims. Wait-lists for services become interminable. Conversation becomes dominated by those who are the loudest and most functional, not those who are so affected they cannot even speak. This leads to popular images portraying disorders such as autism as far less impairing than they really are, which only further marginalizes the greatest sufferers.
Solutions to this dilemma exist. Some people do benefit from campaigns, and research could explore further how to reach the few with the most needs without ensnaring the many. We can reduce efforts to indiscriminately broadcast mental health concerns. Learning about the risks of over-diagnosis can reduce inappropriate self-diagnosis. Educational efforts can help us be more discerning about the accuracy of mental health information on social media.
Poverty, loneliness, and structural inequality drive much mental distress. Treating those conditions as individual medical problems misses the real diagnosis entirely. Clinicians should discern whether medications or interventions are truly necessary.
We must reshape our conversations in mental health to reduce interventions that induce symptoms, and instead foster discernment and agency.
We started out with the greatest of intentions. Unintended consequences have arisen. That’s okay. We learn along the way. Now it’s time to change course.