Transforming the way mental health is understood
Change the Prescription could help transform the way mental health is understood in the UK. This recently published Centre for Social Justice report asks a question we ourselves have been asking for a number of years. Is the UK over-diagnosing mental health conditions? Is this then medicalising large portions of the population who are experiencing the ups and downs of normal life and need a different sort of support? It is an assessment which now seems to be widely shared by GPs. CSJ polling reveals that 84 per cent of GPs agree that society’s approach to mental health has led to the normal ups and downs of life being seen as medical problems.
There are many parallels with our own findings and recommendations. To give just a few examples:
A medical response doesn't address the underlying causes
Both Change the Prescription and Health Action Research Group identify that, whilst government has recognised the seriousness of the reported mental health crisis, the reliance on an essentially medical response has failed to stem the tide. This is because it fails to take account of social determinants of health. For instance, our assessment is that deprivation is probably the single biggest preventable risk factor for serious mental health conditions. Similarly Change the Prescription notes a clear correlation between poverty and the increased risk of suffering from mental ill-health. We both agree that addressing the wider socioeconomic determinants of health is key to early intervention and prevention policy.
Overdiagnosis due to shifting definitions
We both agree that overdiagnosis may be partly due the rise in the classifications of mental ill-health, following the publication of DSM 5 (often described as the Psychiatrists’ Bible) and both quote the criticisms of Dr Allen Frances, a psychiatrist who chaired the taskforce which developed DSM 4, arguing that DSM 5 has expanded in its categories of mental illness, resulting in normal and difficult experiences being named as disorders. In Saving Normal he says, “as we drift ever more toward the wholesale medicalisation of normality, we lose touch with our strong self-healing capacities - forgetting that most problems are not sickness and that only rarely is popping a pill the best solution.”
The language around mental health needs to be clarified
To follow up our concern about over-diagnosis, in our evidence to the House of Commons Health and Social Care Committee in 2021 we recommended the importance of clarifying the terms mental health, mental health problem, mental distress, mental health condition, mental illness and mental disorder - and who is therefore at serious risk and should be a priority for specialist support. Change the Prescription makes the same recommendation i.e. ‘To turn the tide on over-medicalisation it is urgent that: NHS England work with all Mental Health Trusts to establish a shared definition for terms such as ‘disorder,’ ‘illness,’ ‘wellbeing,’ ‘mental health,’ and ‘distress.’
Major socioeconomic consequences
Change the Prescription recognises that the reported mental health crisis isn’t just a health issue. It also has significant social and economic implications i.e. the current medical model is unaffordable: ‘Misunderstood mental ill-health is the leaky bucket draining the nation. No amount of government initiatives to tackle the symptoms of a stagnating economy, flatlining productivity, or the anxious generation will fix the problem unless the leaks are plugged.’ Along similar lines we have identified that, because the root causes of mental health issues are not being addressed, children are now carrying their mental health problems forward with them, from school to university to adult life and the world of work – with significant implications not only for those affected but also their families, their schools, their universities, the NHS, employers, the welfare system and tax revenue.
The value of social prescribing
We have been aware of the value of social prescribing for a number of years, and reported this in a 2021 blog, where we identified social prescribing as a potential alternative to medication, including for emotional and wellbeing support. Change the Prescription explains, ‘One very effective idea is to give what are called ‘social prescriptions’ as a non-medical alternative to pills…. These social prescriptions can involve signposting people to a variety of community services for all ages, from carers to choirs, groups encouraging them to be creative with paints or words, gardening, dancing or walking in nature. All proven to be effective ways to recalibrate patients’ symptoms.’
Social media - identified risks
Change the Prescription identifies that, while social media can have a beneficial effect for some young people, there are clear risks to mental health arising from algorithms pushing self-harm and eating disorder content; and from cyber bullying; as well as potential risks from excessive screentime. This correlates with our own analysis. For example, in a pilot study we conducted with a sample of first year students, in partnership with three universities, young people who had spent most time online for non-study purposes during their A Level years were more likely to report feeling anxious/stressed while at university – and three times more likely to often/always feel lonely at university. Both Change the Prescription and ourselves have independently found evidence of mental ill health being romanticised on social media, a further complicating factor.
An unhelpful conflation of mental health conditions and everyday worries
Change the Prescription suggests that, in a desire to support and enable individuals to have positive mental health, there is a danger that the pendulum has swung too far, and that the boundaries between distress and disorder have become blurred – which risks those who are unwell missing out on the treatment they deserve, and burdening others with unhelpful labels and prescriptions that can hold them back without addressing the root cause of their very real needs. Similarly, we have identified that well-intentioned campaigns to destigmatise mental ill health may unwittingly have led to an unhelpful conflation of clinically diagnosed mental health conditions and everyday worries (which are now being reported as mental health problems) creating an anxiogenic environment – with potentially harmful nocebo effects.
Poor parental mental health - another risk factor
We both agree that poor parental mental health may be driving a rise in the mental ill-health of children and young people and recommend action to reduce risk. This was a focus in our 2019 article in Perspectives in Public Health, where we identified the importance of timely intervention with new parents, starting by identifying who is most at risk, such as the children of parents with a family history of mental illness or at risk of postnatal depression and single teenage parents, each of whom may face difficulties with parent–child bonding. Similarly Change the Prescription identifies that poor parental mental health may be driving a rise in the mental ill-health of children and young people and that navigating the challenges is made more complex when parenting alone.
The value of an evidence-based approach
We share Change the Prescription’s commitment to an evidence-based approach. As an example, from an early stage we suspected that the singling out of universities as potentially toxic environments for the mental health of young adults, by sections of the media and pressure groups, lacked a strong evidence-base. Change the Prescription concurs, noting evidence which found that overall those attending higher education had better mental health than those who did not attend higher education, and this result pertained when analyses were adjusted for age, sex, ethnicity, and highest parental educational qualification.
Family factors - some different perspectives
There are also some interesting variations. For instance, Change the Prescription identifies that young people who have experienced family breakdown before the age of 18 are significantly more likely than those who have not to experience mental ill-health. This is an important point, which we haven’t covered. Conversely, we had identified overprotective parenting as increasing the risk of mental distress, by reducing opportunities to develop resilience and self-efficacy, leaving young people more vulnerable – and contrasted this with the better mental health of young people in the Netherlands, where autonomy-supporting parenting is more common.
Two different but complemetary approaches
Change the Prescription is very much concerned to reduce unnecessary medication for mental health issues (hence the title – Change the Prescription). Because our guiding principle is that prevention is better than cure, we focus on factors increasing or reducing mental health risks, rather than on medical diagnosis and treatment.
The impact of the pandemic
Change the Prescription suggests that the COVID pandemic was a significant risk factor for mental health (although acknowledging evidence that this may not be continuing) whereas, from early in the pandemic we were seeing evidence of a much more nuanced picture. What we probably both agree on is that, once again, it was young people in deprived households who tended to be more adversely affected during the pandemic; and that the cost-of-living crisis post-COVID has compounded risk.
Factors protecting young people's mental health
We probably go further than Change the Prescription in identifying factors research has identified as protecting young people’s mental health, which tend to be overlooked by policy makers because they don’t have a mental health label. This is covered under the social prescribing heading by Change the Prescription (e.g. references to being creative with paints or words, gardening, dancing or walking in nature, as well as separate information on the protective effects of physical activity). These are points we expand on, while also adding further protective factors for mental health including active play (with minimal adult supervision) in childhood, a healthy diet, and being a Guide or Scout (which longitudinal research suggests is associated with above average mental health and lower mental health inequality decades later, at age 50).
Overall, though, our analysis and that of Changing the Prescription, although each was independently conducted, are strikingly similar – suggesting the value of an evidence-based approach.
A final word - from the Beyond the Pills APPG
Perhaps we should leave the last word with the six principles of reform proposed by the Beyond the Pills All Party Parliamentary Group. This is cited by Changing the Prescription and has our full support: “recognising the social and relational nature of mental health problems, addressing the social determinants of distress, challenging societal messages that contribute to emotional distress, promoting positive narratives and language to support recovery, using psychiatric drugs with caution, and prioritising research on psychosocial intervention.”
Michael Baber, February 2025