Eighteen months ago, in an off-the-cuff remark during a discussion on disability benefit cuts, Wes Streeting said mental health conditions were being “overdiagnosed”, riding headlong into another culture war.
He later apologised for the comment, but at the time it seemed the then health secretary had endorsed a populist view that ordinary stresses and disappointments had become too often medicalised, resulting in a surge of bogus clinical diagnoses and creating a “snowflake generation” of fragile, avoidant and workshy young people.
Prof Peter Fonagy’s mammoth review of mental health conditions, autism and ADHD in England, commissioned by Streeting nine months ago, has no truck with the snowflake generation caricature: the steep rise in the prevalence of mental health problems such as anxiety and depression is real, he says, and so is the distress and difficulties they can cause.
I am in awe of their courage. Young people are contending with more powerful forces than I ever faced
The review says the drivers of this rise are cultural and social. Young people are exposed to Covid disruption, financial and housing insecurity, and competitive school and social stresses that are exacerbated by social media. Support services, from Sure Start to youth clubs, have been swept away. There is less belonging, it says, and more loneliness.
Fonagy himself was a severely depressed teenager in 1960s London, he reveals in an unexpectedly tender foreword to the review. Today’s youth have it much harder, he writes. “I am in awe of their courage. Young people are contending with more powerful forces than I ever faced. They are not fragile. They are outnumbered.”
Sceptics may yearn for a mythical time when troubled young people just had to pull their socks up, fit in and learn to deal with life’s inevitable hard knocks. Fonagy makes clear the past is another country and you cannot rewind the clock. “Simple answers are rarely adequate,” he writes.
Fonagy’s brief was not explicitly to settle culture war disputes, however, and the review warns that the rising prevalence of mental illness, ADHD and autism has wider consequences: public services are overwhelmed, people suffer because they cannot get care or support, and the cost to the taxpayer is unsustainable.
The review is frustrated by the public debate’s focus on whether there is too much or too little diagnosis. There is a risk of overdiagnosis, Fonagy admits (though he says there is no evidence it is happening at scale), and he is scathing about the growth and reliability of unregulated private providers of diagnostic assessments.
But the deeper problem, the review argues, is the disproportionate power of the diagnosis in accessing clinical care, special educational needs support in schools, or disability benefits. That encourages unfairness: those who can afford private diagnosis have a higher chance of getting support.
Fonagy’s solution is to reduce the heavy reliance on diagnosis (NHS diagnosis waiting times are 64 weeks). An individual’s needs should be identified and triaged early with the goal of ensuring they swiftly get the support they need.
The challenges Fonagy identifies are also those being grappled with by the imminent Milburn review of the youth jobs crisis, the Timms review of disability benefits, and the government’s Send changes. His solutions may not fly, but his warning is clear: “Continuing as we are is not sustainable.”