A progressive agenda on the medicalisation of mental health

Some theoretical groundwork to start paving the way towards an alternative to cuts, and towards a better, more inclusive society more broadly

One justification for the £5bn worth of cuts to health-related benefits last week is the idea that mental health has been ‘overdiagnosed’ (in Wes Streeting’s words).¹ This argument has been building for a while: Conservative then-Chancellor Mel Stride argued a year ago that ‘mental health culture has gone too far’.

The usual counter to these claims is to focus on the reality of mental distress – that mental ill-health has risen sharply, and that the real problem is that too many people who need treatment aren’t getting it. But in this post, I want to argue that this binary divide in how we see the problem – either a generation of snowflakes on the political right, or a consequence of austerity on the left – is actively unhelpful.

Put simply, if we want a better benefits system, then we need a progressive way of talking about medicalisation. In this long pair of posts, I firstly want to explain why a progressive take on medicalisation is necessary, and in a follow-up post I’ll develop this into an actual alternative agenda to cutting health-related benefits.

Why it’s hard to talk about medicalisation

Put simply, we don’t have a progressive take yet because talking about medicalisation is often seen as denying the reality of mental illness. As the brilliant Lucy Foulkes (who writes about medicalisation; more next week) put it when responding to Wes Streeting:

“the risk is that people in distress are going to get dismissed. Research has highlighted that [people struggling badly with their mental health] are often dismissed and not believed.”

Not only is Lucy’s warning well-taken, but there are international examples of this rhetoric being used to justify welfare cuts. For example, in Sweden from 2010, anti-welfare actors pushed a critique of medicalization, arguing that “problems related to private life or to unemployment were expressed as illness.” This ultimately led to a variety of sharp cuts to sickness/disability benefits and all the distress you might this you might expect from this – albeit starting from a much more generous system than we have in the UK.

But it’s not plausible to ignore medicalisation

Because of all this, many experts have avoided any mention of medicalisation. But still: I think we have to talk about it.

Firstly, it’s just not credible to deny the reality of something that many people think has happened. There’s surprisingly little good data on this – but a King’s Policy Institute report this week found that 47% of the British public thought that ‘mental health problems were just as common among young people in the past, they just weren't identified as mental health problems back then’. This question isn’t perfect,² but it chimes with chatting to people and listening to phone-ins: a sizeable chunk of the British public think that mental health has been medicalised.

Secondly, there’s evidence that the medicalisation of mental health has really happened. The use of statistics in these debates is tricky – e.g. looking at rising diagnoses of mental illness, some will cite this as evidence of medicalisation, while others will cite it as evidence of genuinely deteriorating mental health. But to my mind the best approach is to compare rises in experienced symptoms of distress vs. rises in medical labels of mental illness. (I know this is far from perfect³).

This approach shows that people are much more likely to adopt medical labels than they used to (from a given level of experienced distress). For example, in a 2020 paper, I looked at twenty-year trends in every aspect of health that is covered in the official Health Survey for England. Comparing the early 2010s to the mid-1990s,⁴ far more people aged 25-59/64 reported a longstanding mental illness (rising from 2.1% to 4.6% of the population) – but there were no consistent rises in symptoms of psychological distress.⁵

Finally, even if you uncritically accept trends in self-report disability, the rises in reported disability are not big enough to explain rising health-related benefit claims. The DWP explicitly made this case in the Green Paper: “the significant rise in benefit claims is greater than the rise in overall prevalence of self-declared health conditions. Between 2019/2020 and 2023/2024, the number of disabled working-age people in England and Wales increased by 17%, but the numbers receiving an incapacity or disability benefit increased by double that amount (34%).”

Similarly: while I’m convinced that mental ill-health has got worse, I think that some of the numbers that are being bandied around are not that convincing⁶ – so pinning the opposition to welfare cuts on these numbers is a risky tactic.

So what is a progressive take on medicalisation?

While I think we need to talk about medicalisation, I also think we need to talk about it better - or at least more broadly, in two ways:

Firstly, we increasingly have systems that don’t give people what they need unless they categorise themselves as having a medical condition – what we might term ‘systems medicalisation’. Sam Freedman has explained how education policy changes in 2014 led to the sharp rise in ECHPs, because there was no other way for schools to give children what they needed. Similarly in welfare, my colleague Annie Irvine has argued that:

“When dealing with the welfare system, the only real option people are given to explain why it is difficult for them to work is ill health… It is the only aspect of a person’s experience the benefit system will hear as valid. So, until the welfare system allows a safer space for people to express the full complexity of their circumstances, the statistics will inevitably show an intractable ‘mental health problem’ in the welfare system.”

[Added 27th March: Annie & colleagues have just launched a brilliant new report setting this out in even more detail].

This is medicalisation, but it’s not because ‘young people are woke’ – it’s because we have built systems that don’t work for people unless they get classified as having a medical problem.

Secondly, people experiencing psychological distress may be increasingly excluded from the labour market, and therefore more likely to say that they have a medical condition, more likely to say they have a disability (particularly a work-limiting one), and more likely to claim benefits. We know that ‘light work’ largely disappeared from the labour market in the 1980s, and that declining autonomy and rising intensity at work over the 1990s and 2000s contributed to incapacity claims. We also know that employers are often unwilling to provide deeper forms of flexible working for people with fluctuating conditions, particularly for jobseekers (more on this tomorrow). Rising work-limiting disabilities due to mental health do not necessarily show a rise in distress, nor a rise in medicalisation, but may instead show rising exclusion.

Anyone who talks about medicalisation is at a huge risk of misinterpretation - so to be clear:

• All of these explanations might be occurring simultaneously – and in my view, they probably have. Certainly the evidence for the medicalisation of mental health must be seen alongside the clear evidence that psychological distress has risen in recent years;⁷ evidence for one explanation is not evidence against the other. Which is why it’s so frustrating when people present these as alternatives.

• People’s mental distress is real, whether or not medicalisation and exclusion has been taking place. Or as Annie Irvine puts it, “mental health problems are real, but rarely the whole story”.

• Medicalisation is not necessarily bad – it has some important positives (e.g. giving support to more people that need it), and there’s a huge academic and activist literature debating the pros and cons. The King’s Policy Institute report showed that half the public thought that medicalisation had happened – but far more than this (75%) thought ‘It is a good thing that we are better at identifying mental health problems among young people today, for example, so they can get support’. The question, then, is whether medicalisation is useful – but while conventional medicalisation has complex effects, systems medicalisation and exclusion both look wholly dysfunctional to me.

The alternative to cuts

By talking in this way, we provide a language for an alternative policy agenda – one where savings come from better inclusion (and prevention more broadly), rather than cuts. There’s been some talk of these already, but I think that this approach helps us make the case more clearly and more strongly. But this post is long enough already; I’ll write this later in the week, the other side of the Spring Statement…

1. To be fair to Labour, this often isn’t the leading way that this agenda is framed (including in Streeting’s interview last week, where it was Laura Kuenssberg who introduced the term, and Streeting only endorsed it in passing before emphasising the need for more support). But clearly, Labour are arguing that too many people are receiving health-related benefits.

2. This question isn’t ideal – it forces people to choose between that answer and ‘there has been an increase in the proportion of young people with health problems today – this is a new trend’ (and doesn’t allow people to say that both of these have happened! See also below). Of the people that said the trend was real, a follow-up questions show that 36% thought that it’s because young people are less resilient than young people were in the past (vs. 57% who thought it’s because the circumstances they face are more difficult).

More directly on welfare, the best I can find is a recent New Statesman poll that asked ‘what has caused the sharp rise in working-age people receiving disability and health benefits’, where the second-most popular answer was “Society now sees more health conditions, eg mental health, as valid reasons for not working” (the top answer was ‘that people were trying to cheat the system’ [sigh]). But this doesn’t exactly capture it.

3. There’s several challenges here. Diagnosed mental illness is more varied than the psychological distress mostly captured in surveys. And it’s difficult to capture symptoms of serious mental illness in a survey (compared to full clinical assessments). This is why the Adult Psychiatric Morbidity Survey is so valuable (because after an initial survey, it sends clinically-trained interviewers to do detailed screenings for a wide variety of possible mental health disorders).

4. I’m doing work to update this to 2022 (results later this year). But the most important release this year will be the Adult Psychiatric Morbidity Survey, coming out in July.

5. While the main measure of psychologist distress actually showed a decrease, there were signs of rises in more extreme levels of psychological distress (though showing this sometimes requires using the scales in ways they’re not intended for) – see the paper for details.

6. For example, the mostly indispensable recent IFS report presents evidence on 5.5% rises in ‘deaths of despair’ (deaths due to alcohol/suicide/drugs) from 2015-19 to 2023. But there’s several reasons to be cautious here: (i) it’s not clear they’ve dealt with a 2018 discontinuity in suicide recording (see Fullfact); and (ii) there are some signs that the 2024 latest data will show a much smaller rise in deaths of despair. (While the breakdowns by cause are only available for 2023, the overall mortality rate in 2024 is much closer to the pre-Covid average than 2023, which makes me suspect the deaths by despair figure will go downwards towards its 2015-19 level too).

7. See also https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england