My colleague and friend Tim Hofer is a senior Professor at the University of Michigan in Ann Arbor. He was recently over on sabbatical and, while driving home one evening he described the elaborate measures his university needs to take to cope with an epidemic of mental illness. He said that his university was not alone in the US; all had to employ armies of counsellors. The situation Tim describes has its counterpart on this side of the Atlantic, or at least in the UK. A doctor I know well served in a practice close to a large city campus. She consulted a large and growing number of depressed students and had a big job writing medical reports as examinations approached. And we keep reading reports on the high incidence of young people labelled as depressed. Whence all this angst? And is it a problem that can be tackled by ever larger armies of counsellors? Can it be ‘fixed’ without understanding the origins of the epidemic, if epidemic it is?

Firstly is it real – is the term ‘epidemic’ correct? Well of one thing there can be no doubt – the attention and expression of the problem has greatly increased.[1] And I don’t think it is just an artefact of some sort, even if it does not meet the technical definition of ‘epidemic’.

Could it be caused by a hard life? Depends what we mean by ‘hard’. I understand that depression was less of a problem in the UK during the Second World War and people were more content than in modern life. Okay, some ‘well-known’ things are urban myths so correct me if you can. When I was doing basic training as a conscript in the army we had a torrid time. For example, Sergeants Major would put their faces close to ours and ball insults till the spittle covered our faces. Egregious for sure, but did it make us a miserable lot? Not a bit of it. But there again there is massive solace and more than a little humour in shared hardship. Our recent work shows that people in slums are not particularly unhappy, and the incidence of depression among poor people in Dhaka shows that only small increases in wealth reduce the incidence of depression.[2] Okay, there may be some (or a lot) of cultural reluctance to disclose psychological distress, but people under considerable life stresses in other countries seem to cope a lot better than students in British and American universities. Could it be that the demands of university education are so great that all but the most resilient must crumble in the face of relentless pressure to perform? Follow a history student around all day and you will see that this explanation is risible.

So the distress seems real in circumstances that, on the face of it, are not terribly psychogenic. Now it falls to me to formulate hypotheses. I will start with some (nonexclusive ideas) in the hope that others can come up with further suggestions (including the suggestion that I have got it all wrong):

1. Helicopter parents

Family sizes have been declining for some time but parents now sense that the knowledge economy is taking out the middle tier of jobs. Not much middle ground left; little Naomi will either be in the cognitive elite or she will be doing work her parents consider menial. Many children will thrive as they race from fencing to flute to Mandarin, but some kids will sense the pressure and lose heart.

2. Lack of helicopter parents

When all parents had a fairly insouciant view of their role in nurturing the minds of their children, then there was not much basis for comparison. But hands-off parents now stand out and could seem neglectful. A doctor friend told me that half her depressed students said the parents pressurised them too much while the other half said their parents took no interest. I am reluctant to blame parental pressure or the need to succeed in life.

3. Computer games, etc.

Yes, I think this may be a problem but my reading of the literature (no I have not done a systematic review) is that the toxic effects are at the extremes. That is to say, they can do lasting harm but only among the 5% or so of young people who become seriously addicted.[3]

4. Mobile phones and the internet

Social media, it is said, have reified the perfect, glamorous individual; since this is an ideal that cannot be attained it leads to despair. I have heard this theory advanced a number of times now but it has low verisimilitude for me. That is because the stereotypical perfect body and glamorous lifestyle predate social media. Or maybe it is the social isolation that mobile IT platforms engender that is harmful. Again the evidence seems to suggest that harm is confined to a small proportion of outliers.

5. Fulfilment Paradox

I remember reading a diary entry from a high social class boy before he went off to join the army prior to the First World War. He was clearly suffering from a kind of boredom born from a lack of struggle that such a person may have experienced in Edwardian England. The kind of problem epitomised by Sebastian Flyte perhaps. I read somewhere that the period immediately following retirement is associated with low mood (are my recently retired friends faking their apparent happiness?). And then the old quip; ‘middle aged people have either jobs, boyfriends or breakdowns’. So maybe life it just too easy; while some thrive from the opportunities that their escape from a hand to mouth existence opens up, others crumble under a sense of the ultimate futility of life. Ah yes, lack of meaning – existential angst – is a pursuit for those who do not have to struggle.

Well I am fresh out of ideas so please add or subtract. As stated this list is not exclusive so all or any combination could be in play. Time to look at other cultures. Parents in Shanghai and Seoul, I understand, out-hover those in Hampstead or Long Island. Look for natural experiments (instrumental variables/threshold effects) if you encounter them. Maybe do RCTs if you can find a good hypothesis to test (parents randomised to ban or not ban access to social media?). Understand the neurochemistry as much as you can. But do not put too much store in association studies; by themselves they cannot tell you which way round causality runs.

But I doubt that armies of counsellors are the way out of the putative problem. We used to think that near everybody should be on pills of some sort, but Fiona Godlee has recently argued that we should break this thought cycle and says that ‘pills are not the answer to unhealthy life styles’.[4] Well I think the same type of question has to be asked of both pills and counselling. The thing we call depression in our society might just be a part of life. There is a bandwagon in favour of making low mood a disease and advocating therapy for it. But if 30% of the population is affected, then is this really a good idea?[5] Or should we be looking for more systematic – call them psycho-prophylactic – approaches? Bear down on bullying in school; encourage sport; promote social activities. “Count your blessings, one by one,” my father said before such an approach was called CBT. So here is the Lilford hypothesis: beyond a certain threshold, relying on self-help does more harm than good – the person is sick and needs clinical services. But before that limit is reached, becoming a case does more harm than good, and could even become a self-fulfilling, learned behaviour. And what is that threshold? No person knoweth it, but I doubt it applies to everyone under the 30th centile.

Richard Lilford, ARC WM Director

References:

1. Lilford RJ. The New and Growing Interest in Mental Health: Where Should it be Directed? NIHR CLAHRC West Midlands News Blog. 9 June 2017.
2. Fitch TJ, Moran J, Villanueva G, et al. Prevalence and risk factors of depression among garment workers in Bangladesh. Int J Soc Psych. 2017; 63(3): 244-54.
3. Brunborg GS, Mentzoni RA, Frøyland LR. Is video gaming, or video game addiction, associated with depression, academic achievement, heavy episodic drinking, or conduct problems? J Behav Addict. 2014; 3(1): 27-32.
4. Godlee F. Pills are not the answer to unhealthy lifestyles. BMJ. 2018; 362: k3046.
5. Lilford RJ. Mental Health Disorders: Discrete Entities or the Extreme in a Population Distribution of Attributes? NIHR CLAHRC West Midlands News Blog. 1 February 2019