A cartoon I saw recently summed up the difficulties our society has got itself into over mental health. It depicted the beds of the seven dwarfs from Snow White. Each of them had their name at the foot of the bed, only each one had been crossed out and replaced. Where Happy slept, the sign now read ‘Euphoric’. Grumpy’s name had been replaced with ‘Depressed’, Sleepy had become ‘Narcoleptic’, Sneezy was now ‘Allergic’, Dopey was ‘Mentally Challenged’, and Bashful had become ‘Social Anxiety Affected’. Only Doc remained the same.

It made me laugh but the issue it raises is deadly serious. The worrying truth is that character traits we previously acknowledged as common and part of life’s rich tapestry have become medicalised. I have been a practising psychiatrist for over a quarter of a century, yet increasingly I see the pathologising of normal emotions and ever-expanding types of therapy.

‘The worrying truth is that character traits we previously acknowledged as common and part of life’s rich tapestry have become medicalised’

A worrying example of this was a survey conducted by the National Union of Students a few years back, which reported that an astonishing 78 per cent of students had experienced a mental health problem in a single year.

I know from my own university days that being a student can involve some difficult moments. I remember the relentless volume of work, the intensity of exams, social pressures – and as for relationships, my status as single was such a constant feature of my life then that I began to wonder if something was wrong with me.

Forty years on, students now have the extra burdens of loan debt, the prevalence of social media and the impact of technology on the job market – more of life’s stresses and strains to be navigated. What has changed, though, is that these difficulties are now framed as mental health problems. Students in the survey did not see themselves as unhappy or distressed, but ill.

This places psychiatry at a crossroads. We should save mental health care for those who really need it. And yet the opposite is happening as the diagnoses of mental illness expand.

Take the Manual of Mental Disorders, the reference point we doctors turn to for all psychiatric diagnoses. When it first appeared in 1952 it was 132 pages long and covered 128 categories. Now, 70 years later, it lists 541 categories – a four-fold increase – and at 947 pages was described as ‘thick enough to stop a bullet’.

Dr Alastair Santhouse is a consultant psychiatrist in neuropsychiatry

Yet are we really less psychologically healthy than previous generations?

On the plus side, this ballooning of categories means the stigma that had for so long added to the distress of people suffering from mental health conditions has been removed or lessened and more people now feel willing to come forward to access treatment.

On the other hand, this has also led us to explain the cares of life, of suffering and difference, within the framework of illness. We are now medicalising people who not so long ago would have been considered normal.

Life can indeed be hard, and the hard parts are unavoidable. But life’s problems are a challenge to be overcome. Emotions are the natural consequence of the struggles and triumphs, part of what gives life its variety and meaning. These emotions may be disproportionate, or even exaggerated or prolonged, but they are not necessarily a sign of illness or disease.

Unhappiness, anger, indignation, resentment, suspicion, infatuation, lack of interest in sex, jealousy, elation – these have all been normal human emotions since the beginning of time. To think of them otherwise is to misunderstand people altogether and can lead to unnecessary treatments for diagnoses that aren’t justified.

The current trend means that if someone says they have a mental disorder, they will almost invariably find a professional to endorse it. It is a popular misconception that an individual declaring themselves depressed should be considered to have depression. Maybe, and maybe not. When a new patient tells me they are suffering, I believe them; but I do not always believe they have a mental illness.

Some of the most powerful and effective consultations I have are those in which I am able to tell the individual that their experiences are normal, that to feel that way in response to a life event or situation is a psychologically healthy and normal reaction.

‘Normal’ is a crucial concept in psychiatry; all mental illness is defined by it. There needs to be a yardstick against which we measure an individual’s mental health. But ‘normal’ and therefore ‘abnormal’ have become increasingly flexible, the boundary between them ever more unclear.

How much suspicion do you need before being considered paranoid? How often must you check something before being investigated for obsessive compulsive disorder (OCD)? How sad can someone be after a bereavement before it becomes depression? What events count as traumatic?

Our failure to address these questions has led to the percentage of people in our society who enjoy normal mental health getting progressively lower, while mental ill health is now the commonest cause of those under 44 not working, eclipsing musculoskeletal and chronic health conditions, which were traditionally the main work-limiting conditions.

‘The percentage of people in our society who enjoy normal mental health is getting progressively lower, while mental ill health is now the commonest cause of those under 44 not working’

One explanation for the figures could be that mental illness rates have indeed soared. But the more likely reason is that problems at the milder end of the spectrum are being reclassified as mental health diagnoses and more people see those problems in medical terms.

This is not to say these problems are trivial for the affected individual, but they tend to overlap with what would previously have been considered within the range of normal. I worry about this.

In the past five years there has been a rise of almost one million Britons in contact with mental health services. The figure for 17 to 19-year-olds with a probable mental health disorder has risen from one in 10 to one in four. An estimated 1.8 million people are on mental health waiting lists.

Yet over the same period, referrals for severe mental illnesses have remained the same. Severe depression, anxiety disorders, OCD, bipolar disorder and schizophrenia, require skilled and expert management. Yet such serious diseases can get overlooked in the avalanche of new mental health concerns and by medicalising everyday experiences.

Depression typifies the way in which the boundaries of mental disorder are changing. Our society has achieved a level of wealth and longevity that previous generations could only dream of, and yet we have never been so unhappy. Depression is a ubiquitous diagnosis that has become emblematic of the early 21st century.

Like all psychiatric diagnoses, it is defined by its symptoms. There is no objective measure, no blood test to give a definitive answer, and therein lies the problem.

As a medical student there were days on end when I sat on my own, feeling friendless, sad and lacking in all drive and energy. I was lonely, demotivated, fed up and once or twice on the point of tears, but back then I wouldn’t have dreamt of classifying myself as suffering from depression.

‘Depression typifies the way in which the boundaries of mental disorder are changing’

Many cases of depression I see would have been bona fide cases in any generation. Others, though, share a border with aspects of our normal daily experience. They sometimes reflect lives of disappointment, a lack of meaning and purpose, or thwarted ambition. A patient, Sian, came to me convinced her life was hopeless and everyone around her was happier than she was. I wondered how she knew how happy other people were.

If you look around at strangers on the Tube, or even at your friends, people are rarely obviously ‘happy’. They have bills to pay, sick relatives, mean bosses, bereavements, failing relationships, misbehaving children, illnesses, delayed trains, difficult neighbours, incompetent leadership, pointless wars, leaking roofs, etc, etc. Depression is meant to be different in kind, rather than in degree, from normal. At what point does a normal level of unhappiness tip over into depression?

The fact is that when it is severe, depression really couldn’t be mistaken for anything else. People in this state are withdrawn and sometimes mute, anguish etched on to their faces. I have seen people so depressed that they sit inert, not attempting to eat or drink, simply staring ahead into the unfathomable blackness of their despair.

Even moderate depression can still have a range of deeply unpleasant and disabling symptoms. Because of an inability to take pleasure, individuals are suffused with pessimism, pointlessness and helplessness. But this is not the case for milder cases. All of us experience sadness, low mood, loss of enthusiasm, poor sleep, despair, loss of appetite – yet these days these are counted as symptoms of depression.

Made badly, a diagnosis of depression obfuscates by distilling problems down to a single word. And the remedy, as with many other mental conditions, is all too often another single word – pills. Cheap and easily available, antidepressants are given to people with all sorts of problems that are not depression at all, even if they share some of its features.

In the UK in 2008, the number of prescriptions totalled 36 million. Ten years later, this had almost doubled to 71 million. Using pharmaceuticals to treat such problems can often hide the underlying and more complex problems that lie behind a label. The brutal truth is that antidepressants cannot treat the weight of the 21st century and its inequities, nor can they treat thwarted ambition or messy and unfulfilled lives.

There is no doubt among clinicians who routinely treat depression that antidepressants work, and the more severe the depression, the more effective they are. Yet at mild levels, they are often little better than a placebo.

This leads us back to the discussion as to whether mild depression should be conceptualised differently. While there needs to be some recognition that it makes it harder for an individual to function, thinking of it as an illness might not be justified, or helpful.

There are some diagnoses that patients may positively seek, in the hope that a single unifying diagnosis can contain and explain all that doesn’t feel right about their life. ADHD (attention deficit hyperactivity disorder) fits the bill, thanks to the breadth of its criteria and the fact that they overlap with so many areas that are for many people a common experience. Of every 10 patients I see, two or three have wondered about adult ADHD as an explanation for their troubles. Yet adult ADHD is a diagnosis that barely existed a generation ago.

ADHD was applied to children as a cause of either excessive inattentiveness and lack of focus or hyperactivity, fidgeting and lack of restraint. Often these were just signs of immaturity, which the child grew out of naturally. Only in 15 per cent of cases did it persist into adulthood.

But ADHD that seems to arise for the first time in adulthood is something new. It is proving to be one of the fastest-growing areas in psychiatry and is a cause for concern. Now the NHS has simply buckled under the tsunami of ADHD referrals.

In many areas of the UK, the waiting list for assessment is reported to be at least eight years, involving 196,000 adults.

The difficulty of diagnosing adult ADHD is that it exists on a spectrum, from behaviour that is essentially a variant of normal to something clearly beyond the usual norms.

For someone whose whose life is not significantly impaired, we are in a grey area where societal values start to take precedence over diagnostic boundaries. If any deviation from the expected is sufficient to qualify for a diagnosis or warrant treatment, then we may soon find ourselves in a situation where fewer and fewer people qualify for normal health and virtually everyone is categorised as having mental health issues.

Autism is another example of diagnosis creep, with numbers up 787 per cent in 20 years. The term used to apply to severe disabilities in communication and learning, with the individuals affected frequently non-verbal and attending special schools. But the diagnosis is now loosened to include those who are socially awkward or idiosyncratic even though they have careers and relationships and are broadly functioning in society.

An unfortunate side-effect is that those with more severe difficulties find it harder to access care. The same goes for the much trumpeted PTSD, post-traumatic stress disorder. It certainly exists and I have heard, from patients, haunting accounts of torture, war or accidents in which the person believes they are unlikely to survive. But these are rare.

Now, though, trauma as a concept has become increasingly muddled, and it is hard to know where the line is drawn. There are the big-event traumas, such as wars and being taken hostage, and there are the day-to-day adversities of life. There is no doubt that shocking and life-threatening events can have serious psychological impacts. In my experience, most people cope with them without the involvement of clinicians. They talk to friends or family, or try to put whatever happened out of their minds. In other words, they regain their mental equilibrium through their usual coping strategies. They deal with things; they don’t indulge in them.

Increasingly though, trauma is what the person experiencing it perceives it to be. It has become a self-diagnosis, requiring only a declaration that one has been traumatised. After an on-air row with her co-host Sharon Osbourne on US television, comedian Sheryl Underwood announced she might have PTSD.

‘One of my patients, Gillian, was a woman in her 30s who was referred to me for depression. She’d just been through a messy divorce, her business had gone bust and she saw her whole life as one of struggle, for which she was having “trauma therapy”.’ Picture: Stock image

Trauma has gone from the battlefield to television, and from hostage-taking to hurt feelings. This use of mental health terms to describe what usually has little to do with mental illness has pernicious effects on the sense of well-being of vulnerable people.

One of my patients, Gillian, was a woman in her 30s who was referred to me for depression. She’d just been through a messy divorce, her business had gone bust and she saw her whole life as one of struggle, for which she was having ‘trauma therapy’.

What trauma, I asked. ‘The divorce, the business, the whole thing,’ she replied. I disagreed. Her problem was not about reprocessing memories following a traumatic event, but about navigating the messy realities of her life. Clearly there were issues for her to work through. But to conceptualise them as trauma denied an important aspect of her troubles. They were not about a single traumatic event but rather about Gillian and her perception of her life and her coping strategies.

The language of trauma is a common currency on social media in videos with titles such as ‘Five signs you have trauma that you didn’t know you had’. These can start to frame normal feelings and behaviours as the harbingers of mental illness. They can also introduce the idea that the way you feel is because something has happened to you, something of which you were unaware. All of those unpleasant feelings are suddenly explained.

There are few more representative examples of the current obsession with trauma than ‘trigger warnings’, which alert listeners or viewers that the content they are about to engage with may exacerbate mental health problems. Undoubtedly, they were introduced out of kindness and consideration, very much in keeping with our current cultural climate.

Yet, a recent study suggests the opposite, that trigger warnings increase anxiety in anticipation of the warned-about event and make no difference to the emotional response to it. Evidence has taken second place to what has become a compassionate-sounding cultural habit, developed with the best of intentions that provides either no benefit or actually causes harm.

It is the language of sympathy and kindness, but I am far from convinced that it is helpful, as with so much else in this age of over-diagnosis. But sometimes common sense prevails.

Not so long ago, depression in bereavement was added to the Manual of Mental Disorders. There was a disapproving public reaction that grief, something universally experienced, framed and understood, was now being subject to a medical reductionism. People feared they might not be seen as grieving but rather depressed.

An article in The Lancet spoke of the ‘infiltration of bureaucratic standards and regulations ever more deeply into ordinary life’. The spiritual, the ephemeral, was being brought into the prosaic business of diagnostic classification.

The author, himself recently bereaved after 46 years of marriage, felt by contrast that his pain served a purpose. Grief was not a troublesome irritation, like a fly that needed to be swatted away. It was something to embrace as part of his emergence into a new life.

A study found that a third of bereaved individuals would meet the criteria for ‘prolonged grief disorder’, particularly if it was a child that had died or the death was from suicide, homicide or overdose. But most of them did not see their grief as abnormal. To grieve the loss of a loved one is a perfectly normal response. It did not need a bureaucratic classification. The involvement of psychiatry in grief was largely unnecessary.

Now there’s a diagnosis I have no problem agreeing with.

• Adapted from No More Normal by Dr Alastair Santhouse, to be published on April 10 by Granta, £18.99. © Alistair Santhouse 2025. To order a copy for £17.09 (offer valid to 12/04/25; UK P&P free on orders over £25) go to www.mailshop.co.uk/books or call 020 3176 2937.